As Humanitarian Crises Grow, So Do Risks for Women and Newborns

During humanitarian emergencies, women and newborns face severe disparities and heightened vulnerabilities, increasing their risk of illness and death. Humanitarian crises—caused by conflict, climate-related disasters, or forced displacement—disrupt health systems, limit access to essential services, and increase the likelihood of preventable deaths. In 

, 58% of global maternal deaths, 50% of newborn deaths, and 51% of stillbirths worldwide occurred in the 29 countries with a UN humanitarian response plan or regional response plan. In humanitarian emergencies, a lack of skilled health personnel, inadequate infrastructure, and shortages of essential medicines are common—resulting in limited access to both basic and emergency maternal and newborn care. A fight for humanitarian aid is also a challenge, as maternal and newborn health are often under-prioritized or neglected in humanitarian response.

For many women, the absence of skilled birth attendants during delivery—combined with limited emergency obstetric care—means that life-threatening complications (such as postpartum hemorrhage, sepsis, and obstructed labor) are often left untreated, leading to tragic outcomes. Additionally, routine antenatal and postnatal care is frequently disrupted—contributing to undiagnosed complications like preeclampsia and gestational diabetes—while newborns are at heightened risk of conditions such as asphyxia, prematurity, and infections.

Family planning services are also insufficient during many humanitarian crises, contributing to unintended pregnancies and exacerbating maternal health risks. Adolescent pregnancy, a serious concern, is further compounded by early marriage and gender-based violence, typically more prevalent during crises. Additionally, many women and girls are subjected to sexual and gender-based violence, leading to severe reproductive health complications and limited access to essential care, including mental health support. The mental health impact on pregnant women and new mothers during crises is profound—with high levels of stress, anxiety, and depression affecting both maternal and newborn health outcomes. Breastfeeding and infant nutrition are also compromised due to food insecurity, displacement, and lack of proper support, often resulting in suboptimal feeding practices that threaten infant health.

With the number and complexity of humanitarian crises on the rise, it’s even more important to ensure that the most vulnerable groups—women and newborns—receive the best possible care.  I turned to maternal and newborn health practitioners, implementers, and researchers, and asked seven experts with different backgrounds and experiences what is the one thing they feel needs more attention or policy or funding or understanding related to humanitarian aid and response. They responded with incredible insights into the challenges women and newborns face during humanitarian crises.

Dr. Claudia Donkor, Sexual and Reproductive Health in Emergencies Specialist, UNFPA Somalia on the underutilization and under-funding of the Minimum Initial Service Package (MISP):

The Minimum Initial Service Package for Sexual and Reproductive Health (

) was first introduced in 1996 to address the disruption of access to basic SRH services during humanitarian emergencies. MISP for SRH is a set of essential (often life-saving) activities and services needed to appropriately respond to the urgent needs of women, girls, and vulnerable populations in the first 48 hours of emergencies.

Somalia is a nation grappling with protracted conflict, recurrent climatic shocks, poor maternal and newborn health outcomes, and pervasive gender-based violence. Women and girls, particularly those in humanitarian crises, face limited access to sexual and reproductive health services and information. The MISP for SRH, a crucial framework for addressing these urgent needs, is often underutilized due to lack of understanding and prioritization. MISP for SRH provides a holistic approach to safeguarding the health and rights of women and girls in emergencies, encompassing six key areas: leadership/coordination, prevention and response to sexual violence, HIV and sexually transmitted infection prevention, maternal and newborn health, family planning, and planning for comprehensive SRH services.

, including limited awareness and prioritization of MISP for SRH as a comprehensive package. This lack of understanding hinders effective response efforts, leaving vulnerable women and girls at risk of preventable maternal and newborn deaths and other SRH complications. It is imperative to inform program implementers, humanitarian response teams, and donor organizations that MISP for SRH is an essential part of every humanitarian response. The sexual and reproductive health needs of women and girls should not be overlooked in times of crisis.

Deborah Denis, Strategic Partnerships Research Manager, National African Students Association, New York University on the deprioritization of maternal and newborn health services and education:

The Boko Haram insurgency in Northeast Nigeria displaced more than 

 This decade-long crisis and recent flooding have further strained an already fragile healthcare system and low literacy rates. With thousands of people resettled in camps and host communities, livelihood and healthcare needs remain urgent—especially for maternal health. Most internally displaced individuals come from rural areas, with limited understanding of the importance of maternal healthcare, particularly preventative measures like antenatal care. It is common for healthcare to be sought only when visible illness or childbirth complications occur. Unfortunately, due to limited funding, comprehensive sexual and reproductive health (SRH) and maternal and newborn health (MNH) services are often lacking.

Research shows that maternal health tends to be 

 in emergency preparedness and response. The assumption that pregnant women know how to manage their pregnancies—combined with the belief that general healthcare covers maternal needs—results in higher rates of preventable pregnancy complications and maternal deaths among displaced communities. In regions with 

 levels, such as northeast Nigeria, general awareness of maternal health needs is lower than should be anticipated. In my experience, myths and misconceptions about “Western” medicine exist in these regions and health education on culturally sensitive issues such as maternal health must be intentional. To address this, emergency interventions must integrate educational efforts to raise awareness about maternal health care and design programs that specifically address MNH needs in humanitarian settings.

As humanitarian crises are expected to increase, policymakers must proactively plan maternal healthcare intervention responses. This involves incorporating educational activities and clinical care for pregnant women into emergency intervention strategies and adopting long-term policies that prioritize training skilled healthcare workers.

Mushtaq Khan, Health and Nutrition Senior Advisor, International Rescue Committee Afghanistan on the need for more attention on long-term care for women and newborns: 

In Afghanistan, women and newborns face serious health challenges due to a combination of cultural, political, socio-economic, and infrastructure factors. For example, cultural 

 restrict women’s mobility and require male consent to access healthcare services, particularly in remote areas. When it comes to maternal and newborn health in Afghanistan, the 

 is mainly emergency healthcare, with less attention on equally important long-term care needs, like postpartum care, follow-up newborn care, and perinatal mental health services. In Afghanistan—which at times faces both acute and protracted crises—there must be attention to both the emergency needs and persisting health needs to avoid long-term negative health outcomes.

Since the Taliban took over three years ago, there are multiple factors that lead to high rates of maternal and newborn mortality: poorly resourced and unskilled birth attendants, poor nutrition and mental health for mothers, and lack of credible data on maternal and newborn health outcomes. In addition, newborn care is typically overshadowed by maternal health care leading to high rates of neonatal mortality.

Micronutrient deficiencies among women and newborns are common in Afghanistan’s rural communities, leading to pre-term births, nutritional deficiency complications among mothers, and low-birth weight babies. Mothers have faced multiple compounding traumas from displacement due to conflict and recurring natural disasters—but have no perinatal mental health support. Due to the incredible challenges women and mothers face, immediate and long-term health needs of newborns are often forgotten. Lastly, the current lack of credible data on maternal and newborn health outcomes makes advocacy for prioritizing maternal and newborn health services—particularly their long-term care—very challenging. 

Jihan Salad, Program Specialist, Sexual and Reproductive Health, UNFPA; AlignMNH Steering Committee Member on the health of adolescent girls:

The health of adolescent girls, including adolescent mothers, is 

 and requires urgent attention. In Malawi, where I  worked as a health systems specialist for UNFPA, existing 

 adolescent access to essential health services. Yet Malawi continues to be among the countries with one of the highest adolescent birth rates 

, largely due to early marriages and limited educational opportunities. During crises, adolescent birth rates increase as access to education and healthcare services is often 

. This leaves adolescent girls vulnerable, as the lack of basic services exposes them to unplanned pregnancies. The collapse of social structures also magnifies 

—making it harder for girls to avoid early pregnancies.

This highlights the importance of ensuring adolescents have access to 

 (including outside of the formal health system), to promote health and safety and reduce early pregnancies. It also underscores the need to address inequalities that hinder access to services. For example, establishing safe spaces for adolescents where they can access health services, mental health support, and protection from violence is crucial. In addition, humanitarian policymakers and funding organizations can help by prioritizing resources for mobile clinics and outreach programs to deliver health information and services to adolescents. If we fail to provide these necessary services to adolescents, including adolescent mothers, during crises, the consequences will affect not just the young mothers, but entire communities and future generations.

Harriet Ruysen, Midwife; Research Fellow, London School of Hygiene & Tropical Medicine on not forgetting the newborn:

The number of people trapped in humanitarian settings continues to increase. This year, 

 are affected by conflicts, disease outbreaks, and climate disasters including women, babies, and children. 

show that newborn deaths (babies aged 0- 28 days) account for nearly half (47%) of all child deaths globally. Most of these deaths are happening in countries with 

 crises which exacerbate poverty and malnutrition, cause displacement and trauma, and erode support systems that protect the most vulnerable. Health services are disrupted by depleted human resources, fractured supply chains, intermittent power and water supplies, and damage to buildings, equipment, and infrastructure. Hospitals are increasingly 

 in war—and it can be impossible for women to reach healthcare safely due to lack of transport, active fighting, shelling, unexploded ordinance, or the threat of sexual violence.

A disproportionate number of newborns die (or are 

) for entirely preventable reasons during humanitarian disasters and conflicts. Women are more at 

 of anemia and other exposures that contribute to prematurity, low birth weight babies, and congenital conditions. Stress, insecurity, and malnutrition are known to affect long-term childhood development with potential 

 for future generations. Babies born too 

, too small, or who become sick are particularly vulnerable to health system shocks, power and stock outages, and human resource gaps. However, preterm babies can and do 

 with the right care: in high-income countries, 9 in 10 extremely preterm babies (<28 weeks) survive, compared with just 1 in 10 in low-income countries. It doesn’t have to be this way. The 

Newborn Health in Humanitarian Settings Field Guide

Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings

 are resources that can be used to strengthen country programs for newborn care and expand access to dignified and high quality care during pregnancy, birth, and the postpartum period. Innovative and affordable technologies—like those delivered by 

 in parts of Sub-Saharan Africa—have untapped potential to save newborns in humanitarian settings. To ensure that every child can survive and thrive in a world where conflicts are increasingly protracted—and the impacts of humanitarian crises on health systems are long-lasting—we need to protect newborn lives. 

Rondi Anderson, PhD; Midwife; Senior Reproductive, Maternal, Newborn, and Child Health Advisor, Project Hope on gaps in 24/7 response for maternal and newborn health:

My experience includes humanitarian response in Africa, Asia, and the Middle East; I’ve worked amidst chronic conflict in Somalia, with Rohingya refugees, and for cyclone and flood response in Bangladesh. I’ve responded to earthquakes and chronic conflict in Syria, tropical storms in South and East Africa, and the current humanitarian crisis in Gaza. Causes of maternal deaths cannot be predicted or prevented, so to save women’s lives, response to obstetric emergencies must be available 24 hours a day, 7 days a week. 

There are global standards for the minimum health care package for preventing maternal death in humanitarian settings (MISP for SRH). Alarmingly these standards are often selectively implemented with many outpatient health clinics and mobile teams, and significant 

 in accessible, 24/7 obstetric and newborn emergency response persist. To save women’s lives, all women experiencing obstetric emergencies must have 

 to initial stabilization, transport, and ready health facilities. These are difficult goals to attain but are essential for preventing maternal and newborn mortality. Literature 

 that 58% of preventable maternal deaths and 50% of neonatal deaths occur in humanitarian settings, and access to services is the leading contributor.

In Bangladesh, although the number of midwives were expanded to serve 24/7 in health facilities, emergency transport was weak, resulting in camp births with high maternal and newborn mortality rates. In the northern region of Syria, with more than 2 million people affected, humanitarian response was exclusively mobile teams and static outpatient clinics—with no initial stabilization or transport—and overall, very limited options; maternal deaths were reported regularly by communities and receiving hospitals. In Gaza, inpatient facilities are few and overwhelmed, and many communities are reached only by mobile teams without emergency capacity. A similar situation was reported to me from a Madagascar tropical storm response, where there were mobile teams only; health facilities were damaged and evacuated. Meeting the needs of pregnant women and newborns requires more resources; mobile clinics alone will not solve the problem.

Hani Rukh-E-Qamar, Executive Director and Founder, Canadian Advisory of Women Immigrants; MSc Epidemiology Student, McGill University on the need for sustainable and ethical exit strategies:

During many global humanitarian crises, maternal and newborn health (MNH) is 

, and the needs of the affected communities after a crisis are not taken into consideration. While working at McGill University in collaboration with the 

, I studied the ethics of developing exit strategies in humanitarian settings through a qualitative research project. I analyzed exit strategies in low- and middle-income countries (including Kenya and Liberia), pointing to the need to consider 

—such as sustainability, collaboration, and transparency—in implementing diverse programming, including for maternal and newborn health. For project closure, maternal and newborn health requires particular attention.

The unique nature of maternal and newborn health care means that abrupt closure could have severe and long-lasting consequences on health outcomes. This is especially concerning in humanitarian settings as programs tend to focus on the reduction of maternal and newborn mortality—often lacking ways to support communities in improving other MNH outcomes, such as postpartum care linkages, sustainably. Therefore, MNH programs need to be designed with sustainability at the forefront, ensuring that communities can continue to support these essential services after humanitarian organizations have left.

For example, creating postpartum care interventions that workers who are trained for a variety of roles can handle, and integrating them within local non-governmental organizations (NGOs) may increase sustainability. Mothers need ethical 

 that focus on community-identified investments and resources to serve the community’s short and long-term MNH needs—without having to continuously rely on donors and humanitarian aid—while collaborating with local leaders and being transparent. However, it is important to consider aspects that pull in the opposite direction—such as the pressure to maximize efficiency—or the short-term focus of many humanitarian efforts. Overall, having an ethical exit strategy will allow a community to plan responsibly and allow them to transition from an emergency state to a sustainable one.

Cover photo: Bangladesh. Rohingya women in refugee camps share stories of loss and hopes of recovery. Photo courtesy UN Women. https://creativecommons.org/licenses/by-nc-nd/2.0/

Bangladesh. Rohingya women in refugee camps share stories of loss and hopes of recovery. UN Women. https://creativecommons.org/licenses/by-nc-nd/2.0/

Sarah B. Barnes engages maternal and newborn health experts to better understand what the needs of women and newborns during a humanitarian crisis.

Maternal and newborn health experts on what needs more attention when responding to humanitarian emergencies.

We’re often told that we’re living during a population crisis, a time of simultaneous concerns born of too many people to sustain necessary resources for a healthy planet, and too few working-age people to support a healthy economy. Population dynamics and trends are key to national and international security and contribute to the overall wellbeing of a society. Fertility, along with mortality and migration, is central to population and its importance to demographers, policymakers, economists, and a country’s development is without question. But focusing on population trends without considering the experiences of the billions of individuals who make up those trends—each with a unique life course, personal aspirations, and individual potential—establishes an unhealthy and dangerous tension that can strip women of their rights and leave them socially disenfranchised.

Globally, women are not always decision-makers in population policymaking, but their fertility is frequently seen as both the problem and the solution to a population’s composition, size, and growth. History shows an abundance of national policies that have sought to increase or decrease birth rates, often excluding women’s perspectives about their own fertility intentions. These target-driven fertility policies have had limited long-term success in affecting birth rates. At the same time, those policies that target the number of children a woman should have can have lasting consequences related to diminished autonomy for women and weakened gender equality.

Governments argue that hitting fertility targets, either by decreasing or increasing the number of children a woman has, will improve a nation’s economy and its ability to handle stressors.

Many fertility-related policies have targets that are based on achieving a total fertility rate—a demographic indicator that estimates the average number of children born per woman during her reproductive years—of at least replacement level, which is 2.1 children per woman. While there is nothing inherently wrong with an aggregate measure like the total fertility rate, tension arises when policy decisions favor those measures while failing to acknowledge the preferences, experiences, or desires of women and couples. Examining population data and how a trend changes over time is really just a shorthand way of understanding how people’s lives are changing for any number of reasons.

From Fertility Goals to Individual Choice

The way governments think about fertility and related policies has evolved greatly over the past century. Initially, governments focused on developing policies related to population change, but failed to consider individual—women’s—perspectives in the design, implementation, or impact of such policies. The use of demographic goals to advance development remained relatively unchallenged until 1994, when the International Conference on Population and Development (ICPD), that year held in Cairo, shifted global attention from policies that focus on achieving demographic targets to those grounded in individual choice and that consider the complex and interrelated issues of population, development, and human rights.

 was adopted by 179 governments and highlighted individuals’ fundamental right to make informed decisions about their reproductive health, and clarified that women’s full and equal participation in civil, cultural, economic, political, and social life at all levels were priority objectives for this international community, as was eradicating all forms of sex discrimination. Efforts to achieve these goals have accelerated strategies to eradicate gender-based discrimination and promote tools that empower women to determine the timing and size of their families through better access to family planning, education, and healthcare. When women have access to these services, they can draw on their own life circumstances and personal aspirations to make decisions rather than being subjected to government-set fertility targets.

Thirty years after that groundbreaking meeting in Cairo, the 

 is 2.3 live births per woman, a decrease from 3.3 in 1990. This trend was realized with women’s increased decision-making power about their reproductive health. Access to better healthcare and contraception have also been instrumental in reducing fertility and increasing reproductive choice, as have women marrying later, more girls going to school, and more women entering the workforce. Gender equality and women’s empowerment are the essence of the ICPD Program of Action. As UNFPA’s 1994-Executive Director Nafis Sadik 

 at that time, this approach to development is “liberating women from a system of values which insists reproduction is their only function.”

A History of Policies Used to Drive Fertility Levels

Despite advances coming from the 1994 conference, it is not unusual for governments to create policies focused on women’s reproductive health behaviors with the ultimate goal of affecting fertility rates. Governments argue that hitting fertility targets, either by decreasing or increasing the number of children a woman has, will improve a nation’s economy and its ability to handle stressors. Countries seeking higher fertility favor population growth to support the military, infrastructure, and services; conversely, countries seeking lower fertility see that decreasing population numbers will allow for more resources per person to invest in human capital.

Fertility policies enacted to achieve population goals and fertility targets almost always neglect the experience, needs, and desires of the women and couples they directly impact.

Some countries want to increase births through policies that aim to increase fertility rates (often referred to as pro-natalist), while others hope to slow population growth through policies that aim to inhibit fertility (often referred to as anti-natalist). Experience has shown that it’s too simplistic to assume that a country with high fertility only needs more contraception and family planning policies and a country with low fertility rates can resolve its challenges only with additional supportive family policies. Fertility related policies are just as complex and intricate as those related to migration and aging societies, or any other complex social issue, and policymakers need to consider how people’s lives—especially women—are impacted by attempts to shift fertility preferences. The ICPD paradigm change has demonstrated that policies focused solely on reaching fertility targets are shortsighted and often harmful to women and families.

Policies and practices to promote fertility

Some countries with decreasing fertility rates and projected shrinking populations have felt the need to implement policies to encourage women and couples to have larger families. These are largely financial incentives in the form of tax advantages, welfare benefits, childcare subsidies, and increased parental leave. In 

, for example, government policies have included state subsidized child care and 12 weeks of maternity leave for the first four children.

 have both passed monetary transfer policies designed to consider the cost of child rearing and gender equality (despite these policies, France’s total fertility rate has been below replacement level since 1975). 

’s government has provided loans that can be forgiven if a couple has at least three children. At first glance, these policies may seem beneficial, but they tend to support women and families for only very short periods of time and are not always inclusive to everyone wanting to build a family. Evidence shows, like in 

 that while such policies may cause an immediate surge in birth rates, they have not been shown to increase the number of children a woman will have during her lifetime.

Some fertility-promoting policies can have longer term negative effects by violating a person’s right to decide the timing and spacing of pregnancies. These 

, while encouraging reproduction, often discourage contraceptive use, including sterilization and abortion, which was the case in Singapore, Iran, China, Russia, and Poland. These policies can also be exclusionary—such as in Hungary, where 

 (and the aforementioned loan benefits) is only offered for free to women under the age of 40 who are in a heterosexual relationship—or punitive, like the idea of applying an additional tax on the 

 typically urge women to return to more traditional roles and produce more voters, fighters, workers, and consumers to boost the economy. These movements have often been rooted in nationalistic ideals, infused with racism and xenophobia, with an emphasis on certain populations to have more children to improve the status of a nation. With the rise in conservative candidates in global elections this year, it is also quite possible that we will see an increase in national fertility focused policies that are not centered on how many children a couple wants but instead on fertility targets.

Policies and practices to inhibit fertility

Conversely, countries that deem their population to be too large or growing too quickly have enacted policies to reduce fertility that could have a significant effect on women’s autonomy, gender equity, and access to reproductive health services. In 1952, as a response to its then total fertility rate of 6.2 births, India became the first country to establish a population policy that coincided with a massive government-sponsored family planning campaign to slow their population growth. Other countries quickly followed suit with policies that focused on lowering fertility—largely based on the needs of the government and the idea that smaller families would lead to greater economic benefits. The thinking at that time (when the majority of countries had high fertility rates) was that 

 is both a cause and symptom of slow economic development and that slowing population growth (through lower fertility) would accelerate development.

Certainly, China’s one-child policy from 1980 to 2015 fits into this category and violated people’s rights while also leading to a population age structure that has had an unexpected effect on economic and social behaviors. When this policy was in place, 

 of Chinese women were subjected to forced contraception use, sterilization, and abortions. Another unintended consequence of population reduction efforts: throughout South and East Asia the practice of 

 resulted in millions of aborted female fetuses due to the cultural preference for sons.

In addition to these national-level policies and practices to reduce fertility, researchers have documented policies that attempted to control fertility among targeted populations. For example, a 1970-law led to the sterilization of 25% of 

 in Peru and Indonesia into the 1990s, and in Canada until the 1970s were also subject to policies that forced sterilization and coerced contraceptive use. Eugenic laws and practices have permitted 

 in many countries, particularly targeting racial and ethnic minority women, incarcerated women, disabled women, 

A Future of Policies that Promote Gender Equity

Fertility policies enacted to achieve population goals and fertility targets almost always neglect the experience, needs, and desires of the women and couples they directly impact. Gender equality and women’s empowerment and autonomy must be central to any policy related to fertility. We should also encourage a shift away from the pro- and anti-natalist discourse to one that is fully centered on reproductive health decisions that are voluntary, informed, and rights based.

Deconstructing aggregate indicators like total fertility rate and reflecting on what they mean for individuals helps policymakers better appreciate the intricate forces and dynamics that shape global population structure, changes, and trends. Many fertility-related policy solutions—meant to address growing and/or decreasing populations—have been tried unsuccessfully in part because they did not address the complex forces that shape people’s lives, and often they fail to respond to the real needs of the individual women, including their need to be equal members of society. Now, 30 years after the historic declaration in Cairo, it is a time for honest reflection and change based on evidence and human rights.

 is senior director at Palladium, deputy director at PROPEL Health, and a global fellow at the Wilson Center.

Cover photo: A mobile clinical outreach team from Marie Stopes, a specialized sexual reproductive health and family planning organization on a site visit to Rabai hospital a rural area in the coastal region of Kenya, where they offer many sexual reproductive health services, including the full range of family planning options, emergency contraception, pre- and postnatal care, and cervical cancer screening and treatment. The main activity at Rabai hospital was implants of a five-year contraceptive solution for women. Photo by Jonathan Torgovnik/Getty Images/Images of Empowerment, licensed through 

So often in conversations about demography, the discussion is data-heavy and alarmist, looking at population trends from the 30,000-foot view and leaving out the individual needs of the people. The International Conference on Population Development (1994 in Cairo) was a watershed moment that led to a prioritization of individual needs in development and its Program of Action led to the steering committee of UNFPA and their work on SRHR. 30 years since the Cairo conference makes it an opportune time to highlight the people behind the trends, persistent inequities, and some solutions. 

Fertility-focused policies, women’s rights, and the people behind population data.

Moving Beyond Fertility Targets

Ukraine and its people will feel the effects of the Russian invasion for years to come. More than 

6 million refugees have left Ukraine, and another 8 million Ukrainians are internally displaced

. Among those most affected are Ukraine’s women and girls, who have a greater chance of experiencing gender-based violence, exploitation, and trafficking. They also face escalated maternal and newborn mortality rates stemming from the lack of services and diminished care, along with injuries and trauma due to the ongoing conflict. Less visibly, Ukrainians are confronting severe emotional distress and trauma.

Dr. Henia Dakkak, head of Policy and Liaison Unit, Humanitarian Unit, United Nations Population Fund (UNFPA), is currently living in Moldova to support relief from the ongoing crisis in Ukraine. I spoke with her about the lasting effects of conflict, trauma, and displacement on the health of Ukrainian women and girls.

At the start of the conflict, UNFPA estimated that 

80,000 Ukrainian women were due to deliver a child in the upcoming three months

—a timeline now surpassed. The whole world saw 

images of maternity wards targeted by Russian forces

 and of pregnant women covered in blood. We heard details of the deaths of expectant mothers and of babies born too soon. 

Shockingly high numbers of rape and other forms for gender-based violence have been reported

, and supply chain disruptions and diminishing food supplies are adding to the trauma Ukrainians face. Reports from Ukraine tell us that 

people are suffering from intense fear, constant stress, persistent worry, hopelessness, and panic attacks

A lot of women are experiencing premature labor. And this is not related to nutrition or anything else, but related mostly to the anxiety and to the stress that they are experiencing.

Globally, the world is reckoning with the devastating mental health implications of the COVID-19 pandemic, which has amplified existing mental illness and sparked growing levels of anxiety and depression. Suicide rates have also increased, and maternal mental health and maternal deaths due to suicide have become major concerns for researchers, practitioners, and policymakers. This global mental illness crisis is exacerbated in humanitarian emergencies where, historically, mental health support is not a top priority in the humanitarian response. This is despite the fact that 

nearly everyone affected by humanitarian emergencies endures psychological distress

, and 20 percent are likely to experience depression, anxiety, posttraumatic stress disorder, bipolar disorder, or schizophrenia. Women and girls living in humanitarian crises, along with the health providers who support them, are at heightened risk for prolonged mental health challenges. 

Dr. Dakkak works directly with women, girls, and health care providers affected by the conflict in Ukraine. She expressed a primary concern for maternal and newborn health and declining mental health, a lack of mental health services and family support networks, and resulting increases in preterm deliveries. 

Some 66 percent of preventable maternal deaths and 45 percent of newborn deaths take place in countries affected by recent conflict, natural disaster, or both

stress can increase the likelihood of having a baby born before 37 weeks of pregnancy or of having a low-birthweight baby

. Prematurity is a leading cause of death in newborns and in children under the age of five years. Dr. Dakkak detailed three elements contributing to the stress on Ukrainian women: added responsibilities, worry for their loved ones, and their compromised situation:

“This war has been going on now for more than four months and this has a big effect on the mental health and psychosocial status of women, especially pregnant and lactating women.

“When we look at the countries surrounding Ukraine where the refugees are currently, women are there without their support system. They are now the breadwinner and the ones who are taking care of the children or the elderly. They are the ones who are responsible for the safety and security of their kids while they are in transition.

“They are worried about their future. They are worried about their husbands, their brothers, their fathers—the people that they left behind in Ukraine. And, when you talk with women who are in refugee accommodation centers, they will tell you that there has been an additional element of stress due to people trying to take advantage of them in different ways.”

Dr. Dakkak reported that women are being charged exorbitant prices for necessary things like transportation, and are experiencing gender-based violence, including trafficking and sexual violence. There is also a language barrier for some women and additional stress when caring for a person with a disability:

“What we have seen and what has been reported to us by health care workers during the war in Ukraine is that a lot of women are experiencing premature labor. And this is not related to nutrition or anything else, but related mostly to the anxiety and to the stress that they are experiencing, being afraid for their lives, afraid for the lives of their children, afraid for the lives of their family.

“So, there are a lot of premature labors, and these premature labors, they need additional attention. Most of these labors would require incubators, and many health facilities were not equipped to provide the support needed to sustain the lives of preterm babies. Any time you have premature labor, you also have the possibility of bleeding, and bleeding increases the possibility that a woman might lose her life and the newborn might lose his life. All of this was born from the stress, the anxiety, and the fear that women were living in.

We see a lot of women and girls who turn to suicide because their needs are not being met. It is the same situation with gender-based violence, a lot of women suffer in silence.

“Both women displaced within Ukraine and Ukrainian refugees face a similar situation—they are in a place that is not their home, where they do not have a strong support system. We are dealing with stress and premature delivery both inside Ukraine and in the neighboring countries. I am currently in Moldova, but the majority of premature labors and a lot of the stress and anxiety we have seen are more from inside Ukraine.

“Mental health and psychosocial health have been on the radar of the humanitarian community, but they are not the highest priorities. We see more attention toward trauma, especially when you are talking about an active conflict, like now, and injuries and infectious disease often take precedence over, and attention from, maternal and neonatal health and mental health.” 

The use of rape as a weapon is a highly documented war crime. Sexual violence and rape have long been used to humiliate and torture populations into submission, and humanitarian emergencies can significantly weaken society’s ability to protect people from gender-based violence. Ukrainians are not immune to this violence, and it should be noted that while the vast majority of gender-based violence in conflict is focused on women and girls, men and boys are also subject to these crimes. 

Survivors of wartime rape often sustain long lasting physical injuries, and the possible reproductive consequences can lead to generational societal effects

. Survivors also face long-term mental health consequences, 

“Gender-based violence and intimate partner violence have been on the rise, especially during the COVID-19 pandemic. We should not minimize that, and the physical and mental effects of gender-based violence on women and girls is profound.

“We need to address the reality that gender-based violence existed in Ukraine prior to the invasion, primarily as intimate partner violence. The war and the pandemic have exacerbated it, but it was already here. We need to change social norms and laws to protect women and girls, and we need to make services readily available and accessible for those in need. Unless information is available and services to support the mental health and psychosocial needs for survivors are available, survivors will not come forward.”

Ukrainian women who are raped by Russian soldiers will likely experience severe trauma and distress, and the toll on their mental health can be exasperated by a pregnancy resulting from rape. With restrictive abortion laws in neighboring 

, Ukrainian refugees have limited options to terminate a pregnancy, even one that results from rape. As Dr. Dakkak observes:

“We need to really think about how we can shed more light on mental health and the need for psychosocial support more generally, and shed light on the mental health needs of pregnant women and sexual reproductive health services in emergency settings. I can tell you, there is a lot of anxiety, especially if a woman gets pregnant as a result of being raped, and just thinking about what will happen to that pregnancy. And in some countries around Ukraine, abortion is not legal.

“They will suffer in silence. And do we only see mental health issues related to pregnancy? No, we also see it post pregnancy, we see a lot of postpartum depression. We see a lot of women and girls who turn to suicide because their needs are not being met. It is the same situation with gender-based violence, a lot of women suffer in silence.”

Health Facilities Are Easier to Rebuild Than Health Providers

More than 200 attacks on health facilities have occurred in Ukraine since the invasion by Russia

. The attacks on health facilities have led to the deaths of health care workers, the destruction of life-saving equipment and medications, disruptions of supply chains, and a mass exodus of health care workers fleeing Ukraine. Everyone is working hard on the supply chain issues, and improvements are slowly happening, but the rebuilding of health facilities and a strong cadre of health care personnel will take more time. The trauma and stress health workers face in humanitarian emergencies is significant, long-lasting, and often overlooked. Dr. Dakkak explains:

“When I came to Moldova in the first week of the war, we immediately received information about shortages of maternal medicines and supplies that were needed by the main obstetric hospital in Odesa. When the supply chain is disrupted, even if you have the medical personnel available, they are at a loss of what to do when they don’t have access to necessary medications. So supply chains are one element of distress. What we also have seen from the media coverage, and what UNFPA personnel who are working in Ukraine have all had to witness first-hand, are the targeted attacks on health facilities, which is another major concern.

“The supply chain is a big issue, and everybody is working very hard to make sure that we address all the gaps. But a lack of health personnel is something that would need more time because you cannot replace health personnel very quickly, you cannot train health personnel very quickly. That means a loss of lives is a loss for the health sector generally, and for the health of Ukrainian families.

“Ukraine needs a lot of support to rebuild the health system to the level that it was there before the war. But I think as in any situation where you have a big emergency or disaster, the issue that you must think about is, how do we build—not back—but forward, and better? How do we make these hospitals more capable of withstanding these types of attacks, and how do we work with the medical personnel to truly support them and save their lives? There are many campaigns, including UN Security Council resolutions, which recognize these elements are very important for safety and security in general, and for peace and security throughout the world; understanding that hospitals, schools, and medical personnel should be protected and given the utmost attention.”

National and international organizations are gathering evidence for a potential war crimes investigation against Russia

. War crimes include a range of violations of international law, which 

include targeting civilians, torture, taking hostages, rape and other sexual violence of civilians, enlisting children, and deliberate destruction of civilian infrastructure during armed conflict

. Investigating and prosecuting war crimes is laborious and time consuming and often left unresolved. Dr. Dakkak states:

“And these attacks should be constituted as crimes. Let’s face it, this is not only happening in Ukraine—it’s happening in many places around the world—in Burkina Faso, in Mali; attacks on health facilities happen in Iraq. Attacks like these have happened in Syria. It will take time. It will take effort. It will take a lot of advocacy. There must be accountability for these crimes.

“And there should be some sort of recognition that even armies should not be utilizing health facilities, schools, and health personnel as targets in these types of settings, situations, or emergencies. I think everybody needs to understand that there is a price for these types of attacks. And there should be some sort of reparations. Because if we continue being complacent, we will have more of these discriminatory attacks on health facilities and health personnel.

“There is a lot of good capacity in Ukraine and neighboring countries, but they need funding, and additional medical teams to come and help build the system back. And something that we also need to recognize is that not everybody has the same ability to work under the stress of this type of situation. Health care workers also need mental health support and services.”

Sarah B. Barnes is the project director of the Maternal Health Initiative at the Woodrow Wilson International Center for Scholars, where she leads the program’s research. She works closely with practitioners, researchers, donors, international development agencies, and policymakers to connect issues of gender, maternal and global health, and women’s leadership to foreign policy. She is also the editor of the Dot-Mom column on New Security Beat.

Cover photo: A pregnant woman whose pelvis had been crushed and her hip detached during Russian shelling is evacuated from a maternity hospital in Mariupol, Ukraine, March 9, 2022. The woman was taken to another hospital closer to the front line but did not survive. AP Photo/Evgeniy Maloletka.

Sarah B. Barnes speaks with Dr. Henia Dakkak, head of Policy and Liaison Unit, Humanitarian Unit, United Nations Population Fund (UNFPA), who is currently living in Moldova to support relief from the ongoing crisis in Ukraine. They examine the lasting effects of conflict, trauma, and displacement on the health of Ukrainian women and girls. 

Mental, Maternal, and Newborn Health

 has created large volumes of human displacement. In 2013, Dr. Ihlas Altinci was among those who fled the devastating conflict – leaving Aleppo for Turkey.  

Eight years on, however, she is a sexual and reproductive health advisor for 

, where she also manages projects and health facilities involving refugees and other populations in Syria. 

Dr. Ihlas (as she prefers to be called) has just the background to succeed in such a vital mission. After graduating from medical school in Romania in 1996, she returned to Syria, earned a master’s degree in family medicine in Damascus and conducted the country’s first study on violence against women while working as a general practitioner in Aleppo.

After fleeing Aleppo, Dr. Ihlas’s journey has been both challenging and productive, wreaking havoc on her family, but allowing her to deepen her commitment to providing 

reproductive health services for women who have been displaced by conflict

Dr. Ihlas says she started to put more emphasis on reproductive health because, “I observed that it was a bit neglected. Everybody was talking about primary health care, secondary health care, trauma care. We had many casualties because of the war, and shelling, and so on. So maternal and pediatric health was not really at the center of attention.”

She adds that she was lucky in 2015 to have “a manager who shared my view, and thought that there should be a person who was dedicated only to reproductive health issues. And I was that person, luckily for me.”

Sarah B. Barnes, Director of the Wilson Center’s Maternal Health Initiative, interviewed Dr. Ihlas, about the impact that human displacement has on women and girls and their reproductive and maternal healthcare, and the need for women’s leadership.

Dr. Ihlas recalls her life in Aleppo before Syria’s civil war – and the factors that compelled her to flee the country with her family.

In Aleppo, I had everything any doctor could dream of – our house, our summer house, my clinic. I used to work when I wanted to, and in the way I wanted to, because I was controlling my own issues.

I had a clinic in one of the poorest neighborhoods of Aleppo. No one understood the notion of family medicine in Syria. Not then, not now. So, I used to tell people: “I'm a general practitioner.” My patients were mainly women and girls.

Since I was young, I knew that I could do whatever I wanted. I could travel, I could study, I could have my own dreams, my own plans. My mother and my father supported that. 

But to go into this neighborhood and practice medicine there, and see little girls brought to me because I needed to test their virginity, or because they were subject to sexual harassment or attempted rape, and that I needed to do something… That was very difficult for me…. Practicing in this poor neighborhood put me face to face with [parts of] my society that I knew nothing about.

Dr. Ihlas says a case of mistaken identity in 2013 was her catalyst to leaving Syria. 

One day, I went to one of the government buildings to register my daughter’s birth, who was only two months old. A person stopped me and told me: “Come with me.” He took me to a room and let me wait there. Then four or five men came to interrogate me. They [accused me of being a suicide bomber]. They had received intelligence saying that a woman wearing sport shoes and sports clothes would come to this area and blow herself up. 

I told them: “I'm a doctor. These are the papers of my daughter. I just gave birth to her.” I was wearing sporting clothes because I lived very far away from the governmental building. There was no transportation. I had no fuel to use my car. So, I walked. This is why I was wearing sporting shoes. 

I remember the four or five of them just standing in front of me in a dark room, in a basement somewhere. And they said: “We have arrested you because of the shoes you are wearing.” 

I was very, very lucky that one of them was convinced that I was not lying. And he let me go. 

I was sure that next time I was arrested for any reason, and I didn’t find a person who believed me, I would just disappear. So, two weeks later, I took my husband, my children, and we left. I left everything: the house, the summer house, the money, the furniture, everything. I just took my clothes…my children, and my husband – and that's it.

I threw away those shoes, by the way. I really liked those shoes…. I didn’t want to disappear just because someone thinks that I'm a terrorist.

Dr. Ihlas’ problems intensified when her family arrived in Turkey after leaving Aleppo. They did not cross the border officially because they were “terrified” and snuck out, she recalls. Her extended family stayed in Syria, but pledged to support her, her children, and her husband when they fled.  

Turkey was supposed to be just a station in our journey. We were supposed to go to Germany. My family members were supposed to support me in that. 

But the moment we arrived in Turkey, the persons who were supposed to help us said: “You know what? We changed our minds. We cannot support you anymore.” I needed €5,000 to travel to Germany. I had only €500.

We spent those €500 in the first two days renting a house of 18 square meters. My house in Aleppo was 250 square meters. The six of us were packed in those 18 meters in inhuman conditions. We had no heater…. So, for four months, I don't know how we managed by ourselves. I was lucky to find a job as a translator.

One of the first significant challenges in Dr. Ihlas’ experience as a refugee was the breakup of her marriage

Because of the pressure and so on, me and my husband got divorced. We arrived in February. We were separated in September or October.

Because of the pressure and so on, me and my husband got divorced. We arrived in February. We were separated in September or October. I don't remember because the pressure was very, very high. He didn't expect that my family would just dump me, that no one wanted to talk to us anymore because we didn’t stay. They kept asking us: “Why did you leave?”

For three years, I was a single mother with four children. It was a very good experience for me [although] I lived some very bad days. As a single mother and a refugee, I’ve been subject to all the kinds of harassment you can think of. So have my children. 

But it was very good that I went through this because it helped me understand life. As I told you, I always thought that my life would be brilliant. I'm brilliant. I will have the best children, future, and everything. I have the money; I have the knowledge.

But then life taught me very nicely that I should be better. And I should, I should fight harder. Because in the same way life gives to you, it takes from you. Now, life needs to know what kind of person you are. And I'm still, still trying to reveal what kind of person I am. We are not safely on shore yet.

Luckily for me, I did reunite with my husband after three years. It's lucky also for the children, because living as a single mother as a refugee was terrible. But I survived it. My children also survived it. And we will keep doing it until we figure out what will happen with our country. 

Eventually, Dr. Ihlas was able to put her skills into practice in a new environment as a sexual and reproductive health and rights advisor for CARE-Turkey. She says it can be difficult work – both in a rapidly shifting landscape of displacement, as well as in the gender politics surrounding health care. 

Even if it is very difficult to provide health services here, I see hope in what we are doing – specifically in providing sexual and reproductive health care services to our beneficiaries. 

My job with CARE is the source of joy and inspiration and hope for the future. Even if it is very difficult to provide health services here, I see hope in what we are doing – specifically in providing sexual and reproductive health care services to our beneficiaries. I believe that change has begun in the Syrian society. I saw it in myself. I saw it in many midwives working inside Syria, and also in [those receiving services and their families]. 

The war revealed a clear picture of male dominance in Syrian society. As Syrian females, no matter where we are with our own eyes, we also see that the amplification of the male role in society is not that real. Men used to tell us: “We take the decisions. We do this. We are able to do everything. We handle calamities. We handle situations. You just sit at home and take care of your children.”

But when a real calamity or a real disaster happened, we saw men perplexed, crying, running away, and not able to manage the situation. The one who actually managed it was the woman. Maybe I'm a bit biased when I say this. But, I say it because I lived it. I saw it in myself, in my sister’s life, in my relatives’ lives, in our beneficiaries, and female health care providers. They are the ones who are up to the challenge.