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JERUSALEM – Walaa didn't expect the birth of her fourth child to cause much anxiety. But when contractions began, the whole family was beside themselves.
No ambulances were seen on the streets of the Gaza Strip town of Rafah, she said. The city is now so overcrowded with displaced families that there is hardly anything left for the 27-year-old to eat.
When her uncle Wissam, a doctor, reached the tent where she had been living in the cold for weeks, he said, he could see that they were running out of time. “I’m having the baby now,” she kept telling him. It was dark and she was scared.
His cell phone flashlight was all they could see.
The humanitarian catastrophe caused by Israel's three-month military operation against Hamas in Gaza counts some 52,000 pregnant women among its worst victims. As airstrikes push 1.9 million people into an ever-smaller corner of the besieged enclave, disease is spreading, famine is looming and anemia is so high that the risk of postpartum hemorrhage has risen sharply and breastfeeding is often impossible. CARE International estimates that 40 percent of pregnancies are high-risk.
Prenatal care is virtually non-existent – the rest of Gaza's hospital network is in ruins, operating at 250 percent capacity and being consumed by treating scores of victims of Israeli bombings. Far more women give birth outside medical facilities – in displacement camps, even on the streets – than inside them.
Damage to facilities and communications failures – the Strip was without cell service for a week this month – have left Gaza's health ministry unable to collect data reliable data on infant or maternal mortality during the conflict. But doctors and aid groups say the number of miscarriages and stillbirths has risen sharply.
“What we know about pregnancy-related complications is that it is difficult to prevent them in any situation, but the way we save the life of a woman and a newborn is to treat the complication quickly,” said Rondi Anderson, midwifery specialist for the Project HOPE Auxiliary Group.
“So it's the women who have access to emergency care who survive,” she said. “Women who don’t do this die.”
The only place Wissam could find to deliver his frightened niece's baby was a patch of cold earth between the tents. Helpers hung up sheets to give the woman some privacy. No one had been able to contact Walaa's husband, and her mother was so afraid that she sometimes had to look away. They cut the boy's umbilical cord with an unsterilized scalpel and filled tin cans with hot water to keep him warm. He weighed 7 pounds and Walaa named him Ramzy.
The family spoke on condition that only their first names be used because they feared for their safety if Israeli troops entered the city.
They fled their home in northern Gaza so suddenly that no one thought to get clothes for the baby. This week, Ramzy was wrapped in a onesie that another child in the camp had outgrown. He wailed as Walaa, still in pain from tearing during childbirth, gingerly sat up.
The 16-year blockade imposed by Israel and Egypt after Hamas seized control of Gaza had already made pregnancy and childbirth more difficult for expectant mothers. According to Medical Aid for Palestine, before the current conflict, hospitals often lacked adequate equipment and training for neonatal staff, and more than half of pregnant women suffered from anemia.
Hamas militants poured out of the enclave on October 7 to kill around 1,200 people and take another 240 hostage in Israel. Israel responded with bombings and ground warfare to destroy Hamas, killing nearly 25,000 Palestinians to date, most of them civilians.
The South African legal team that accused Israel at the International Court of Justice this month of committing genocide during the conflict argued that obstructing life-saving treatment since October 7 amounted to preventing births.
An Israeli lawyer called allegations that the country is hindering the delivery of food, water, fuel and other supplies essential to Gaza as “tendentious and biased” and said it was working “around the clock” to increase the volume of aid there get into the enclave.
Hanaa al-Shawa, 23, gave birth to her first child, Ayla, during the coronavirus pandemic and the little girl, she said, brought a “glimmer of hope” to her family. Shawa and her husband Mustafa, 25, were overjoyed when they learned in July that another child was on the way. The war began in October and the future they had dreamed of fell apart. “I felt overwhelming joy,” Shawa recalled. “I didn’t know that this joy would turn into great suffering.”
Nearly 20,000 babies were born in Gaza in the first 105 days of the war, UNICEF reported on Friday. Delays in the delivery of life-saving supplies, the UN Children's Fund said, led some hospitals to perform caesarean sections without anesthesia. Spokeswoman Tess Ingram said she met a nurse at the Emirati maternity hospital in Gaza who helped perform postmortem C-sections on six dead women.
“Seeing newborns suffer while some mothers bleed to death should keep us all awake at night,” Ingram told reporters Friday. “In the time it took to present this to you, another baby was probably born, but in what?”
“Becoming a mother should be a time of celebration,” she said. “But in Gaza another child is being sent to hell.”
For the five pregnant women interviewed by Washington Post reporters, fear that mother or child might not survive permeated their waking thoughts — and also appeared in nightmares.
Shawa and Mustafa left their home on Yarmouk Street in Gaza City in the second week of October. Israeli forces had ordered 1.1 million people in the northern Gaza Strip to move south for their own safety.
“I was afraid I would have a miscarriage because of the power of the rockets,” she said.
Many pregnant women made the 20-mile journey from north to south on foot, their legs swollen and joints heavy as they carried their luggage, three women who made the trip told The Post.
When Ayla was born, her family had a room full of toys ready for her. The room where Shawa's second child, a girl, will spend her first weeks at a friend's house in the Tel al-Sultan area was contaminated with asbestos, she said.
“We only carried Ayla here in the clothes she was wearing and we don’t even have anything warm for her,” Shawa said. “If I am unable to care for her, what will I do for my next child?”
Increasing food shortages and malnutrition can cause potentially life-threatening complications during childbirth, leading to low birth weight, wasting, failure to thrive and developmental delay.
Shawa said she had only eaten canned food and had no access to fruits or vegetables since leaving home three months ago. Doctors said her iron levels were low and her blood pressure was high. Mustafa searches every day, but has not found a suitable medication to control it.
Saja Al-Shaer, 19, felt like she was too young to become a mother. Her weight had dropped to less than 50 kilograms, she was suffering from anemia and her husband had also been unable to get her medication. “He knocked on pharmacy doors for three days,” she said. “I don’t know if I’m going to see this kid or not.”
In late December, doctors at Al-Aqsa Hospital, 11 miles north, treated a pregnant woman whose high blood pressure caused eclampsia and brain hemorrhage, according to Deborah Harrington, a British obstetrician who volunteered as a doctor on the Aid to Palestinians team.
The baby was delivered by cesarean section, Harrington said. When the doctor left two weeks later, the mother was still on life support.
“These women present in a much more extreme state,” Harrington said. “They just don’t get treatment for high blood pressure. You will not be screened for diabetes. If they are diabetic, they will not receive treatment for their diabetes.
“They know that actual access to medical care, as is often the case for women in conflict, is very difficult and fraught with danger. There is often no light at night, making getting around very difficult. You can't call an ambulance because there is no signal. The women I saw were very scared.”
From the corner of the damp room where Walaa cared for Ramzy on Friday, she worried about where they would find clean water or baby food. Her family had searched everywhere for diapers but came up empty. In Tel al-Sultan, Shawa focused on rumors that the Israeli army would again order them to evacuate. The walking, the carrying, the feeling that nothing around her was hygienic – all of it frightened her.
But she had made a decision that neither lack nor military orders could change. She would name her daughter after her sister-in-law, who had been killed weeks earlier in an Israeli airstrike while trying to find shelter for her own children.
The girl, she said, would be called Heba. In Arabic it means blessing from God.
Mahfouz reported from Cairo and Harb from London. Loay Ayyoub in Rafah contributed to this report.
Israel-Gaza war
According to National Security Council spokesman John Kirby, US naval forces launched three more attacks against Houthi forces in Yemen on Friday morning, using anti-ship missiles. Internet and mobile communications have been gradually restored in the Gaza Strip, ending a weeks-long outage that left most of the territory's 2.1 million people cut off amid a war and humanitarian crisis.
Pakistan launched retaliatory strikes against militants in Iran on Thursday, the Foreign Ministry said, as tensions in the Middle East appeared to be escalating.
October 7 attack: Hamas spent more than a year planning its attack on Israel. A Washington Post video analysis shows how Hamas exploited vulnerabilities created by Israel's reliance on technology at the Iron Wall, the security barrier on the Gaza Strip border, to carry out the deadliest attack in Israel's history. Stock traders made millions of dollars in anticipation of the Hamas attack, according to a study.
Israeli-Palestinian conflict: The Hamas-controlled Gaza Strip has a complicated history. Learn what was behind the Israel-Gaza War and read about the history of the Israeli-Palestinian conflict.