by Zeina Jamaluddine, Reham Jaffal, Sanaa Al Najjar, Mahmoud Al Kahlout, Tamam Abu Zeid, Hala Mughari, Ghada Al Jadba, Rami Habash, Bassam A Abu Hamad, Akihiro Seita & Oona Maeve Renee Campbell
Bulletin of World Health Organization 2026;104:386–395
DOI: http://dx.doi.org/10.2471/BLT.25.293829 Open access
Abstract available in 5 additional languages
Abstract
Objective To assess the impact of conflict on maternal and neonatal mortality and health-care utilization among pregnant refugee women in the Gaza Strip.
Methods The study involved data on pregnancy outcomes for 17 713 refugee women in the Gaza Strip who were pregnant on 8 October 2023 and received antenatal care from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). We obtained data from UNRWA’s electronic health records, an UNRWA phone survey and the Palestinian Ministry of Health’s lists of deaths for October 2023 to June 2024.
Findings Overall, 168 maternal deaths were identified, yielding a pregnancy-related mortality ratio of 948 per 100,000 pregnancies compared to a maternal mortality ratio of 30 per 100,000 live births before the conflict. The pattern of age-specific, pregnancy-related deaths suggested that most were trauma-related. The stillbirth rate among women with known pregnancy outcomes was 10.3 per 1000 births compared with 6.0 per 1000 before the conflict, and the neonatal mortality rate was 9.4 per 1000 live births compared with 6.6 per 1000. The preterm birth rate was also higher, at 13.6% versus 9.7% before the conflict. Although most deliveries (97.3%) remained facility-based, there was a shift from government to non-governmental organization facilities.
Conclusion The conflict in the Gaza Strip was associated with substantial increases in maternal and neonatal mortality and preterm births. Utilization of health services remained high, but delivery locations shifted to lower-level facilities and hospital stays shortened, raising concerns about the quality of care.
Introduction
In the Gaza Strip, the maternal mortality ratio between 2018 and 2022 averaged 30 per 100 000 live births, which was substantially lower than the global average of 223 per 100 000 in 2020. According to the Palestinian Ministry of Health, the neonatal mortality rate was 6.6 per 1000 live births in 2022, which again compared favourably to the 17.3 per 1000 reported globally in 2024; the stillbirth rate was 6.0 per 1000 births, which was also lower than the global rate of 13.9 per 1000. In addition, high proportions of antenatal care (100%), skilled birth attendance (100%) and facility-based delivery (99.4%) confirmed that the health-care system was robust. As of 2020, the total fertility rate was also high, at 3.9 births per woman. In 2017, around 48% of women aged 15 to 49 years in the Gaza Strip were original inhabitants (i.e. non-refugees), whereas the remaining 52% were descendants of individuals displaced from their homes in 1948 (i.e. refugees). The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides free primary health-care services to Palestinian refugees through 22 health centres in the Gaza Strip, including antenatal care and partial support for childbirth. In 2010, UNRWA developed an electronic health record (e-health) system that generates comprehensive maternal and neonatal health data. The system includes the registration of pregnancies during antenatal care. The conflict in the Gaza Strip which started on 7 October 2023 severely disrupted health-care services, including UNRWA’s. Health infrastructure was extensively damaged by the Israeli armed forces and many health personnel were killed. By January 2025, emergency obstetric and newborn care were available only in seven of 18 partially functioning hospitals, in four of 11 field hospitals and in one community health centre. Access to life-saving emergency obstetric and newborn care was drastically limited and there were reports of caesarean sections being conducted without anaesthesia or electricity. The entire population of the Gaza Strip had an insecure food supply and limited access to water. In 2021, over half of pregnant women in the Gaza Strip were anaemic, which increased the risk of preterm birth and intrauterine fetal growth restriction. Both these conditions had already been made more likely by malnutrition. In addition, infectious disease outbreaks were occurring, which in turn also affected underlying health and nutritional status. The aims of our study were to derive indicators of maternal and neonatal mortality and of health service use in the Gaza Strip after the outbreak of the conflict and to compare these indicator values to equivalents before the conflict started. We analysed data from UNRWA’s e-health records, which were supplemented by a phone survey conducted by UNRWA and by data on deaths recorded by the Palestinian Ministry of Health.
Fort a detailed picture of how bad the situation was for almost 18,000 pregnant women, see the following flowchart on page 388, contrasting 2023 and 2024, before and after the disruption of health services and the genocide that took place:
Fig. 1. Flowchart, study of maternal and neonatal outcomes in pregnant women, Gaza Strip, 2023–2024 (https://pmc.ncbi.nlm.nih.gov/articles/PMC13223687/pdf/BLT.25.293829.pdf)
The text of the article unfortunately does not allow the flowchart to be copied and shared. It clearly documents, however, the serious deterioration in maternal and neonatal health among refugees in the Gaza Strip following the onset of the conflict on 7 October 2023. Moreover, roughly a quarter of women in the study cohort were unreachable by phone. As these women and their babies probably had the worst outcomes and the worst experiences of using health care, the findings are likely to represent a best-case scenario and to have under-estimated the worst adverse events.
The authors conclude: “Our study is an attempt to systematically document maternal and perinatal mortality during an active conflict. The study provides evidence that the conflict in the Gaza Strip severely affected maternal health outcomes and patterns of access to health care. These findings demand an immediate and sustained international response focused on: (i) supporting a ceasefire to end traumatic deaths due to bombing; (ii) protecting health-care facilities and personnel; (iii) ensuring unimpeded access to emergency obstetric and newborn care; (iv) addressing the underlying determinants of maternal and neonatal ill-health, including problems with food security, water and sanitation; and (v) supporting families in which a mother who died had given birth to a live infant. In the longer term, we would also argue for: investing in rebuilding an equitable health system for the Gaza Strip and conducting a comprehensive needs assessment.”