Extract from ABC News
The sound of women and newborn babies screaming in pain is constant inside Gaza's hospitals.
WARNING: This story contains distressing content.
Amid the raging war, women are reportedly giving birth on rubble-filled floors, undergoing emergency caesareans with no anaesthetic or pain relief, and even dying after childbirth due to a lack of medical supplies.
Despite few functioning hospitals still in operation in Gaza, it's estimated 180 babies are being born into the war zone every day.
The United Nations Children's Fund (UNICEF) has warned women, children and newborns are disproportionately bearing the brunt of the war.
'Pregnant women living amid rubble'
In early November, the UN agency reported there were some 50,000 pregnant women in Gaza, and 15 per cent of them were likely to experience birth- or pregnancy-related complications.
Yafa Abu Akar lives in Khan Younis in Gaza, sheltering with thousands of others in abandoned buildings.
She told the ABC she personally knew women who had bled to death giving birth in Nasser hospital, the only hospital in the area, which is barely functioning due to constant bombardment by Israeli forces.
She told the ABC doctors performed an emergency caesarean on one 25-year-old woman she knew because of complications.
Due to heavy bleeding, the woman had to have her womb removed after birth — a situation that could have been avoided if proper health care was available, she said.
"She's young, it was her first child, and she won't be able to have kids again. Some other women didn't survive at all from bleeding out," Yafa said.
"Pregnant women are living amid the rubble and women are facing dire circumstances in every aspect of their life here."
In October, the World Health Organization (WHO) warned patients were being operated on without aesthetic due to low medical supplies.
Since then, the situation has gotten worse, with the WHO decrying the "decimation" of Gaza's health system while commending health professionals there for continuing to work under extreme circumstances.
Yafa said a woman she knew in Khan Younis, who was nine months pregnant, had endured a "horrible situation".
She said doctors "were forced to cut open her stomach to get the baby out" with no pain relief.
During that time the woman lost her husband, mother and father to the war.
"Her child, a girl, lived, thankfully, but after what? [The woman] lost her whole family in the war," Yafa said.
UNICEF expressed concerns that women who were unable to make it to hospitals in Gaza would have to give birth in unsafe conditions.
They predicted maternal deaths would increase given the lack of access to adequate care.
According to Yafa, those concerns are being been borne out.
In other parts of Gaza, she said she had heard of pregnant women who didn’t make it to hospitals in time being forced to give birth inside whatever remained of their homes.
Some had died and left children behind, she said.
Giving birth in hospital safely 'impossible'
Oxfam partner Juzoor is one of a handful of organisations operating in northern Gaza.
It supports 500 pregnant women among up to 35,000 others crammed into 13 shelters that are without clean water or proper sanitation.
In some situations, up to 600 people are sharing one toilet.
Giving birth in a hospital safely had become "impossible", Juzoor's executive director Umaiyeh Khammash said.
He said in each of the 13 shelters Juzoor runs, at least one newborn had died due to preventable causes over the past month.
Mr Khammash said this number was "very high" and was being reflected in a significant increase to the infant mortality rate in Gaza.
According to Juzoor's network of doctors, premature births have also increased by between 25 per cent and 30 per cent, as stressed and traumatised pregnant women faced a myriad of challenges, such as walking long distances in search of safety, running away from bombs and being crowded into unsafe shelters.
Meanwhile, the entire 2.3 million population of the Gaza Strip is facing crisis levels of hunger and the risk of famine is increasing each day, according to the UN's Integrated Food Security Phase Classification (IPC).
At least one in four households — or 577,000 people — in Gaza are already facing catastrophic hunger, suffering from an extreme lack of food, starvation and exhaustion of coping capacities, the IPC found.
The United Nations Population Fund (UNFPA) estimated 45,000 pregnant and 68,000 breastfeeding women in Gaza did not have enough food to eat, putting them at a higher risk of developing pre-eclampsia, haemorrhages, or even dying.
UNFPA said malnourished women also faced the prospect of having babies with a low birth weight.
'It's extremely challenging to be pregnant in Gaza'
Médecins Sans Frontières (MSF) deputy director Natalie Thurtle just got back to Australia from Jerusalem, where she was responsible for coordinating MSF's medical emergency response in Gaza over the last two years.
"It's extremely challenging to be pregnant in Gaza right now," Dr Thurtle said.
She said women were being discharged from hospitals as soon as they could walk after birth because there was nowhere for them to receive postnatal care.
"Those babies are being born … but are they being born safely? Almost certainly not," Dr Thurtle said.
Doctors say everyday issues that could otherwise be managed with proper healthcare are being missed due to the lack of continuity in care.
They range from women who have gestational diabetes to newborns needing to gain more weight.
"For people who need to have a managed birth and need to have medical help around their birth, that's not consistently and sustainably available," Dr Thurtle said.
She said "urgent care is essentially not happening" for women in labour, given the number of people needing treatment from war injuries.
"All of those services are falling over. Every day the space that [MSF] can work in is getting smaller. Every day the security is getting worse," Dr Thurtle said
MSF staff have been working in Gaza's hospitals and clinics throughout the conflict, but they say hospitals and ambulances are under siege.
The organisation said patients and medical staff were being injured and killed, and access to the wounded and sick was impeded by insecurity, lack of fuel, and mobile phone connectivity.
MSF said hundreds of healthcare workers have already been killed, including three of its own staff, while nearly 60 ambulances had been hit and damaged.
"We cannot work in this level of conflict with not enough aid making it in, with healthcare, and infrastructure being directly targeted," Dr Thurtle said.
"We desperately need this to stop. Until it stops we just almost cannot work … it's almost impossible."
In particular, Dr Thurtle said the severity of children's injuries in Gaza was "extremely confronting" and still haunted her.
"Hearing about the children who are dead on arrival, children who've got rotting limb injuries from very delayed presentation to care, from being bombed.
"These children without any surviving family, which is very common now who need anaesthetic and then when they wake up from surgery [screaming].
"Pick a story, because there's a lot of tragedy."
Women take the pill to stop menstruating
In addition to the daily struggles of finding drinkable water, food, and proper shelter, practising feminine hygiene, including the use and disposal of sanitary napkins, is a daily struggle for women.
Yafa said many women were taking birth control to stop menstruating because of the lack of access to sanitary napkins.
"Most women use whatever material is available to them during their periods," she said.
"They have no other choice. Their health is weak because of the lack of food, water, and nutrition.
"The pill has affected many women's mental health, their wellbeing in general."
Dr Thurtle said it was "really quite grim for all of the females who menstruate in Gaza".
"If you think about changing, [and] having menstruation where you have no access to sanitary products, where you only have one toilet between 20 people, you're living in an environment where you can't keep yourself clean, you can't shower," she said.
"That may not be the most dramatic manifestations of the war but it's still extremely dehumanising."
Dr Thurtle and Yafa said women were bearing the brunt of the war.
Yafa said they were often forced to fend for their families, with men injured, sick or killed during the war.
"[Women] have to find wood for [cooking] food, and shelter for their children, searching in between blown-up homes, and wherever they can," Yafa said.
"They're forced to look between the rubble just for things just to survive."
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