Summary

R.M., 31, was two months pregnant when Israel began its military campaign in the Gaza Strip following the Hamas-led attack on southern Israel on October 7, 2023. Her family struggled to find food. “I was literally starving,” she told Human Rights Watch. “We were all in famine in northern Gaza. We had no gas to cook with. We had one meal a day to conserve firewood. … Flour was very, very expensive. No food. No chicken. No meat. I lost a lot of weight.”

She also had health problems: “I already had low blood pressure and would faint a lot. I got lightheaded and dizzy. I had no energy, couldn’t stand on my own.” The family went to Rafah and visited a doctor in his private clinic for a checkup, but he could provide no examination beyond an ultrasound or give her any vitamins or calcium. R.M. suffered multiple urinary tract infections but did not go to a clinic because she had heard they had no medicine.

The fighting complicated R.M.’s difficult delivery on May 5. “I went into labor at 2 a.m.,” she said. “I was in so much pain, and we were trying to find a way to reach the hospital.” She said that at the hospital, she was not given any medication or an epidural. After she delivered, she had to change the pads she was wearing herself. “I went to the bathroom alone. It was terrible, very difficult,” she said. “No one took care of me. Not a single nurse came to check up on me, monitor me, or ask how I was.”

R.M. left the hospital at 6 a.m., just over four hours after giving birth to a girl. “I was exhausted and couldn’t walk,” she said. “I was holding my newborn, and with my husband and three other children, we had to look for someone willing to drive us [to my parents’ home]. It took hours until a car stopped for us. My husband told the driver we would give him anything [if he drove us].”

A few days later, R.M.’s family was forced to evacuate Rafah for Khan Younis, where they have been living in a tent under harsh conditions. Her newborn daughter quickly developed diarrhea, which can be life-threatening.

R.M.’s difficult pregnancy and delivery reflect the extraordinary challenges faced by many Palestinian women and girls in the Gaza Strip since the beginning of the hostilities. Across Gaza, women have had limited access to safe places to give birth, even when they face a high-risk delivery.

Read a text description of this video

Shaima Suhail Abu Jazar, Medical evacuee from Gaza:

It was 2 a.m.  The bombing started.  

 

The bombing was very, very heavy. 

 

At 2:30 a.m., Hudaifa (son) and Jenan (daughter) came together from their room.  

 

They said: “Mom, we can’t sleep.”  

 

“We're very scared.”

Narration:

When the bombing started, Shaima was at home in southern  Gaza with her husband, and three of their four children. 

 

Their youngest child was staying the night at her grandparent’s’ house. 

 

Shaima was nine months pregnant with their fifth child.

Shaima Suhail Abu Jazar:

Jenan was in the middle, so I told her, sleep on this side and leave (twin) brother next to your (older) brother.”   

It was barely a minute after I switched them when the bombing happened. 

 

Jenan was martyred, may God have mercy on her.   

 

Her two legs were cut off, and she had a big piece of shrapnel in her head. 

 

Mohammed, my son, was also martyred.

Narration:

Israel’s military offensive in Gaza following the Hamas-led attacks on October 7, 2023, has severely harmed the healthcare system there.

Israeli authorities have also unlawfully restricted humanitarian aid and medical supplies to people in Gaza, amounting to the war crime of collective punishment.

As the occupying power in Gaza, Israel’s actions violate the right to the highest attainable standard of health for pregnant women and girls and their children across Gaza. 
 

Israeli authorities should facilitate the urgent restoration of Gaza’s healthcare system so that all people, including pregnant women and babies, have access to quality medical care.

Shaima Suhail Abu Jazar:

This leg was next to my husband.  

 

When the bombing happened, it was set on fire,  flesh was melting before my eyes fat was dripping, as if it was a barbecue. 

 

It was a very scary sight.   

 

When the bed flew and I fell to the ground, water containers flew, and fell next to me, and I started scooping water from it to cool my leg down. 

 

Half of my foot has melted away. 

 

If I hadn’t poured water on it all of it would have melted. 

 

My gut feeling was that Jenan, Mohammed and my husband had been martyred. 

 

The paramedics took a long time to find me because I was under the rubble and among the ruins. 

 

As soon as they found me, I told them, “I'm pregnant, save the baby.”

Narration:

The first hospital Shaima was taken to in Gaza, among the few still functioning at limited capacity, was full, so she had to be moved to another one. 

 

Shaima’s legs were broken in seven places, and a metal fragment had pierced her abdomen. 

She felt the baby move and begged doctors to perform a caesarean section, but they said she was not stable enough for the surgery.

Two days later, the baby stopped moving.  

 

Three days after the bombing, Shaima had a stillbirth.

Shaima Suhail Abu Jazar:

As soon as I reached the maternity hospital, I told the doctor, 

 

“I am not able to have a single contraction".

 

He said to me, "I want you to lift your leg, and God will help you."  

 

After one contraction the fetus came out dead.  

 

I held him for four minutes, and they took him from me and shrouded him.  

 

I told them to name him after his father, Abdullah.

Narration:

Doctors in Gaza told Shaima that her legs needed amputating.

She was eventually evacuated along with her two surviving children to Egypt to get a second opinion, and from there to Qatar. 

 

Shaima has had over forty operations.

Shaima Suhail Abu Jazar:

I was bed-ridden for five months.  

 

In Gaza, if anyone as much as just walked by my bed I would scream from pain.  

 

But thank God, now I can move my legs.

Narration:

While Shaima’s physical wounds are beginning to heal, her emotional scars remain raw.  

 

But she puts on a brave face for the sake of her two surviving children, seven-year-old Maryam and ten-year-old Hudaifa, who are with her in Doha.

Shaima Suhail Abu Jazar:

I wait for the children to sleep so I can cry. I don't want to cry in front of my children. I flip through photos of my husband and children, and I cry.

Narration:

Hudaifa’s grief over the loss of his older brother Mohammed, and his twin sister Jenan, runs so deep that sometimes he acts out imaginary role-plays.

Shaima Suhail Abu Jazar:

At night Hudaifa puts a doll next to him here and here. 

 

One named Jenan and one named Mohammed.  

 

He talks to them at night. He says, “Forgive me, Jenan, I used to hit you.” 

 

And then he turns to the other doll and says, “forgive me Mohammed. “Yes, brother, you were my support.

You defended me at school.

If anyone wanted to do anything to me, you would come to my defense.

Who will defend me from now on?”

Text on screen

Following 48 surgeries and extensive physiotherapy, Shaima began to walk again. 

 

The international community should press Israel to lift its unlawful blockade on Gaza, cease all unlawful attacks on healthcare facilities, and stop obstructing the delivery of lifesaving assistance.  

Since the hostilities started in Gaza, Israel has imposed an unlawful blockade of the territory, imposed several restrictions on humanitarian aid, and attacked medical facilities and personnel. In mid-January, Israeli authorities and Hamas agreed to a multi-phase ceasefire that includes the entry into Gaza of humanitarian aid, the return of Israeli hostages held in Gaza, and the release of Palestinian prisoners.

As of January 2025, emergency obstetric and newborn care is only available at seven out of 18 partially functioning hospitals across Gaza, four out of 11 field hospitals, and one community health center, compared to a total of 20 hospitals and other smaller healthcare facilities that functioned before October 7, 2023. The World Health Organization shared with Human Rights Watch an assessment of needs that identified 19 types of medical equipment and 24 types of medication for prenatal, delivery and postnatal care that were in short supply and urgently needed as of December 2024.

The quality of health care offered by the few remaining medical facilities and service providers is severely diminished. Women like R.M. are rushed out of sometimes packed hospitals within a few hours of childbirth to make room for other patients, many of them war casualties. All medical facilities operating in Gaza face unsanitary and overcrowded conditions and serious shortages of essential healthcare goods including medicine and vaccines. Medical workers, hungry, overworked and at times under military attack, try to triage and attend to the many victims of attacks, while also addressing increasing cases of water-borne and other communicable diseases.

Israeli authorities’ military offensive has led to the forced displacement of over 90 percent of the population of Gaza—1.9 million Palestinians—often multiple times, amounting to war crimes and crimes against humanity. As a result, it is usually impossible to inform women of where they can safely access health services, and hard for women to reach the few services that are available. The constant displacement of the population as so-called “safe areas” change and because of frequent Israeli military evacuation orders has made it nearly impossible for community networks to establish themselves and for healthcare workers and volunteers to track individual pregnancies or families’ needs. Consequently, women and newborns rarely have access to follow-up and postnatal health care.

There is little information available on the survival rate of newborns or the number of women experiencing severe morbidities or dying during pregnancy, while giving birth, or postpartum. However, in July, maternal health experts reported that the rate of miscarriage in Gaza had increased by up to 300 percent since October 7, 2023.

From March to April 2024, UN Women surveyed 305 women across Gaza’s five governorates, or regions, including 37 pregnant women.[1] Of these pregnant women, 68 percent had experienced medical complications. Of the 68 percent, 92 percent reported urinary tract infections (UTIs), 76 percent anemia, 44 percent hypertensive disorders, and 28 percent preterm labor. Other concerns included bleeding (20 percent), hemorrhage (16 percent), and stillbirth (12 percent). Before October 2023, the rates of such medical complications were considerably lower.[2]

Israel’s blockade of Gaza in violation of international humanitarian law and the use of starvation as a method of warfare have caused acute food insecurity for most people living in Gaza. As of October 17, 2024, nearly 133,000 people faced catastrophic or famine-levels of food insecurity, and 664,000 faced emergency levels of shortages, according to the Integrated Food Security Phase Classification (IPC).[3] The IPC also reported an estimated 60,000 cases of acute malnutrition among children between the ages of 6 and 59 months, and 16,500 cases of pregnant and breastfeeding women who needed treatment for acute malnutrition. The United Nations Population Fund (UNFPA) reported that at the end of December 2024, over 48,000 pregnant women were experiencing emergency and catastrophic food insecurity. In such circumstances, pregnant women in Gaza cannot maintain the good nutrition and healthy diet critical for their own health during pregnancy and postpartum, and for fetal development.

Limited access to safe water is a major problem for pregnant women in Gaza. Many have reported dehydration and some have said they are only able to access highly saline water. Others spoke of being unable to wash themselves throughout their pregnancy. The lack of access to adequate nutrition, water, and sanitation has serious health consequences, particularly for pregnant women and girls and their children. Many health conditions may be caused or significantly worsened by such deprivation, including anemia, eclampsia, hemorrhage and sepsis, all of which can be fatal without proper medical treatment, which has been very hard to access in some parts of Gaza.

Pregnant women in Gaza also described how, like many others in Gaza, their mental health has been under immense strain since the start of the hostilities.

Pregnant women in Gaza have very few options to seek better conditions outside Gaza. According to the World Health Organization, of the over 12,000 people in need of medical evacuations, the requests of only 5,383 have been approved and carried out. Since Israel’s closure of the Rafah crossing between Gaza and Egypt between May 2024 and January 2025, only 436 patients could medically evacuate from Gaza.

Armed conflict between Israel and Hamas and Palestinian armed groups in Gaza is governed by international humanitarian law. As the occupying power in Gaza, Israel is obligated under the Fourth Geneva Convention to ensure that the civilian population gets food, water, and medical supplies to the fullest extent of the means available to it. Israel needs to maintain at a reasonable level the material conditions under which the population of the occupied territory lives. In addition, the Fourth Geneva Convention provides that expectant mothers shall be the object of particular protection and respect. Israel is obligated to allow the free passage of all consignments of medical and hospital stores and of essential foodstuffs, clothing, and medical supplies intended for children under 15, expectant mothers, and maternity cases.

Human Rights Watch has found that Israeli forces in Gaza imposed a near total ban on water, food, and electricity and used starvation as a method of war, which are war crimes, and committed crimes against humanity by repeated forced transfers of the population. They have also unlawfully obstructed the delivery of humanitarian aid and attacked medical facilities and healthcare personnel. These policies have had a direct effect on women and girls in pregnancy, childbirth, and postpartum.

Since October 2023, Israeli authorities have deliberately obstructed Palestinians’ access to water. Between October 2023 and July 2024, the more than 2 million Palestinians in Gaza had access to an average of between 2 and 9 liters of water per day, far below the minimum emergency humanitarian standards of 15 liters per capita per day recommended by the World Health Organization. Israeli authorities have intentionally deprived Palestinian civilians in the Gaza Strip of adequate access to water since October 2023 and are responsible for the crime against humanity of extermination and acts of genocide, and may be responsible for the crime of genocide, which requires acts of genocide to be committed with genocidal intent.

The Israeli military has obstructed humanitarian aid entering Gaza, first by banning it outright and later by imposing onerous restrictions. According to OCHA, since May, humanitarian aid entering Gaza has dropped dramatically. The situation worsened significantly in October 2024, with approximately 43 percent of all humanitarian movements coordinated with Israeli authorities to reach those in need across the Gaza Strip being denied, marking the highest rate of denial of access recorded since the hostilities began in October 2023.

Israel is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which remains in effect during armed conflict where Israel has effective control. Israeli authorities have violated the rights to the highest attainable standard of health and other rights of pregnant women and girls. This includes the right to dignified, respectful health care throughout pregnancy, childbirth, and postpartum and newborn care, as well as adequate access to food, water, and adequate housing.

Israel should ensure that its conduct complies with its obligations under international humanitarian and human rights law, as well as the legally binding orders from the International Court of Justice in South Africa’s case alleging that Israel is violating the Genocide Convention of 1948. The court has issued provisional measures that include requiring Israel to prevent genocide against Palestinians in Gaza, enable the provision of basic services and humanitarian assistance, and prevent and punish incitement to commit genocide.

Israel should immediately cease all unlawful attacks, including attacks targeting healthcare facilities, workers, and transportation; civilian infrastructure essential for the rights to food, water, and housing; and aid workers. It should stop obstructing the delivery and dispersal of humanitarian assistance and end the arbitrary detention of healthcare workers in Gaza. When issuing evacuation orders, Israel should take into account the needs of pregnant women, as well as civilians with disabilities and those who are sick or injured, and ensure that evacuation areas can provide for their needs.

Israel is also obligated to use all the resources at its disposal to ensure that everyone in Gaza, including pregnant women and girls and their children, are able to enjoy their human right to health. This includes ensuring the full restoration of Gaza’s healthcare system so that all patients, including pregnant women and babies, have access to quality medical care.

Under human rights law, all civilians have the right to leave their country, including for medical reasons, as well as the right to return. Israel should lift the closure of the Gaza Strip and permit the free movement of civilians to and from the Gaza Strip, subject to individual screenings and physical inspections for security purposes only as necessary, with transparent requirements.

Methodology

Human Rights Watch has been denied access to the Gaza Strip despite repeated requests to the Israeli and Egyptian authorities. For this report, Human Rights Watch interviewed 17 people between June and December 2024, including eight Palestinian women who had been pregnant while living in Gaza during the hostilities. The interviews were conducted either remotely or in person in Doha, Qatar. Two of the women lost their fetuses due to explosive weapons attacks that injured them. Human Rights Watch also spoke to six medical workers from Gaza who had firsthand knowledge of the situation faced by pregnant women after October 7, 2023. Human Rights Watch also interviewed international medical staff working at three international humanitarian organizations and agencies operating teams in Gaza about the provision of care to pregnant women.

Researchers informed all interviewees about the purpose and voluntary nature of the interviews, and the ways in which Human Rights Watch would use the information. We obtained consent from all interviewees, who understood they would receive no compensation for their participation.

This report draws on additional research conducted by Human Rights Watch on the Israeli military’s offensive in Gaza since October 7, 2023, including into the use of explosive weapons in attacks, access to essential elements for survival including food and water, forced displacement, blockages in incoming lifesaving humanitarian aid, unlawful attacks on known locations of aid workers, and the arbitrary detention and torture of Palestinian medical workers.[4]

While women and girls in Gaza face many hardships, including those related to their sexual and reproductive health and rights, such as contraception and safe abortion care, this report is limited to maternal and newborn health.

I. Impact of Israeli Military Operations on Pregnant Women and Maternal Health

Israel’s blockade of Gaza and its military’s conduct of hostilities have resulted in deaths and injuries to pregnant women and girls and deprived them of consistent access to health care. Israeli forces have imposed forcible displacement that has been especially harmful to pregnant women. They have also attacked and degraded communications infrastructure, limiting women’s access to functioning healthcare facilities, medication, and other goods essential for their health during and after pregnancy. Israel’s blockade has also largely prevented pregnant women who need access to medical care abroad from being able to leave Gaza safely.

Deaths and Injuries

As of January 9, Israeli military operations had resulted in the deaths of more than 46,000 Palestinians and injuries to over 100,000 others, according to Gaza’s Ministry of Health. This includes at least 14,555 children, of whom 793 were under one year of age.[5]

Because of the lack of adequate data and the destruction of Gaza’s health monitoring capacity, Human Rights Watch was unable to assess either the total number of incidents in which pregnant women and girls were injured or died, or the number of instances in which such attacks caused the death of a pregnant woman’s fetus. However, Human Rights Watch has reported on Israeli attacks in the course of the hostilities in which pregnant women were killed or injured.

In December 2023, Israeli forces stormed into a home in Gaza City and opened fire on a room where a family was sheltering, killing seven people including a pregnant woman.[6] Gaza resident Hassan Abu Abeid described an October 19, 2023, attack that killed 30 members of his family, including his wife and two of their children. His wife was six-months pregnant—the couple was expecting a boy whom they planned to call Adam.[7]

For this report, researchers also spoke with two women who lost their pregnancies due to injuries sustained during explosive weapons attacks.

Forced Displacement

Israeli military operations have led to the forced displacement of over 90 percent of the population of Gaza—1.9 million Palestinians—often multiple times.[8] Most have been displaced at least once, with many displaced up to 10 times since October 7.[9]

The constant displacement of people has disconnected pregnant women from adequate health care. It makes it extremely challenging for them to receive relevant health information, to follow providers’ recommendations, and to access vital prenatal services like checkups and screening appointments. As of January 8, 2025, UNICEF reported the deaths of eight infants and newborns from hypothermia since December 26, 2024, due to continued lack of basic shelter combined with winter temperatures.[10]

A senior aid official said that because of the constant displacements, healthcare workers, humanitarian workers and volunteers found it impossible to follow up with women and their babies on their health outcomes and to find out, for example, if a woman or her baby died during or right after childbirth.[11]

Lack of Communication Mechanisms

The Israeli government’s degradation of Gaza’s communication infrastructure has also severely hampered humanitarian efforts to coordinate assistance and disseminate up-to-date information. Human Rights Watch documented phone and internet disruption in Gaza as a result of the Israeli military’s numerous airstrikes.[12] The Israeli authorities’ actions have included damage to core communications infrastructure, cuts to electricity, fuel blockades, and apparently deliberate shutdowns through technical measures.

In October 2024, OCHA reported that the lack of communications has “brought the already challenging delivery of humanitarian assistance to a complete halt and is depriving people of life-saving information.”[13] Disruptions to electricity and telecommunication services have also made hotlines to support women giving birth at home unreachable, compounding the risks for women, according to the UN-mandated Independent International Commission of Inquiry on the Occupied Palestinian Territory, including East Jerusalem and Israel (Commission of Inquiry).[14] A United Nations Population Fund (UNFPA) representative said that because UN and service provider teams in Gaza did not have access to printers, they could not print flyers to give women to tell them where services were available—information that was critical because providers had to constantly relocate operations. These factors also reduced the ability of healthcare providers to engage with networks of midwives and aid delivery partners.[15]

The Israeli Blockade and its Restrictions

The Israeli government has occupied the Gaza Strip since June 1967.[16] For the past 17 years, it has imposed a closure on Gaza, and has, with exceptions on narrow grounds, banned Palestinians from leaving.[17] Israeli authorities have also imposed sweeping restrictions on the entry of various goods, including food as well as other essentials vital for the realization of economic rights.[18]

Despite the impacts of the blockade on Gaza, the territory had a relatively robust maternal healthcare system prior to October 2023.[19] Residents had regular access to maternal health care in centers and hospitals run by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) or the Gaza Ministry of Health, or in private facilities.

Immediately after the Hamas-led October 7 attacks in southern Israel, Israeli authorities cut off essential public services, including water and electricity, to Gaza’s population and blocked the entry of all but a trickle of fuel and humanitarian aid, acts that amount to war crimes.[20]

Medical workers said that as a result of these restrictions, there have been both chronic and acute shortages of essential medicine, including insulin, antibiotics, analgesics and anesthetics.[21] The blockade has also severely limited access to other healthcare resources essential for the right to health, including vaccines and medical devices and equipment.

Israel has used starvation as a weapon of war in Gaza, which is a war crime.[22] Human Rights Watch found that Israeli forces were deliberately blocking the delivery of water, food and fuel, while willfully impeding humanitarian assistance, apparently razing agricultural areas deliberately, and depriving the civilian population of goods and services indispensable for their survival.

Since January 2024, the International Court of Justice (ICJ) has three times ordered Israel to enable the provision of basic services and humanitarian assistance into Gaza. But Human Rights Watch research found that Israel has contravened the court’s legally binding orders by continuing to obstruct the entry of lifesaving aid and services into Gaza.[23]

Limited Medical Evacuations

Prior to and during the hostilities, Israel and Egypt have prevented most people in Gaza from leaving, even those requiring lifesaving medical care not available in Gaza. According to the World Health Organization (WHO), of the over 12,000 people in need of medical evacuations, only 5,383 requests have been approved and carried out.[24] About 25,000 sick and wounded patients are in need of medical treatment they can only receive abroad, including 12,500 cancer patients, according to Gaza’s Health Ministry.[25] Since Israel’s closure of the Rafah crossing between Gaza and Egypt between May 2024 and January 2025, only 436 patients were able to medically evacuate Gaza, according to WHO.[26]

Gaza’s medical system has a strict triage rubric in place, with the Health Ministry only requesting medical evacuations for those in the most critical need of urgent care that Gaza’s medical facilities cannot currently provide, based on lists submitted on a regular basis by all hospital directors. The Health Ministry shares its consolidated list with Egyptian health authorities, which then shares the list with the Coordinator of Government Activities in the Territories (COGAT), a unit in Israel’s Ministry of Defense. COGAT decides which individuals on the list to give security clearance to, and thus permission to evacuate to Egypt.[27] Dr. Khalid Abu Samra, an internal medicine specialist in Gaza, said hospitals only request evacuation permission for pregnant women if they have preeclampsia or a history of immune disease or acute cancer.[28] Dr. Abu Samra’s sister, a nasopharynx cancer survivor, was the only woman Human Rights Watch was able to identify who was medically evacuated from Gaza during pregnancy because of her medical history.

II. Near Collapse of Gaza’s Maternal Healthcare System

Since October 7, 2023, Gaza’s healthcare system, including its maternal healthcare system, has nearly collapsed and its ability to provide care for some 50,000 pregnant women has been drastically diminished.[29]

According to the World Health Organization, between October 7, 2023, and December 4, 2024, there were 591 attacks on healthcare facilities in Gaza that damaged 33 hospitals and killed 854 people and injured 1,262 others. Those harmed included healthcare workers, patients, and displaced Palestinians sheltering in and around hospitals.[30] In December 2023, Israel carried out an attack that destroyed Gaza’s largest fertility clinic and with it, over 3,000 embryos.[31]

The Gaza Ministry of Health has reported that more than 1,054 health workers and medical professionals have been killed during the hostilities, including at least six pediatricians and five obstetrician-gynecologists, and that Israeli forces have detained more than 330 healthcare workers.[32] Human Rights Watch has documented the torture and degrading treatment of detained Palestinian healthcare workers, including the deaths of two doctors in detention.[33] In addition, at least 369 aid workers, including some working with medical organizations, have been killed.[34]

As of January 2025, emergency obstetric and newborn care is only available at seven out of 18 partially functioning hospitals across Gaza, four out of 11 field hospitals, and one community health center, compared to a total of 20 hospitals and other smaller healthcare facilities that functioned before October 7, 2023.[35]

Al-Sahaba Hospital in Gaza City was the only functioning dedicated maternity hospital in northern Gaza in late September 2024, with 20 maternity beds and 20 surgical beds, according to its medical and administrative director, Dr. Naem Ayoub.[36] He said between his hospital and Kamal Adwan, the only general hospital in the north with a neonatal intensive care unit and maternity and pediatrics department, they had a total of 16 working incubators left. According to UNICEF, there were 105 incubators in northern Gaza before the war.[37]

More generally with regard to conditions in healthcare facilities, the number of people injured in the military attacks needing emergency or critical care remains high, which means those healthcare facilities that still operate have very limited capacity to treat non-urgent cases.[38]

The hostilities have also forced some healthcare workers to stop working to care for their own families, including a midwife and a pediatrician Human Rights Watch interviewed.

From March to April 2024, UN Women surveyed 305 women across Gaza’s five governorates, or regions, including 37 pregnant women.[39] Among the pregnant women surveyed, 68 percent had experienced medical complications. Of these 68 percent, 92 percent reported urinary tract infections (UTIs), 76 percent anemia, 44 percent hypertensive disorders, and 28 percent preterm labor. Other concerns included bleeding (20 percent), hemorrhage (16 percent), and stillbirth (12 percent). Before the hostilities, the rates of such medical complications were considerably lower.[40]

Quality of Care Degraded

Access to adequate health care is impeded by the chokehold on bringing goods into Gaza since October 7, which has led to critical shortages of fuel, which is used to generate the electricity required to operate medical facilities and equipment; of all medicine and supplements; and of all medical supplies, including materials for critical tests and replacement parts for medical and power-generating equipment.[41] These issues are compounded by overcrowding of medical centers (see below). The World Health Organization shared with Human Rights Watch an assessment of needs that identified 19 types of medical equipment and 24 types of medication needed for prenatal, delivery and postnatal care that were in short supply and urgently needed as of December 2024.[42]

Dr. Naela Masri at Nasser Hospital in Khan Younis said in late September:

To be honest, all capabilities to provide maternity services are weak. Most equipment, like ultrasound machines, and tools to equip surgical rooms are lacking. Women give birth without any privacy. There are no blankets to cover them. … Sanitary and disinfecting materials don’t exist, like chlorine and hand soap, which haven’t been available for long periods.

Dr. Adnan Radi, an obstetrician-gynecologist in northern Gaza, said in late September that his hospital was short of all medications, including epidurals, most anesthetic drugs, surfactant to help the breathing of preterm babies who have underdeveloped lungs, and birth control, which is a vital component of reproductive health. The hospital was also short of replacement parts for medical equipment.[43]

In a letter to the administration of US President Joe Biden in October 2024, US healthcare workers who had volunteered in Gaza said they had witnessed women undergoing vaginal deliveries and even Cesarean sections without anesthesia and that these women had been given nothing but Tylenol afterwards, because no other pain medications were available.[44]

Heba al-Nashef, a 37-year-old midwife who was part of a UN delegation to Gaza in June, told Marie Claire magazine that al-`Awda, a hospital in northern Gaza, “didn’t have the right sutures for women sometimes, or enough CPAP [continuous positive airway pressure] machines for respiratory support, or safe umbilical cord clamps for the babies. Some midwives were using the lace of a mask, soaked in alcohol, to wrap around the umbilical cord to stop it from bleeding.”[45] This practice is safe only in sanitized conditions. Al-Nashef said that once a baby was born, there were no sheets to absorb the amniotic fluid or dry the baby, so medical staff used diapers instead.

Dr. Nawal al-Solih, a 58-year-old pediatrician, said that after an attack in November 2023 killed one of her children and injured two others, she accompanied her son to Shuhada al-Aqsa Hospital for treatment.[46] While there, she provided medical assistance to the hospital and said she saw how it had very little functioning medical equipment and no way to sterilize instruments and wounds.

The United Nations Population Fund (UNFPA) representative said she had observed poor sterilization systems, including sterilizing medical instruments with alcohol and fire.[47]

Ayah Abu Khatir, a 29-year-old midwife, said that early in the war, her medical team at an UNRWA camp in Nuseirat ran out of iron and folic acid supplements, which are recommended during pregnancy. Khatir also described the lack of medication to treat urinary tract infections, which a number of pregnant women interviewed had experienced and which can lead to serious health complications for pregnant people if inadequately treated.[48] Frequent power cuts delayed ultrasounds, and blood and urine tests were not carried out, since there was no electricity to power the testing equipment. Abu Khatir said all the team could do was check women’s weight, heart rate, and blood pressure.

Preexisting medical conditions or conditions that can be brought on or worsened by pregnancy, including hypertension, diabetes, epilepsy, anemia, and cardiovascular diseases, can lead to serious health complications for pregnant and recently pregnant women. Some acute health conditions that occur during or after pregnancy can be fatal if not adequately treated, including infections and sepsis, hemorrhaging, eclampsia, and preterm labor.[49] Anemia also heightens the risk of preterm birth and anemia in infants, which can lead to developmental disabilities.

Dr. Radi said his private hospital, al-`Awda, was unable to offer any prenatal care services, which are essential for preventing and treating these conditions by identifying high-risk pregnancies, making early diagnoses, and providing appropriate care.

Overcrowded Conditions

Israa Mazen Diab al-Ghul, 30, who was pregnant when the war broke out, described how her pregnant sister-in-law, Hiyam al-Mashi, had to take a horse and cart to get to the hospital when she went into labor in February.[50] An hour after giving birth, hospital staff asked her to leave, so other patients could be accommodated. She and her newborn returned to a room with 25 other people in a house in Nuseirat where her family was sheltering.[51]

The overcrowded conditions in healthcare facilities that continue to function in Gaza contribute significantly to the worsening quality of medical care for all patients, including pregnant women and newborns.[52] In February, Samira Hosny Qeshta, a midwife working at al-Helal al-Emirati maternity hospital in Rafah, an area that has since been depopulated following Israeli military evacuation orders, said there were only five beds for deliveries: “It was exhausting; we handled 78 cases in one night.”[53] As the last hospital providing maternity care in Khan Younis, al-Nasser hospital and its medical team were handling between 25 and 30 deliveries a day, MSF said in July 2024.[54]

Patients are rushed out of the hospital soon after treatment to make space for others. Dr. Ayoub of al-Sahaba Maternity Hospital said that because of overcrowding, the hospital was discharging women within four hours of delivering their babies, except for those who underwent Cesarean sections. They were scheduled for surgery in the morning and had to leave that same evening.[55]

Samira Hosny Qeshta, a midwife who worked at al-Helal al-Emirati maternity hospital in Rafah, described the impacts of overcrowding to UNFPA: “While one woman is giving birth, we bring another case, and there’s no bed. We say, ‘Get up, sit on a chair,’ and she just gave birth. There’s no hygiene, there’s no privacy. ... It’s miserable.”[56]

Heba al-Nashef, a 37-year-old midwife, told Marie Claire in June that in al-`Awda Hospital, it was “35 degrees [Celsius], with a hot sewage smell, and no clean running water.”[57] She said that women were only brought to the delivery room downstairs “when a woman pushes and you see the head.”

Discharging mothers and their newborns so quickly after childbirth means they cannot be monitored for potentially life-threatening health issues. “The first 24 hours postpartum are the riskiest for complications, and with people living in dire conditions, it’s important to keep the patient in the hospital as long as possible,” said Rita Botelho da Costa, MSF’s midwife activity manager.[58] 

Dr. Radi said at least one mother had died soon after delivery because of sepsis and a lack of antibiotics in late September.[59]

Not all women are able to make it to a hospital in time for their delivery because of the hostilities.[60] Dr. Nawal al-Solih, a pediatrician, said while was providing medical support at Shuhada al-Aqsa Hospital in early November 2023, some women came to the hospital after they had already given birth because they had faced significant challenges in coming to the hospital, leading to delivery risks.[61]

Project HOPE, an international global health and humanitarian aid non-governmental organization, shared the testimony of Shaima, a midwife working at al-Sahaba Hospital in northern Gaza from November 2024:

The reality for pregnant women in northern Gaza is grim. We are seeing both women and newborn babies die from preventable causes. Almost every day I see a woman with postpartum hemorrhage, the leading cause of death for pregnant women. Most of these women gave birth at home or in a tent and were rushed to the hospital due to bleeding. This week, a woman came into the hospital with a baby stuck in her birth canal. The baby’s head was out for half an hour. The baby later died. Pregnant women are frequently malnourished here and have no access to prenatal vitamins or proper nutrition. We will continue to see more people die unless there is better healthcare access.[62]

Access to Medical Care

All the pregnant women and healthcare workers Human Rights Watch interviewed said the scale of fighting meant that civilians in areas under attack have been unable to safely travel within the Gaza Strip, including to healthcare providers. The unsafe routes women have had to navigate amid the fighting and without safe transportation have often been delaying access to health care and put them at higher risk of complications, MSF said.[63]

In addition, Israeli authorities have imposed severe movement restrictions, preventing many civilians from moving between different areas of Gaza in vehicles and forcing them to instead travel by foot, often over long distances. They have had to navigate restrictions on where they can go and wait for long periods at Israeli checkpoints.[64] Randa Zakout, 24, was seven-months pregnant when Israeli forces told civilians to evacuate south. She had to walk for six hours to reach Rafah.[65]

Ridana Zukhra was at Shifa Hospital in early November when Israeli forces surrounded it and told people inside to leave. She was six months pregnant at the time. Zukhra, her brother, who had a wound on his hand from a large strike on a building, and her 3- and 5- year-old children left, carrying white flags. She said a tank then fired at them, severely wounding the left leg of her 5-year-old daughter, Ghazal. Zukhra, her brother, her children, her cousin, and a doctor who was behind them, ran into a nearby building where they stayed for five days for fear of being targeted again. During those five days, Ghazal’s wound started to smell and developed gangrene. The doctor treated Ghazal without any medication or bandages, amputating her left leg without anesthetic and sealing the wound with a heated knife.[66]

The family had almost no food or water. Zukhra’s cousin was also pregnant at the time. Eventually they fled south, waiting for four hours at an Israeli-manned checkpoint before getting to Nasser hospital, where doctors said Ghazal had blood poisoning and that her leg needed to be amputated even higher. Ghazal eventually was medically evacuated with Zukhra, but Zukhra’s husband, brother and son—all of whom had recently contracted hepatitis A—were denied permission to evacuate with them.[67]

III. Impact of Poor Nutrition, Water and Sanitation

Adequate prenatal health care for pregnant women includes access to a diet that provides the right nutrients to support pregnancy and health, clean water for drinking and sanitation, and medical services, including checkups and prenatal tests. Because of the hostilities in Gaza, pregnant women have been unable to access these essential elements of prenatal health care.

In its report based on interviews with 305 women from Gaza from March to April 2024, UN Women found that 99 percent of survey respondents who had recently been pregnant or had pregnant women in their households experienced challenges related to nutrition and 78 percent said they had no access to tests to assess their nutritional and health status.[68] All the pregnant women that Human Rights Watch interviewed said the lack of prenatal care had had specific effects on them.

Nutrition

Maintaining good nutrition and a healthy diet during pregnancy is critical for the health of the pregnant person and fetus.[69] But this has been nearly impossible in Gaza since the beginning of the hostilities.

Five months into the hostilities, in February, the Global Nutrition Cluster, a UN-led mechanism to support humanitarian emergencies including in Gaza, reported a steep rise in malnutrition among children and pregnant and breastfeeding women in the Gaza Strip, as food and safe water became increasingly scarce, and diseases proliferated.[70]

As of October 17, 2024, nearly 133,000 people faced catastrophic or famine-levels of food insecurity and 664,000 faced emergency levels of shortages, according to the Integrated Food Security Phase Classification (IPC).[71]

There were about 50,000 pregnant women in Gaza as of December 2024, the WHO said, with at least 180 women giving birth daily.[72] The IPC reported an estimated 16,500 cases of pregnant and breastfeeding women who would need treatment for acute malnutrition in October 2024.[73] The United Nations Population Fund (UNFPA) reported that at the end of December 2024, over 48,000 pregnant women were experiencing emergency and catastrophic food insecurity.[74]

A pregnant person’s nutritional health significantly influences the development of the fetus as well as the long-term growth and wellness of the child.[75]

The lack of access to adequate nutrition in Gaza is having a severe effect on young children. The Global Nutrition Cluster reported in February 2024 that 1 in 6 children under the age of 2, or 16 percent, who were screened at shelters and health centers in northern Gaza in January 2024 were found to be acutely malnourished.[76] Of these, nearly 3 percent suffered from severe wasting, the most life-threatening form of malnutrition. The IPC reported an estimated 60,000 cases of acute malnutrition among children between the ages of 6 and 59 months as of October 2024.[77] Prior to October 7, just 0.8 percent of children under 5 in Gaza were acutely malnourished. Malnutrition can have serious physical and cognitive impacts among children, which can lead to a disability.[78]

Water and Sanitation

Israa Mazen Diab al-Ghul, 30, said accessing clean water was her biggest challenge when she was pregnant between October 2023 and April 2024.[79] She said her husband spent hours each day trying to find clean water, but sometimes failed. She said that for 48 hours in early 2024, the family had to drink sea water: “I vomited, and I was worried it would kill the baby. I was praying that the war would end before I gave birth. Then I started begging that God would take the baby, so I wouldn’t need to give birth during this war.”

Insufficient and inadequate water and sanitation can have particularly dangerous effects for vulnerable groups, including pregnant women and young children, including from the spread of water-borne diseases, viruses, and infections from unsanitary facilities like toilets.[80] The pregnant women interviewed all spoke about their challenges in getting access to water both for drinking and for sanitation purposes.[81]

Dr. Naela Masri in Khan Younis said many pregnant patients of hers had contracted hepatitis A due to poor sanitation.[82] She said they showed symptoms including severe vomiting, which she suspected in some cases had led to miscarriage.

Samira Hosny Qeshta, the midwife at al-Helal al-Emirati maternity hospital in Rafah, told UNFPA: “Most of the women come with infections. The bathrooms are shared, and infections are easily transmitted. They can’t even change their underwear, and all of this contributes to infections.”[83] One pregnant woman told a Canadian media outlet that she had caught infections from unsanitary toilets in the area to which she had fled.[84]

Like hundreds of thousands of civilians in Gaza, Shaima Suhail Abu Jazar fled her house to seek shelter in a safer location after October 7.[85] She spent 120 days while pregnant sheltering in a school in Tal al-Sultan refugee camp. During that time, she said she lived in a classroom with at least 50 other people, in a school that was housing thousands, with only one bathroom for everyone in the school. During those 120 days, she could never wash herself. She said that every four or five days, a vehicle with a tank of non-potable water would come to the school and people would buy any water left in the tank. Shaima said this was often the only water they had to drink, leading many, including her, to suffer from diarrhea and vomiting.

Ridana Zukhra, 25, said on most days during the war in Gaza while she was pregnant, she did not have access to water to wash herself or even her hands.[86] She spent about a month at Shifa Hospital as a caregiver to her injured mother who was a patient there. She said the limited water at the hospital was restricted for medical purposes and for the medical workers and patients to use. She said she often spent two or more hours a day walking to try to find water. 
 

IV. Healthcare Issues

Since the beginning of hostilities on October 7, 2023, pregnant women and girls and those who have recently given birth in Gaza have been faced with a range of healthcare issues that are challenging to address even when not under wartime conditions. These include miscarriage, preterm birth and low birthweight, poor postnatal care and follow-up, inadequate nutrition for babies, and heightened psychological impacts.

Miscarriage

Miscarriages are not uncommon under normal conditions, but the risk of miscarriage is significantly higher among those exposed to physical trauma and psychological stress.[87] Israeli military attacks have caused grave physical injuries to pregnant women and extreme stress, as pregnant women and girls have lived under constant fear of attack while grappling with displacement, material deprivation, and the trauma of having lost loved ones.[88] In July, maternal health experts reported that the rate of miscarriage in Gaza had increased by up to 300 percent since October 7, 2023.[89]

Human Rights Watch spoke to two women who sustained injuries during Israeli attacks and subsequently experienced miscarriage and stillbirth, which they attributed to their injuries. Shahad al-Qutaiti, 23, was seven-months pregnant when the war began. She was at home when a munition hit her apartment building in Gaza City without warning on October 11.[90] She said:

Suddenly something strong hit me. Everything became black and I felt like I was flying. I was catapulted. Then I stopped moving, and I saw the sky and the street and rubble everywhere. I was lying in the middle of the street. I screamed [to my husband Ali], ‘Where are you?’ He heard me and shouted, ‘Shahad!’

And I saw that I had no left leg, and I saw that my husband had lost both legs and his left arm. We looked at each other. He was alive at that moment. He looked at his arm, and asked, ‘Where is my hand, where is my hand?’ I didn’t answer, I didn’t think I could speak. We looked at each other, then the ambulance came, and they took us to Shifa Hospital, and that was our last farewell. I never saw him again. Those were the hardest days of my life.

Shahad miscarried immediately after the attack. She also suffered multiple fractures and burns to her right leg, and her left arm had a deep wound exposing her bone. Her arm had to be operated on several times, but the hospital treating her was unable to provide her with any painkillers because of blockade-induced medicine shortages.

Shaima Suhail Abu Jazar, 33, was nine months pregnant when her apartment building in Rafah was hit by an explosive munition without warning at about 2 a.m. on February 12, 2024.[91] The attack killed her husband, 16-year-old son, and 11-year-old daughter. Abu Jazar was severely injured in the attack, sustaining significant burns and fractures to her legs, feet, and belly. Her father brought her to the nearby Najar Hospital, but there was no room to treat her. After she had been kept waiting in a tent outside for three hours, her father took her to the European Hospital, where she waited for another three hours before going into surgery. Abu Jazar said she felt the fetus moving around for two days after the attack, but on the morning of the third day, felt no more movement. “I had been begging the doctors to do a Cesarean to get my baby out,” she said. “But because of my state and loss of blood, they said no. Then the baby stopped moving. They made me give birth naturally.” She had a stillbirth.

Dr. Ayoub of al-Sahaba Maternity Hospital said his hospital had not been collecting statistics, but his teams were seeing miscarriages and stillbirths at a far greater rate than they had seen before the war.[92] In late September, he said the body of a woman who was nine months pregnant had been brought in, in order for doctors to try to save the fetus, but that by the time they had carried out the Cesarean section, the fetus had died because the mother had been dead for over two hours at that point.

Preterm Birth and Low Birthweight

Human Rights Watch could find no statistics on the number of preterm and stillbirths during and prior to the hostilities and none of the women interviewed experienced a preterm birth, but all healthcare providers interviewed said that, anecdotally, cases seem to have increased.[93] Preterm births and low birthweight are common indicators of severe malnourishment and can be compounded by stress, fear, and exhaustion, all factors linked to the hostilities.[94]

Maternal stress is a well-established risk factor for preterm birth.[95] Additionally, stress can negatively impact the immune system, increasing susceptibility to infections that can also lead to preterm birth.[96] Stress, anxiety, and depression experienced by women during pregnancy can also harm the fetus and increase the risk of cognitive, behavioral, and emotional impacts on children.[97]

Randa Zakout, 24, was seven months pregnant when Israeli forces ordered civilians in northern Gaza to evacuate to the South. She said she had to walk for six hours to reach Rafah.[98] She gave birth to her daughter, Warda, shortly after arriving in Doha, Qatar, where she and her son had been evacuated because of injuries sustained after a strike on their home.[99] Warda’s birthweight was lower than average, and Zakout said she and Warda both had iron and calcium deficiencies.

Dr. Naela Masri, head of Nursing and Primary Care at Nasser Hospital in Khan Younis, said in September that many of the babies her hospital was delivering were underweight: “Many babies are born extremely thin, with low weight. … [We have so many of these] ‘small for date’ [babies] nowadays. We used to sometimes see babies born weighing over four kilograms [over average birth weight]. Now, after the war started, we don’t see these cases at all.”

Dr. Ayoub of al-Sahaba Maternity Hospital said that while the hospital had no capacity to collect current statistics, he estimated that of every 10 babies they were delivering in late September, four were preterm, a rate far higher than before the hostilities.

Some babies born preterm need to spend time in a neonatal intensive care unit and in incubators to survive and develop.

Dr. Ahmed Al Shaer at al-Helal al-Emirati maternity hospital in Rafah said they had so few incubators and so many preterm babies that, “we have to put four or five babies in one incubator. ... Most of them don’t survive.”[100] Medical experts warned that the risk of infections spreading when babies share incubators is high, especially when, as is the case in Gaza, hospitals cannot adequately clean and sterilize the incubators.[101] Dr. Ayoub of al-Sahaba hospital said they had no choice but to continue putting two and sometimes more babies in the same incubator: “We know we are taking the risk of killing them both, but at the same time, if we don’t put them in the incubator together, they will both die.”[102]

In September, Dr. Adnan Radi said al-`Awda Hospital had carried out 200 deliveries over the previous month, 50 of them Cesarean sections. He said the hospital did not have a single bed or incubator available for neonatal care despite the high number of preterm births, nor any beds available in the intensive care unit for mothers requiring critical care. Dr. Radi said this was leading to deaths:

Most of the babies we are delivering with severe low birthweight are dying of perinatal asphyxia in front of us and we can’t do anything. We try to intubate the babies. Sometimes it has helped, but the picture is very gloomy. … We have not been collecting statistics but in the last month I can remember more than six babies with low birthweight dying in front of me.

Dr. Khalid Abu Samra, an internal medicine specialist, was at Shifa Hospital both when Israeli forces surrounded and occupied it starting on November 17, 2023, and on November 19, when UNRWA staff evacuated 31 preterm babies. He said five babies had died in the previous days because of electricity cuts and fuel and milk shortages.[103]

Preterm babies are at higher risk of health complications and developmental disabilities, especially when not supported by adequate health care and early intervention programs, which are currently virtually impossible to administer or access in Gaza.[104]

Poor Postnatal Care and Follow-up

When women and newborns are discharged immediately after delivery from overcrowded hospitals, or stuck at home due to insecurity and fear, or forcibly displaced, they cannot access adequate post-birth health care, including follow-up checks and counseling on how to care for newborns. In April, MSF said that although it was providing postnatal care at three primary healthcare centers, it was nearly impossible to support mothers and follow up on their and their babies’ health in the weeks following birth due to the prevailing situation.[105]

The sub-optimal prenatal care—or no care at all—pregnant women in Gaza have been getting heightens the risk of complications after giving birth. “Some women are delivering prematurely, often with postpartum complications exacerbated by their living conditions,” said Mohamad Shihada, MSF’s nursing team supervisor working in the organization’s neonatal intensive care unit of al-Nasser hospital, in July.[106] In September, MSF said that across the three medical facilities its staff were operating in, 25 percent of women who had Cesarean sections developed infections afterwards.

An international medical worker said that because women were being discharged from hospital so soon after delivery to make way for other patients, they were not receiving the usual post-partum support and counseling from healthcare providers. Such support includes advice to mothers on how to care for themselves and their infants; how to maintain hygiene and promote healing in challenging circumstances; how to bond with their infants, important for infant development; and how to support breastfeeding.[107]

Inadequate Nutrition for Babies

Feeding infants in Gaza during the hostilities has been a particular challenge. Pregnant women, new mothers, and medical staff said breastfeeding has been complicated by stress, birth trauma, lack of adequate nutrition and water for new mothers, and lack of privacy in conditions of displacement.[108]

Some families have faced difficulties obtaining formula in cases where mothers are not breastfeeding or when infants need supplemental nutrition. Some said they did not have adequate access to drinking water for formula. Abdulhafith al-Khalidi said before he evacuated from Gaza in March, babies in his family and of friends regularly suffered from fevers and digestive issues. He said the water they had access to was so contaminated, that when added to formula powder, it simply did not mix.[109] In a letter to the Biden administration in July, American healthcare workers who had volunteered in Gaza stated they “watched malnourished new mothers feed their underweight newborns infant formula made with poisonous water.”[110]

MSF reported in April that “formula milk is not easily available, nor is drinking water to mix it with or to properly clean the bottles.”[111] An international medical worker said the lack of clean water in Gaza as well as the low availability of formula meant that feeding babies formula was “extremely precarious.”[112]

These conditions have been making children sick. Cases of diarrhea in children under 5 years of age rose from 48,000 to 71,000 in just one week starting December 17, 2023, equivalent to 3,200 new cases of diarrhea per day, according to UNICEF.[113] The 3,200 new daily cases recorded in December represented a 2,000 percent increase from the average rate of cases prior to October 7.[114]

In July, MSF staff reported seeing children with dehydration, hepatitis A, and skin infections.[115]

Several people told Human Rights Watch they knew of children, including their own, contracting hepatitis A and suffering diarrhea and vomiting.

Asma Taha, a pediatric nurse practitioner, described seeing babies die “every day” in the letter to the Biden administration. She said, “they had been born healthy,” but their “mothers were so malnourished that they could not breastfeed, and we lacked formula or clean water to feed them, so they starved.”[116]

Psychological Impacts

The physical damage of Israel’s relentless military offensive has caused deep psychological scars for many Palestinians in Gaza who have lost their homes and their sense of security and community.

All the pregnant women interviewed spoke about the extreme mental strain of living in constant fear for their lives and their pregnancy while in Gaza, leading to stress, fatigue and anxiety. They described the hardship of instability and stress, being forced to repeatedly relocate to seek safety and shelter following Israeli military evacuation orders. They all said they felt like they had to manage everything alone.

“I was constantly worried,” R.M. said. “I kept thinking about giving birth during the war, day and night. … I swear they were the worst days of my life, pregnancy during the war. … I’m tired of saying I’m tired.”

Ridana Zukhra described giving birth after being evacuated to Egypt:

I had a difficult birth. My body couldn’t handle it with the displacement and exhaustion. I was suffering. When I gave birth, it was a very difficult delivery. For hours I was in labor, for hours I couldn’t push from exhaustion. … I gave birth, and my body needed rest, but I couldn’t rest. I carried my breastfeeding baby and my injured daughter [with her amputated leg], one on either side. I told myself I had to handle all this on my own. ... My daughter now walks with an artificial limb.

Of the 305 women surveyed in March and April 2024 by UN Women, 75 percent said they regularly felt depressed, 65 percent frequently felt nervous and had nightmares, and 62 percent often were unable to sleep.[117]

Israel’s attacks, the unlawful blockade, and its restrictions on humanitarian aid have also meant that mental health services were very limited.[118] Mental health and psychosocial support services, which were already difficult to access prior to the hostilities, have grown even scarcer since the start of the Israeli military’s attacks on Gaza.[119]

V. Pregnancy During Armed Conflict

The association between armed conflict and specific indicators of maternal and child health, such as rates of preterm birth, miscarriage, or maternal health outcomes, is poorly documented. However, available research suggests that armed conflicts have particularly adverse effects on maternal and newborn health.

A global study on maternal and child health, analyzing 20 years of data from the Uppsala Conflict Data Program and the World Bank, concluded that “armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare.”[120] An article in the medical journal The Lancet concluded that, “[w]omen of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings” and “armed conflict increases indirect mortality among children and women.”[121] A 2020 study covering three decades in 53 countries found that exposure to conflict is associated with miscarriage and stillbirth.[122]

Exposure to armed conflict appears to have negative impacts on birth outcomes.[123] Inadequate maternal nutrition and access to health care, often consequences of conflict, can also increase the likelihood of adverse maternal health and birth outcomes.[124]

The WHO says conflict is a factor that increases the risk of mental disorders during pregnancy and in the first year after delivery.[125] It also says poor prenatal mental health can have a range of adverse impacts on both the mother and infant and the family more broadly from increased rates of serious maternal health illnesses to adverse birth outcomes such as low birthweight, to greater risk of poor physical health and emotional and behavioral problems for the child.[126] 
 

VI. Relevant International Humanitarian and Human Rights Law

Armed conflict between Israel and Hamas and other Palestinian armed groups in Gaza is governed by international humanitarian law, also known as the laws of war. This includes the Geneva Conventions of 1949, notably Common Article 3 and the law of occupation, as well as customary international humanitarian law. International human rights law applies to Israel where it has effective control in the Occupied Palestinian Territory.

International Humanitarian Law

As the occupying power in Gaza, Israel has the obligation under article 55 of the Fourth Geneva Convention to ensure that the civilian population gets food, water, and medical supplies “[t]o the fullest extent of the means available to it.”[127] The ICRC Commentary of 1958 on the Fourth Geneva Convention states that “the Occupying Power is responsible for the provision of supplies for the population and places that Power under a definite obligation to maintain at a reasonable level the material conditions under which the population of the occupied territory lives.” [128] The Commentary clarifies that it “essential” that the occupying power takes the necessary measures to procure the necessary food and medical supplies needed by the population of the occupied territory.[129]

The Fourth Geneva Convention and customary international humanitarian law provide special protections for women and children. The Fourth Geneva Convention states that expectant mothers “shall be the object of particular protection and respect.”[130] The ICRC Commentary sets out that the specific needs of pregnant women and mothers of young children be treated with particular care with regard to the provision of food, clothing, medical assistance, evacuation, and transportation. Expectant mothers are entitled to adequate medical care and priority in treatment based on medical grounds.[131]

Warring parties must allow and facilitate the rapid and unimpeded passage of humanitarian relief for civilians in need. They may not arbitrarily refuse to allow delivery of humanitarian assistance. They are specifically obligated to allow the free passage of all consignments of medical and hospital stores and of essential foodstuffs, clothing and medical supplies intended for children under 15, expectant mothers, and maternity cases.[132]

Human Rights Watch has found that Israel’s effective blockade of Gaza constitutes collective punishment of the civilian population and the use of starvation as a method of warfare.[133] These are grave breaches of the Fourth Geneva Convention and customary international humanitarian law, and amount to war crimes.

Human Rights Watch has also found that since October 2023, Israeli authorities have deprived Palestinians in Gaza of access to the amount of water needed for survival, including by cutting and later restricting water and fuel in the Gaza Strip, and cutting off electricity, and by deliberately destroying water and sanitation infrastructure and materials used to repair water infrastructure.[134] Israeli authorities’ actions amount to the intentional creation of conditions of life calculated to bring about the destruction of part of the civilian population of Gaza. This was part of a mass killing of members of the civilian population, and, as a state policy, amounts to a widespread and systematic attack directed against a civilian population.

Israeli officials are responsible for the crime against humanity of extermination, which is an ongoing crime. They are also responsible for acts of genocide, as defined by the Genocide Convention, and may be responsible for the crime of genocide, which requires acts of genocide to be committed with genocidal intent.

International Human Rights Law

Israel’s obligations as an occupying power under international humanitarian law to provide for the well-being of the civilian population are spelled out under international human rights law. Israel is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which remain applicable during armed conflicts.

Israel maintains that its human rights obligations do not extend to the occupied territories. However the UN Committee on Economic, Social and Cultural Rights, the body charged with interpreting the ICESCR, have repeatedly found that states are bound to respect the human rights treaties they have ratified outside their state borders, and that the provisions in the ICESCR, as well as other human rights treaties, “apply to all territories and populations under its effective control.”[135] The International Court of Justice endorsed this view in its 2004 Advisory Opinion regarding Israel’s separation barrier, and stated that Israel is “bound by the provisions of the International Covenant on Economic, Social and Cultural Rights,” in the territories that it occupies, including Gaza.[136]

Israel bears the obligations to respect, protect, and fulfill all economic, social, and cultural rights, including the rights to food, water, housing, and health.

The UN Committee on Economic, Social and Cultural Rights, in its general comments interpreting the obligations of states with respect to the rights enshrined in the ICESCR, has reiterated that states must comply with certain core obligations that represent the minimum essential levels of these rights, non-compliance with which cannot be justified even in times of conflict, as they are non-derogable.  

Article 12 of the ICESCR recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The committee, in its general comment on the right to health, outlines immediate, core obligations to the right to health that must be complied with, regardless of the circumstances.[137] These include:    

• ensuring the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;    

• ensuring access to the minimum essential food that is nutritionally adequate and safe, to ensure freedom from hunger to everyone;    

• ensuring access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water;    

• providing essential drugs as defined under the WHO Action Programme on Essential Drugs; and    

• ensuring equitable distribution of all health facilities, goods and services.[138]  

The Committee also confirmed additional “obligations of comparable priority” to these non-derogable minimum core obligations, including:      

• ensuring reproductive, maternal (prenatal as well as post-natal) and child health care;

• providing immunization against the major infectious diseases occurring in the community;

• taking measures to prevent, treat and control epidemic and endemic diseases;    

• providing education and access to information concerning the main health problems in the community, including methods of preventing and controlling them; and    

• providing appropriate training for health personnel, including education on health and human rights.[139]

In situations of armed conflict, the Convention on the Rights of the Child, to which Israel is a party, directs states to “undertake to respect and ensure respect of rules of international humanitarian law which are relevant to the child and ensure protection and care of children who are affected by the armed conflict.”[140] The UN Committee on the Rights of the Child has noted provisions of the Convention that are essential for the realization of the rights of children affected by armed conflict. These include, in part: protection of children within the family environment; ensuring the provision of essential care and assistance; access to food, health care and education; and ensuring humanitarian assistance and relief and humanitarian access to children.[141]
 

Recommendations

To the Israeli Government

Consistent with its obligations as an occupying power under international humanitarian law and international human rights law with respect to the right to health of all people in Gaza, notably pregnant women and girls and their children, the Israeli government should:

• End unlawful attacks on civilians and civilian objects, including those essential for the survival of Gaza’s population, such as medical facilities and water and sanitation infrastructure;

• Restore access to electricity, water, and telecommunications services to the civilian population;

• Facilitate the urgent restoration of Gaza’s healthcare system so that all patients, including pregnant women and babies, have access to quality medical care;

• Take all measures to ensure that the civilian population gets food, water, and medical supplies to the fullest extent of the means available to it, with a particular focus on pregnant women and newborns by:

  • Stop obstructing humanitarian assistance – particularly food, including those items needed by children on special diets, water, medicine, assistive devices, and fuel – from entering Gaza by fully opening its crossings, urgently opening additional ones, and not placing unjustified restrictions that prevent humanitarian goods from entering Gaza;

  • Ensure that humanitarian aid can reach all parts of the Gaza Strip and that civilians can safely receive it;

  • Lift the closure of Gaza and permit the free movement of civilians and goods to and from Gaza, subject to individual screenings and physical inspections for security purposes only as necessary, with transparent requirements; publish lists of banned items that are consistent with international standards on “dual-use” items, and provide written justification for any rejections, with the possibility of appeal;

  • Eliminate the “dual-use” label on medical-related supplies, assistive aids, and accessible technology like eyeglasses, wheelchairs, walkers, canes, hearing aids, and other assistive devices needed by people with disabilities and people with chronic health conditions, the restriction of which invariably has a disproportionate negative impact on civilians compared to any military advantage.

• Permit Palestinian civilians in Gaza who choose to exercise their right to leave Gaza, including for medical treatment, to travel abroad via Israel; reopen the Israeli side of the Rafah border crossing with Egypt to ensure that Palestinian civilians in Gaza who choose to exercise their right to leave Gaza, including for medical treatment, will not without a lawful reason be prevented from doing so, while ensuring their right to return to Gaza;

• During hostilities, where evacuation is unavoidable, implement an evacuation system that provides accurate and timely information to the civilian population with instructions on how to safely reach evacuation areas, and that ensures they are safe, have adequate shelter, and meets other humanitarian requirements;

• When issuing evacuation orders, take into account the needs of people with disabilities, and those who are sick or injured, many of whom are unable to leave without assistance. Ensure that evacuation areas can provide for the needs of pregnant people, people with disabilities, the sick, and the injured;

• Support the provision of mental health and psychosocial support services to expectant mothers and women who recently gave birth.

To the Egyptian Government

• Keep the Egyptian-controlled side of the Rafah border crossing open to Palestinian civilians who want to exercise their right to leave Gaza, in line with the customary international law obligation of nonrefoulement, not to expel or return anyone to a place where they would face the threat of persecution, torture, or other serious harm;
• Ensure Palestinians fleeing Gaza are provided with basic services and support, including access to health care, education, and protection, and help to facilitate the onward movement of Palestinians from Gaza who have legal pathways to other countries.

To All Governments

• Publicly condemn violations of international humanitarian law by all parties to the conflict in Gaza, including Israel’s forced displacement of the civilian population in Gaza as a war crime and crime against humanity;
• Publicly condemn Israel’s violations of international human rights law against the civilian population of Gaza, including with respect to the rights to food, water, shelter, health, and other fundamental rights;
• Call upon Israeli authorities to immediately end violations and cooperate with international judicial bodies and investigative mechanisms;
• Continue to support the efforts of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in the Occupied Palestinian Territory and more broadly by providing adequate funding for:
  • the humanitarian response in Gaza, including resources for sexual and reproductive health services;
  • strengthening information networks to ensure that women and other vulnerable groups know where to go and how to access humanitarian assistance and medical services;
  • Establishing mother and child safe spaces in collective centers to increase privacy and specialized services for pregnant women, adolescent girls, and children;
  • Supporting the urgent restock of hospitals and health clinics with essential medications, medical supplies, and electricity/fuel, especially targeting the needs of women and girls (including nutritional supplements for pregnant women and infants, and resources for birthing mothers);
  • Mental health and psychosocial support services for people in Gaza, especially pregnant women and children, and also for humanitarian responders and health workers – including through accessible helplines and improved access to up-to-date referral information across sectors.
• Press Israel to ensure reproductive medical and mental health specialists can enter Gaza without restrictions;
• Abide by the International Court of Justice’s binding orders and advisory opinion. Consider the review and possible suspension of bilateral agreements with Israel, such as the European Union-Israel Association Agreement, and the United States-Israel Free Trade Agreement;
• Suspend military assistance and arms sales to Israel so long as its forces commit violations of international humanitarian law with impunity;
• Enforce domestic legislation limiting the transfer of arms and military assistance for violations of international human rights and humanitarian law;
• Publicly support the International Criminal Court, uphold the court’s independence, and publicly condemn efforts to intimidate or interfere with its work, officials, and those cooperating with the institution;
• Urge Israel to grant access to independent, international monitors, including from the UN Commission of Inquiry on the Occupied Palestinian Territory and the Special Procedures;
• Impose targeted sanctions, including travel bans and asset freezes, against Israeli officials credibly implicated in ongoing serious violations, for the purpose of ending these violations;
• Address long-standing impunity by Israeli authorities and Palestinian armed groups for serious crimes under international law, and support reparations for all victims of gross human rights abuses;
• Support the creation of a register of damages, caused by unlawful Israeli action to persons in the Occupied Palestinian Territory, for the purposes of calculating reparations.

Acknowledgments

This report was researched and written by Belkis Wille, associate crisis, conflict, and arms division director. Research support was provided by Skye Wheeler, senior women’s rights division researcher, and Milena Ansari, Israel and Palestine assistant researcher.

Anagha Neelakantan, senior crisis, conflict and arms division editor, and Ida Sawyer, crisis, conflict and arms division director edited the report. James Ross, legal and policy director, provided legal review. Tom Porteous, deputy program director, provided programmatic review.

Specialist reviews were provided by Milena Ansari; Heather Barr, associate women’s rights division director; Emina Ćerimović, associate disability rights division director; Lama Fakih, Middle East and North Africa division director; Niku Jafarnia, Bahrain and Yemen researcher; Balkees Jarrah, associate international justice program director; Matt McConnell, economic justice and rights division researcher; Skye Wheeler; and Margaret Wurth, senior children’s rights division researcher.

The report was prepared for publication by crisis, conflict and arms division associates, Nīa Knighton and Mennah Abdelwahab; publications officer, Travis Carr; and senior administrative manager, Fitzroy Hepkins.

We would like to thank the individuals who made this report possible by sharing their experiences with us despite the severe trauma and hardship they and their communities were experiencing at the time of the interviews.