Pregnant women struggle to access medical care on Ukraine's front lines

MYKOLAIV, Ukraine — At six months pregnant, it’s hard for Olga to decide where the safest place is to wait out her term, amid airstrikes bombarding her town in southern Ukraine almost daily. Lying in a bomb shelter in a maternity hospital in Mykolaiv — one of the front lines of the war — the 30-year-old mother said she’s terrified of bringing her unborn daughter into this world and feels lucky she was able to get to the hospital when she needed help.

Pointing to a photo on her phone of an unexploded missile that landed around the corner from her home days earlier, Olga, who only wants to be identified by her first name for safety reasons, said she took advantage of the window of calm from incessant shelling to get to a maternity hospital when she started having stomach cramps. But since arriving, she’s spent much of her time running up and down the steps to and from the bomb shelter, which has increased the pain, she said.

“It’s horrifying bringing a baby into this because you don’t know what will happen tomorrow,” Olga said.

One month into Russia’s invasion of Ukraine — that has killed nearly 1,000 civilians, wounded thousands, and decimated cities displacing some 10 million people — and access to medical care is becoming increasingly cut off with pregnant people particularly at risk.

Since the invasion on Feb. 24, there have been at least 4,300 births with another 80,000 expectant mothers in the next three months who might not have access to critical maternal care, according to the United Nations, which has warned that oxygen and medical supplies including for the management of pregnancy complications are running “dangerously low.”

Russia, which is being accused of war crimes, is targeting hospitals. Since the start of the war, there have been at least 64 attacks on health care, according to the World Health Organization, including the bombing of a maternity hospital in the besieged southern town of Mariupol.

The war has also disrupted supply chains, prevented distributors from operating, and left many women in hard-hit areas unable to access prenatal care or see doctors if there’s an emergency. Roads and bridges have been damaged and many people are too afraid to leave their homes amid the shelling, according to locals, health workers, and humanitarians.

During trips to several cities and towns affected by the fighting, health staffers, and volunteers helping expectant women, injured soldiers, and civilians, told Devex they were either running low on supplies or anticipated they would be nearly out of stock within a month. Packaged medicaments are Ukraine’s third-largest import after petrol and cars, according to The Observatory of Economic Complexity, an online platform that documents global economic activity.

“We are mostly concerned with our stocks, whether [they] will be enough to provide enough care,” said Dr. Andriy Hrybanov, medical director for Mykolaiv’s Maternity Hospital Number 3. 

On top of a supply shortage, there’s starting to be a lack of personnel, he said. Since the invasion, approximately 15% of his staff have left, those who remain are exhausted, working around the clock. His hospital is currently the only fully functioning maternity clinic in town — the other two lack electricity because of the conflict. Staffers fear the hospital could get crowded, especially in the bomb shelter in the basement, which is being used not only by patients but also by civilians as there’s no other shelter in the area.

Olga has been shielding with several other pregnant people as well as a host of others from the community who sought safety when the sirens went off at 3 a.m. the previous night. Hospital beds, some with patients or tired neighbors, lined the narrow dim hallway of the shelter, while a storage space had been converted into a makeshift delivery room.

According to Hrybanov, approximately 40% of births at the hospital have occurred in the shelter since Russia invaded. While it’s doable — though not ideal — to deliver babies in the shelter, what remains challenging is when women need cesareans, he said.

If a woman has to be operated on while the sirens are ringings, she has to be carried up four flights of steps from the bomb shelter to the operating room, which can be dangerous for the mother and the baby. Cesareans at night pose the added risk of being on the top floor of a building with the light on, which can attract attention making them a target, Hrybanov said.

In recent days, Russia’s ramped up attacks on Mykolaiv, killing 40 marines in a rocket attack on a military barracks and killing at least nine civilians standing in line at a cash machine. The town is the last line of defense before the large city of Odesa, which if taken by Russia will give it control of the Black Sea and one of the country’s main supply routes.

‘It's a risky situation and that's why we need to react’

Before the war, Ukraine had a robust maternity health system, “one of the best organized” said Dr. Galyna Maystruk, head of the local organization Women Health and Family Planning Charity Foundation, and the association member in Ukraine for the International Planned Parenthood Federation.

But after a month of fighting, at least 15 out of 70 specialized perinatal centers for pregnant people have stopped working, she said. Some cities are completely cut off with no access to data, such as in Sumy and Kharkiv in the northeast, and in Mariupol in the southeast, which are being decimated by airstrikes.

UNFPA said only 29 out of 65 local health care facilities that provide shelter or crisis solutions for women and girls are operational and one-third of the cities in which it operates are now occupied by Russian forces.

At the maternity hospital in Mykolaiv, Hrybanov said there have already been fewer deliveries in the first two and a half weeks of the war — 49 compared with the usual number of approximately 150 a month. Some women have started arriving later than they should because they’ve been too afraid to come, with others not being able to come at all, he said.

In mid-March, a woman who lived 25 kilometers (16 miles) from the hospital was prevented from leaving her house to deliver because her neighborhood was encircled by Russian tanks, said Hrybanov. The woman found a local doctor to assist her, who had no experience delivering babies, and together they called Mykolaiv’s health department and delivered the baby while being mentored by a doctor over the phone, he said.

The baby and mother are fine, but Hrybanov worries situations such as this could lead to increased maternal deaths and stillbirths, he said.

“Of course, it's a risky situation and that's why we need to react,” he said. Adding that the hospital hasn’t yet received much international support from aid groups or the U.N.

Bottlenecks and access

When the invasion began, many international organizations and the U.N. paused operations and evacuated most of their staff and have only recently started to return. Local health workers said they’ve been largely relying on volunteers to collect and transport medicine, food, and donations from Ukrainians and neighboring countries to the hospitals, but they don’t have enough medicine, particularly for trauma injuries.

In Odesa, most aid the military hospital receives is from countries such as Poland, the Netherlands, and the Czech Republic, Yana, a volunteer at the hospital who coordinates medical supplies and only wanted to use her first name, said. But aid from abroad is taking longer to enter Ukraine than at the start of the war, due to increased checkpoints within the country and bottlenecks at the border, she said. Doctors lack equipment such as tourniquets, cotton to stop bleeding, and strong painkillers among other things, she said.

As Russia scales up its air bombardments amid its largely stalled ground operations, humanitarian convoys and ambulances are being hit more often, Yana said. In the middle of March, an ambulance carrying patients trying to reach a military hospital near the Russian occupied city of Kherson was struck, injuring several doctors inside.

While it’s hard getting aid into cities that are under Russian occupation, such as Kherson, Yana said it’s still possible in some areas where the Russians have less presence if it's discreet and backroads are used instead of main routes, she said. “[but] if the city or the village is completely surrounded, we can't get there.”

Across the country, health workers and volunteers said their biggest concern was dwindling medical supplies. Further north in the capital Kyiv, Olga Bashey, a volunteer front-line paramedic told Devex she’d been waiting weeks for an order of tourniquets.

Bashey’s been working on the front lines since 2014 after Russia annexed Crimea and backed separatists to fight the Ukrainian government in the eastern regions of Donetsk and Luhansk. She said she’s never experienced a lack of supplies or a delay in shipment when responding in the east like she is now.

‘Even as fast as everyone is trying to move, it feels slow’

As the war intensifies and continues longer than initially expected, aid groups are scaling up the delivery of medicines and supplies. Last week, the International Committee of the Red Cross delivered more than 200 tons of relief supplies, medical material, thousands of blankets, and tarpaulins, and deployed dozens of additional staffers to the region, including medical workers, said the group in a statement.

WHO has delivered up to 100 metric tons of supplies to support trauma, surgery, and primary health care, including oxygen, insulin, surgical supplies, and anesthetics, a spokesperson for the WHO told Devex. It also sent vital medical supplies to hard-hit cities including Mykolaiv. The agency said it has established supply lines from its warehouse in the western city of Lviv, which has been spared so far from major attacks, to other parts of the country, but it’s still “unable to deliver critical and lifesaving medical supplies everywhere where there is a need.”

Some agencies said they are conducting pilot missions to assess the risk of bringing in cross-border aid, figure out the logistics, and establish networks on the ground, which isn’t always easy.

“Even as fast as everyone is trying to move, it feels slow because it’s difficult with such a major response with finding the right people to talk to and the situation is changing daily,” said Liz, a health adviser for Medair in Ukraine who preferred to use her first name only. It’s often hard to find the right local authorities to speak to and coordinate with because many are no longer at work since they’re responding to the crisis or can’t be reached by phone, she said.

Medair is trying to work with and through the robust volunteer response to identify gaps, which can be challenging in a developed country, such as Ukraine, which already has strong systems in place compared to a country with less established systems, she said. “It’s sometimes easier to work from nothing than with something,” she said.

Local groups said what’s needed now, specifically to help pregnant people, are mobile kits so health workers can have makeshift operating rooms within a few hours if they don’t have access to the right facilities to deliver babies. Pregnant people should also be prioritized during evacuations through humanitarian corridors, said Maystruk of the Women Health and Family Planning Charity Foundation.

While organizations scramble to get aid in, maternity hospitals in less hard-hit areas are bracing for an influx of women and hoping they’ll have enough supplies and space to support them. Earlier this month, three months pregnant Iana Bakulina, traveled to Odesa for medical care because shelling prevented her from reaching her doctor in her hometown of Mykolaiv.

“I came to save my health,” she said.

Seated in the waiting room of the hospital, Bakulina said she’ll stay in Odesa until she delivers because it’s too unsafe to return. Rubbing her stomach, she’s excited to give birth to her first child. But Bakulina doesn’t want to consider what could happen in six months if she has to deliver the baby during the war.

“I think about good stuff only and I think everything will be fine,” she said.

Update, March 24, 2022: This article has been updated with the latest number of casualties.