Mental, Maternal, and Newborn Health

Ukraine and its people will feel the effects of the Russian invasion for years to come. More than 6 million refugees have left Ukraine, and another 8 million Ukrainians are internally displaced. Among those most affected are Ukraine’s women and girls, who have a greater chance of experiencing gender-based violence, exploitation, and trafficking. They also face escalated maternal and newborn mortality rates stemming from the lack of services and diminished care, along with injuries and trauma due to the ongoing conflict. Less visibly, Ukrainians are confronting severe emotional distress and trauma.

Dr. Henia Dakkak, head of Policy and Liaison Unit, Humanitarian Unit, United Nations Population Fund (UNFPA), is currently living in Moldova to support relief from the ongoing crisis in Ukraine. I spoke with her about the lasting effects of conflict, trauma, and displacement on the health of Ukrainian women and girls.

At the start of the conflict, UNFPA estimated that 80,000 Ukrainian women were due to deliver a child in the upcoming three months—a timeline now surpassed. The whole world saw images of maternity wards targeted by Russian forces and of pregnant women covered in blood. We heard details of the deaths of expectant mothers and of babies born too soon. Shockingly high numbers of rape and other forms for gender-based violence have been reported, and supply chain disruptions and diminishing food supplies are adding to the trauma Ukrainians face. Reports from Ukraine tell us that people are suffering from intense fear, constant stress, persistent worry, hopelessness, and panic attacks.

A lot of women are experiencing premature labor. And this is not related to nutrition or anything else, but related mostly to the anxiety and to the stress that they are experiencing.

Globally, the world is reckoning with the devastating mental health implications of the COVID-19 pandemic, which has amplified existing mental illness and sparked growing levels of anxiety and depression. Suicide rates have also increased, and maternal mental health and maternal deaths due to suicide have become major concerns for researchers, practitioners, and policymakers. This global mental illness crisis is exacerbated in humanitarian emergencies where, historically, mental health support is not a top priority in the humanitarian response. This is despite the fact that nearly everyone affected by humanitarian emergencies endures psychological distress, and 20 percent are likely to experience depression, anxiety, posttraumatic stress disorder, bipolar disorder, or schizophrenia. Women and girls living in humanitarian crises, along with the health providers who support them, are at heightened risk for prolonged mental health challenges. 

Mental Health and Preterm Deliveries

Dr. Dakkak works directly with women, girls, and health care providers affected by the conflict in Ukraine. She expressed a primary concern for maternal and newborn health and declining mental health, a lack of mental health services and family support networks, and resulting increases in preterm deliveries. Some 66 percent of preventable maternal deaths and 45 percent of newborn deaths take place in countries affected by recent conflict, natural disaster, or both. During pregnancy, stress can increase the likelihood of having a baby born before 37 weeks of pregnancy or of having a low-birthweight baby. Prematurity is a leading cause of death in newborns and in children under the age of five years. Dr. Dakkak detailed three elements contributing to the stress on Ukrainian women: added responsibilities, worry for their loved ones, and their compromised situation:

“This war has been going on now for more than four months and this has a big effect on the mental health and psychosocial status of women, especially pregnant and lactating women.

“When we look at the countries surrounding Ukraine where the refugees are currently, women are there without their support system. They are now the breadwinner and the ones who are taking care of the children or the elderly. They are the ones who are responsible for the safety and security of their kids while they are in transition.

“They are worried about their future. They are worried about their husbands, their brothers, their fathers—the people that they left behind in Ukraine. And, when you talk with women who are in refugee accommodation centers, they will tell you that there has been an additional element of stress due to people trying to take advantage of them in different ways.”

Dr. Dakkak reported that women are being charged exorbitant prices for necessary things like transportation, and are experiencing gender-based violence, including trafficking and sexual violence. There is also a language barrier for some women and additional stress when caring for a person with a disability:

“What we have seen and what has been reported to us by health care workers during the war in Ukraine is that a lot of women are experiencing premature labor. And this is not related to nutrition or anything else, but related mostly to the anxiety and to the stress that they are experiencing, being afraid for their lives, afraid for the lives of their children, afraid for the lives of their family.

“So, there are a lot of premature labors, and these premature labors, they need additional attention. Most of these labors would require incubators, and many health facilities were not equipped to provide the support needed to sustain the lives of preterm babies. Any time you have premature labor, you also have the possibility of bleeding, and bleeding increases the possibility that a woman might lose her life and the newborn might lose his life. All of this was born from the stress, the anxiety, and the fear that women were living in.

We see a lot of women and girls who turn to suicide because their needs are not being met. It is the same situation with gender-based violence, a lot of women suffer in silence.

“Both women displaced within Ukraine and Ukrainian refugees face a similar situation—they are in a place that is not their home, where they do not have a strong support system. We are dealing with stress and premature delivery both inside Ukraine and in the neighboring countries. I am currently in Moldova, but the majority of premature labors and a lot of the stress and anxiety we have seen are more from inside Ukraine.

“Mental health and psychosocial health have been on the radar of the humanitarian community, but they are not the highest priorities. We see more attention toward trauma, especially when you are talking about an active conflict, like now, and injuries and infectious disease often take precedence over, and attention from, maternal and neonatal health and mental health.” 

Gender-Based Violence and Lasting Trauma

The use of rape as a weapon is a highly documented war crime. Sexual violence and rape have long been used to humiliate and torture populations into submission, and humanitarian emergencies can significantly weaken society’s ability to protect people from gender-based violence. Ukrainians are not immune to this violence, and it should be noted that while the vast majority of gender-based violence in conflict is focused on women and girls, men and boys are also subject to these crimes. Survivors of wartime rape often sustain long lasting physical injuries, and the possible reproductive consequences can lead to generational societal effects. Survivors also face long-term mental health consequences, as do their children. Dr. Dakkak also notes:

“Gender-based violence and intimate partner violence have been on the rise, especially during the COVID-19 pandemic. We should not minimize that, and the physical and mental effects of gender-based violence on women and girls is profound.

“We need to address the reality that gender-based violence existed in Ukraine prior to the invasion, primarily as intimate partner violence. The war and the pandemic have exacerbated it, but it was already here. We need to change social norms and laws to protect women and girls, and we need to make services readily available and accessible for those in need. Unless information is available and services to support the mental health and psychosocial needs for survivors are available, survivors will not come forward.”

Ukrainian women who are raped by Russian soldiers will likely experience severe trauma and distress, and the toll on their mental health can be exasperated by a pregnancy resulting from rape. With restrictive abortion laws in neighboring Poland, Hungry, Romania, Ukrainian refugees have limited options to terminate a pregnancy, even one that results from rape. As Dr. Dakkak observes:

“We need to really think about how we can shed more light on mental health and the need for psychosocial support more generally, and shed light on the mental health needs of pregnant women and sexual reproductive health services in emergency settings. I can tell you, there is a lot of anxiety, especially if a woman gets pregnant as a result of being raped, and just thinking about what will happen to that pregnancy. And in some countries around Ukraine, abortion is not legal.

“They will suffer in silence. And do we only see mental health issues related to pregnancy? No, we also see it post pregnancy, we see a lot of postpartum depression. We see a lot of women and girls who turn to suicide because their needs are not being met. It is the same situation with gender-based violence, a lot of women suffer in silence.”

Health Facilities Are Easier to Rebuild Than Health Providers

More than 200 attacks on health facilities have occurred in Ukraine since the invasion by Russia. The attacks on health facilities have led to the deaths of health care workers, the destruction of life-saving equipment and medications, disruptions of supply chains, and a mass exodus of health care workers fleeing Ukraine. Everyone is working hard on the supply chain issues, and improvements are slowly happening, but the rebuilding of health facilities and a strong cadre of health care personnel will take more time. The trauma and stress health workers face in humanitarian emergencies is significant, long-lasting, and often overlooked. Dr. Dakkak explains:

“When I came to Moldova in the first week of the war, we immediately received information about shortages of maternal medicines and supplies that were needed by the main obstetric hospital in Odesa. When the supply chain is disrupted, even if you have the medical personnel available, they are at a loss of what to do when they don’t have access to necessary medications. So supply chains are one element of distress. What we also have seen from the media coverage, and what UNFPA personnel who are working in Ukraine have all had to witness first-hand, are the targeted attacks on health facilities, which is another major concern.

“The supply chain is a big issue, and everybody is working very hard to make sure that we address all the gaps. But a lack of health personnel is something that would need more time because you cannot replace health personnel very quickly, you cannot train health personnel very quickly. That means a loss of lives is a loss for the health sector generally, and for the health of Ukrainian families.

“Ukraine needs a lot of support to rebuild the health system to the level that it was there before the war. But I think as in any situation where you have a big emergency or disaster, the issue that you must think about is, how do we build—not back—but forward, and better? How do we make these hospitals more capable of withstanding these types of attacks, and how do we work with the medical personnel to truly support them and save their lives? There are many campaigns, including UN Security Council resolutions, which recognize these elements are very important for safety and security in general, and for peace and security throughout the world; understanding that hospitals, schools, and medical personnel should be protected and given the utmost attention.”

National and international organizations are gathering evidence for a potential war crimes investigation against Russia. War crimes include a range of violations of international law, which include targeting civilians, torture, taking hostages, rape and other sexual violence of civilians, enlisting children, and deliberate destruction of civilian infrastructure during armed conflict. Investigating and prosecuting war crimes is laborious and time consuming and often left unresolved. Dr. Dakkak states:

“And these attacks should be constituted as crimes. Let’s face it, this is not only happening in Ukraine—it’s happening in many places around the world—in Burkina Faso, in Mali; attacks on health facilities happen in Iraq. Attacks like these have happened in Syria. It will take time. It will take effort. It will take a lot of advocacy. There must be accountability for these crimes.

“And there should be some sort of recognition that even armies should not be utilizing health facilities, schools, and health personnel as targets in these types of settings, situations, or emergencies. I think everybody needs to understand that there is a price for these types of attacks. And there should be some sort of reparations. Because if we continue being complacent, we will have more of these discriminatory attacks on health facilities and health personnel.

“There is a lot of good capacity in Ukraine and neighboring countries, but they need funding, and additional medical teams to come and help build the system back. And something that we also need to recognize is that not everybody has the same ability to work under the stress of this type of situation. Health care workers also need mental health support and services.”

Sarah B. Barnes is the project director of the Maternal Health Initiative at the Woodrow Wilson International Center for Scholars, where she leads the program’s research. She works closely with practitioners, researchers, donors, international development agencies, and policymakers to connect issues of gender, maternal and global health, and women’s leadership to foreign policy. She is also the editor of the Dot-Mom column on New Security Beat.

Cover photo: A pregnant woman whose pelvis had been crushed and her hip detached during Russian shelling is evacuated from a maternity hospital in Mariupol, Ukraine, March 9, 2022. The woman was taken to another hospital closer to the front line but did not survive. AP Photo/Evgeniy Maloletka.