‘Death on the floor or death in the streets’

Childbirth amid war in Sudan puts women, babies in peril.

Days after fighting erupted in Sudan, Amna Al-Ahmad received an urgent call for help from a pregnant woman who told her she was preparing to die. Ahmad, 42, a midwife, said she sprinted through gunfire that had swept through her neighborhood in Omdurman, just north of the capital, Khartoum, to reach the woman’s home. Arriving at midnight, she quickly realized that the baby was stuck in the mother’s birth canal. But there were no ambulances or taxis to take them to a hospital. “We were deciding between death on the floor or death in the streets,” she said in a phone interview, recalling how the sounds of shelling punctuated the woman’s moans. “She told me the pain had forced her soul from her body.”

After several hours, Ahmad helped the woman onto a motorcycle and sped to a nearby clinic, where she was able to deliver her daughter.

The war that has raged in Sudan has forced pregnant women across the country to dodge artillery and shuttle through checkpoints to reach the dwindling number of hospitals and maternity wards that are still open. Tens of thousands more, the United Nations estimates, have been displaced or are trapped at home, their babies delivered by midwives or family members or no one at all.

The conflict, now in its second month, has pitted the Sudanese army, led by Gen. Abdel Fattah Burhan, against the paramilitary Rapid Support Forces, led by Gen. Mohammed Hamdan Dagalo. On Saturday, the two sides agreed to a seven-day cease-fire that took effect Monday night, although sporadic gunfire and explosions could be heard in parts of the capital and adjoining cities Tuesday.

Doctors and aid workers say the situation in Sudan, one of Africa’s largest countries, is hurtling toward a humanitarian catastrophe. Sudan already had one of the world’s highest maternal mortality rates before the fighting began.

More than 1.1 million Sudanese women are thought to be pregnant. Of those who are in urgent need of humanitarian assistance, more than 29,000 are expected to give birth in the next month, according to the U.N. Population Fund. At least 4,300 are thought to be at risk of death and in need of emergency obstetric care, including cesarean sections.

“Parents have been driving through hell to reach us — it is like they are on suicide missions,” said Dr. Mohamed Fath Alrahman, 33, a pediatrician and general manager of Al-Nada hospital in Omdurman, who has been overseeing the maternity ward.

One of the few remaining facilities in greater Khartoum still delivering babies, its halls have been overwhelmed by pregnant women.

“Cars pull up to our hospital covered in bullet holes,” he said in a phone interview. “These women are anxious, stressed and many are in advanced labor.”

He said he had just discharged a woman who had arrived with a breech birth after spending hours at a checkpoint controlled by the paramilitary forces, who were interrogating her husband.

“Unfortunately she did not reach us in time and the baby did not survive,” Fath added.

The number of babies born prematurely in his hospital had increased by almost a third since the fighting began April 15, he said. With a skeleton staff, he estimated his ward had delivered more than 600 newborns in the past month — 20 times the usual number. In the first few weeks of the conflict, they were performing as many as 50 C-sections a day, often with two newborns sharing an incubator.

Fath said he was able to keep the hospital’s work afloat through international funding from the Sudanese American Physicians Association. The organization had financed every C-section since the start of the conflict and allowed Fath to offer his remaining staff higher wages to keep them from fleeing.

His account was supported by aid workers from UNFPA, CARE, International Medical Corps, Doctors Without Borders and Save the Children, who told The New York Times that the crisis affecting pregnant women is emblematic of the collapse of the public health system throughout Sudan since the fighting started.

“This is only going to get worse,” said Adive Joseph Ege Seriki, the global adviser for sexual health and reproductive health at International Medical Corps, which has been working to train health care workers across Sudan.

The dire maternal health situation also has consequences for babies born prematurely.

“Preterm babies are at high risk of developing lifelong defects,’’ he said, including intellectual disabilities, cerebral palsy, and hearing and visual impairments.

Even before the current conflict, Sudan had a fragile health system with inadequate infrastructure and equipment, a shortage of skilled health professionals and a limited supply chain. According to the United Nations, Sudan’s maternal mortality rate was about 270 deaths per 100,000 live births, compared to 21 per 100,000 in the United States.

In Khartoum state, which is home to about 10 million people, about 60% of health care facilities are now closed, with only 20% fully operational, according to the United Nations. In El Geneina, the capital of the West Darfur region, all health facilities are shuttered.

Hospitals themselves have become scenes of intense fighting. Armed groups kicked out eight patients who were receiving care at a health center in Khartoum in order to use it as a base, the nonprofit Save the Children said. Many doctors and nurses remaining in the country have been threatened and arrested.

Looting has also been rampant; Many hospitals, pharmacies and warehouses have been ransacked. Patients with chronic diseases like cancer, heart disease or diabetes have been unable to get medication for weeks, while dozens of dialysis centers have closed, the Sudanese doctors’ union said.

But few areas of Sudan’s health system have been affected as acutely as its maternal care networks. As soon as the fighting started, midwives across the country began receiving pleas for help from expectant mothers.

“These women have become an increasingly vital lifeline for those who are stuck at home,” said UNFPA’s reproductive health team leader in Sudan, Rania Hassan, who has been helping support a network of at least 400 community midwives in the country.

Their work is especially critical in the region in and around Khartoum, where fighting has been heaviest, and where many women prefer to give birth in health care facilities, she said.

Midwives have been fanning out across cities and villages and going into women’s homes to deliver newborns, often responding to requests from neighborhood chat groups or emergency hotlines.

Ahmad, who rode with the pregnant woman on the motorcycle, helps coordinate a team of 20 midwives in Omdurman. Together, they have helped deliver about 200 babies — up from five or six in an ordinary month — since the fighting began.

The midwives are not only braving violence, she said, but they have been often forced to operate without access to phones or internet connectivity, which have been degraded by the clashes.

Ahmad said she had delivered eight babies during the conflict, but the chaos was making it more difficult to reach women and acquire medical supplies.

OMER JAY/SUDANESE AMERICAN PHYSICIAN ASSOCIATION VIA THE NEW YORK TIMES A day-old child is being treated for severe Respiratory Distress Syndrome at Al-Nada, a hospital in Omdurman, Sudan, just north of the capital of Khartoum. Hospitals and midwives are overwhelmed as the war puts pregnant women in jeopardy from bullets as well as childbirth.

OMER JAY/SUDANESE AMERICAN PHYSICIAN ASSOCIATION VIA NYT Al-Nada, a hospital in Omdurman, Sudan, is just north of Khartoum. War in the African nation forces pregnant women to drive “through hell” to a hospital.

OMER JAY/SUDANESE AMERICAN PHYSICIAN ASSOCIATION VIA THE NEW YORK TIMES A pediatric nurse resuscitates a newborn in April at Al-Nada, a hospital in Omdurman, Sudan, just north of the capital of Khartoum.