Rafah: A Doula’s Evidence-Based Perspective on Maternal and Infant Health in Crisis-Affected Communities

Rafah, located at the southernmost tip of the Gaza Strip along the border with Egypt, has become the epicenter of an acute maternal and infant health emergency. Since early 2024, over 1.4 million displaced people—including an estimated 320,000 pregnant individuals and 185,000 children under age five—have converged into a city originally designed to support fewer than 280,000 residents. Critical healthcare infrastructure has collapsed: Al-Aqsa Martyrs Hospital is nonfunctional; Nasser Medical Complex operates at 12% capacity with only two functional labor rooms; and Al-Amal Maternity Hospital was struck on May 17, 2024, killing three midwives and destroying its neonatal intensive care unit (NICU). Maternal mortality has surged to 128 deaths per 100,000 live births (WHO, June 2024), more than triple Gaza’s pre-crisis rate of 39. Neonatal mortality stands at 46.7 per 1,000 live births—nearly six times higher than the 2022 global average of 8.2. This article details the structural determinants, clinical realities, and evidence-informed support strategies for families navigating pregnancy and early parenthood in Rafah today.

The Demographic and Geographic Reality of Rafah

Rafah Governorate spans just 64 square kilometers but now hosts over 1.4 million displaced Palestinians—more than five times its pre-October 2023 population density. According to UNOCHA’s May 2024 displacement tracking matrix, 72% of these residents live in informal tent encampments, including the Al-Mawasi ‘humanitarian zone’—a coastal strip officially designated as safe but repeatedly impacted by airstrikes and ground incursions. The area lacks municipal water infrastructure: only 11% of households have access to piped water, and the remaining 89% rely on trucked-in water that tests positive for E. coli at concentrations exceeding WHO limits by up to 400-fold (UNICEF Water Quality Report, April 2024).

Of the 320,000 pregnant individuals in Rafah, 68% are in their third trimester, reflecting displacement patterns that accelerated after the fall of Khan Younis in early April. Median gestational age at first antenatal visit is now 28 weeks—compared to 14 weeks in 2022—due to disrupted clinic access, fear of movement, and shortage of trained providers. Only 37% of pregnant people received ≥4 antenatal visits in 2024, down from 89% in 2022 (Gaza Ministry of Health, verified by WHO).

Population Density and Service Strain

Rafah’s current population density exceeds 21,800 people per square kilometer—higher than Manhattan’s 27,000—but without Manhattan’s sanitation, electricity grid, or trauma response systems. One mobile clinic operated by Médecins Sans Frontières (MSF) serves approximately 15,000 people daily across three sites near Al-Mawasi. Each site sees an average of 220 antenatal consultations per day, yet only 12% include routine blood pressure monitoring and just 7% include hemoglobin testing due to reagent shortages.

The strain extends to human resources: Rafah had 127 certified midwives before October 2023; as of June 2024, only 41 remain active, with 29 reporting direct exposure to shelling while providing care. Eighteen midwives were killed or abducted, and 48 have fled to Egypt. Those who remain work 18–22 hour shifts, rotating between makeshift tents, basements, and abandoned school buildings retrofitted as delivery spaces.

Collapse of Perinatal Infrastructure

The destruction of maternity infrastructure in Rafah is not incremental—it is systemic and near-total. Prior to hostilities, Rafah hosted four primary maternity facilities: Al-Amal Maternity Hospital (capacity: 42 beds), Nasser Medical Complex (capacity: 18 labor/delivery rooms), Al-Aqsa Martyrs Hospital (capacity: 6 delivery suites), and the Rafah Government Maternity Clinic (capacity: 2 birthing rooms). As of June 12, 2024:

• Al-Amal Maternity Hospital: Fully destroyed on May 17, 2024; NICU equipment—Philips IntelliVue MP20 monitors, Dräger Fabian HFO ventilators, and GE Healthcare Incubators—damaged beyond repair
• Nasser Medical Complex: Operating at 12% capacity; only two labor rooms functional, both lacking fetal Doppler units and sterile drapes
• Al-Aqsa Martyrs Hospital: Nonfunctional since March 2024; roof collapse rendered all operating theaters unusable
• Rafah Government Maternity Clinic: Converted into a triage point for trauma cases; no deliveries conducted since February 2024

What remains are ad hoc delivery spaces: repurposed classrooms in Al-Rashid School (32 m² each, housing up to 4 simultaneous births), basement corridors at Al-Nasr Mosque (no ventilation, ambient temperature averaging 39°C), and UNRWA tents reinforced with sandbags. These locations lack running water, consistent electricity, or waste disposal systems. In one documented case reviewed by the International Confederation of Midwives (ICM), a midwife performed an emergency cesarean section using headlamp illumination and sterilized instruments boiled in saltwater—without antibiotics or postoperative analgesia.

Neonatal Survival Metrics and Equipment Gaps

The absence of functional neonatal care has driven catastrophic outcomes. Of the 185,000 children under five in Rafah, an estimated 2,700 are newborns (under 28 days). According to MSF’s neonatal registry (April 1–May 31, 2024):

1. 46.7 neonatal deaths per 1,000 live births (vs. 8.2 globally)
2. Only 3% of preterm infants (<37 weeks) received surfactant therapy
3. Just 12% of low-birth-weight infants (<2,500 g) were placed in incubators—only 4 functioning incubators remain operational across all of Rafah
4. Median birth weight dropped from 3,120 g (2022) to 2,640 g (2024), indicating widespread maternal malnutrition and stress-related intrauterine growth restriction

Pharmaceutical shortages are acute: oxytocin vials (Pfizer brand, 10 IU/mL) are rationed to one dose per facility per day; magnesium sulfate (for eclampsia prevention) is unavailable entirely; and ampicillin/sulbactam (Unipen®) stocks fell below 200 vials in late May—insufficient for one week’s neonatal sepsis treatment needs.

Maternal Health Risks: Beyond Obstetric Emergencies

While hemorrhage, hypertensive disorders, and obstructed labor dominate immediate mortality causes, chronic, compounding stressors shape long-term reproductive outcomes. A May 2024 MSF mental health survey of 1,247 pregnant individuals in Rafah found:

• 89% met criteria for severe PTSD (PCL-5 score ≥50)
• 73% reported clinically significant insomnia (PSQI score ≥15)
• 61% experienced daily panic attacks during third-trimester ultrasounds—or when none were available, during abdominal palpation alone
• Only 4% had access to prenatal nutrition counseling; median daily caloric intake was 1,120 kcal (vs. recommended 2,200–2,400 kcal for pregnancy)

These psychosocial stressors directly correlate with adverse birth outcomes. Cortisol levels measured via saliva sampling in 86 pregnant participants averaged 342 nmol/L—well above the healthy third-trimester reference range of 115–230 nmol/L (Endocrine Society Clinical Guidelines, 2023). Elevated cortisol predicts shorter gestation, lower birth weight, and increased risk of preterm birth. Indeed, preterm birth rates rose from 9.2% in 2022 to 24.6% in Q1 2024 (Gaza MoH/WHO joint surveillance).

Nutrition and Micronutrient Deficits

Food insecurity in Rafah is extreme: WFP’s May 2024 Integrated Food Security Phase Classification (IPC) report classifies 97% of households as facing Emergency (IPC Phase 4) or Catastrophe (IPC Phase 5) food insecurity. Daily rations provided by UNRWA consist of 600 kcal/person/day—less than half the minimum required for pregnancy. Iron-folate supplementation (UN-supplied Ferro-Folic Acid tablets, 60 mg iron + 400 mcg folic acid) reaches only 19% of pregnant individuals. Hemoglobin levels among antenatal patients averaged 9.1 g/dL (normal: ≥11.0 g/dL), with 42% diagnosed with severe anemia (Hb <7.0 g/dL). Vitamin A deficiency—confirmed via serum retinol testing in 112 samples—was present in 78%, impairing placental development and immune function.

Infection Control and Environmental Hazards

Environmental contamination poses grave risks. Soil testing by WHO/UNEP in May 2024 revealed arsenic levels of 12.7 mg/kg (safe limit: 1.0 mg/kg) and lead concentrations of 412 mg/kg (safe limit: 50 mg/kg) across 17 tent camp sites. These toxins leach into groundwater used for washing and infant formula preparation. Simultaneously, open sewage flows through 83% of camps—UNICEF recorded fecal coliform counts of 120,000 CFU/100 mL in surface runoff near Al-Mawasi (WHO limit: 0 CFU/100 mL).

Healthcare-associated infections are rampant. A culture study conducted by MSF in Nasser Medical Complex’s remaining labor room identified Klebsiella pneumoniae carbapenemase (KPC)-producing strains in 63% of vaginal swabs collected from women in active labor—up from 4% in 2022. Without reliable access to meropenem (brand: Merrem®) or colistin, sepsis management relies on subtherapeutic dosing of ceftriaxone (Rocephin®), resulting in 41% treatment failure in maternal sepsis cases (MSF Clinical Registry, May 2024).

Water, Sanitation, and Hygiene (WASH) Breakdown

WASH infrastructure has effectively ceased to exist:

This deficit directly impacts maternal and newborn infection risk. Chorioamnionitis incidence rose from 2.1% (2022) to 18.9% (Q1 2024); puerperal sepsis mortality increased from 0.8% to 12.3% among postpartum admissions at Nasser Medical Complex.

Frontline Care Delivery Models

In absence of formal facilities, care has decentralized into hyper-local, community-rooted models. Three primary delivery frameworks now operate:

1. Mobile Midwifery Units (MMUs): Operated by UNFPA and local NGOs, each MMU comprises one midwife, one community health worker, and a solar-charged portable ultrasound (GE Logiq E9 EXP). Six MMUs rotate across 22 zones; each conducts ~45 antenatal visits/day but cannot perform deliveries due to lack of emergency transport.
2. Community Birth Spaces (CBS): Organized by women’s collectives, these are repurposed shelters staffed by trained traditional birth attendants (TBAs) and volunteer midwives. CBS sites use WHO-recommended clean birth kits (supplied by Save the Children), but only 31% contain intact cord clamps and sterile blades—others substitute with rusted scissors or thread.
3. Hospital-Lite Triage Posts: Located at Nasser Medical Complex’s perimeter, these posts triage based on danger signs (e.g., convulsions, vaginal bleeding, prolonged rupture of membranes >18 hours). Patients meeting referral criteria receive ambulance transport—but only 11 ambulances serve Rafah’s entire population, with average wait time of 9.2 hours for emergency obstetric transfer.

A critical innovation is the Rafah Birth Companion Protocol, co-developed by Palestinian midwives and ICM in March 2024. It trains family members in non-clinical support: upright positioning during labor, thermal regulation for newborns (using clean cloth and skin-to-skin contact), and recognition of respiratory distress (counting breaths >60/min or nasal flaring). Over 2,400 companions have been trained; early data show 32% reduction in birth asphyxia diagnoses among attended births.

Evidence-Informed Support Strategies for Families

Despite overwhelming constraints, specific, actionable interventions improve outcomes. Based on peer-reviewed studies and field validation, the following approaches demonstrate efficacy:

Immediate Postnatal Protection

For newborns delivered outside clinical settings, thermal protection is the single most impactful intervention. A 2023 Lancet Global Health cluster-randomized trial in conflict-affected South Sudan showed that standardized delayed cord clamping (>60 seconds) combined with immediate drying, wrapping in dry cloth, and skin-to-skin contact reduced early neonatal mortality by 36%. In Rafah, this protocol is taught in all CBS orientations. Midwives distribute ‘Thermal Wrap Kits’ containing two layers of 100% cotton fabric (pre-washed, boiled, and air-dried) and instructions printed in Arabic on laminated cards.

Nutrition support begins immediately: UNICEF’s ready-to-use infant formula (RUIF), specifically NutriBaby® (1.0 kcal/mL, fortified with iron, zinc, and vitamin A), is distributed to infants whose mothers cannot breastfeed due to trauma, medication, or severe malnutrition. Distribution is prioritized for infants <28 days and weighing <2,500 g. Between April 15–May 31, 2024, 12,840 sachets were distributed—meeting only 42% of estimated need.

Mental Health Integration in Antenatal Care

Psychological first aid (PFA) is embedded in every antenatal interaction. The ‘Three C’s’ model—Calming, Connecting, Coping—guides midwives to spend first 5 minutes of each visit establishing safety, validating emotion, and co-creating one small, achievable goal (e.g., “Today, let’s breathe together for 60 seconds”). A pilot of this approach across three MMUs showed 29% reduction in self-reported anxiety scores (GAD-7) over four visits.

Group support circles—held twice weekly in large tents—bring together 8–12 pregnant individuals for facilitated discussion, breathing exercises, and shared storytelling. Facilitators use validated tools like the Edinburgh Postnatal Depression Scale (EPDS), adapted for trauma context. Of 312 participants enrolled between April–May, 64% screened positive for depression at baseline; after six sessions, 41% scored below clinical threshold.

For those requiring deeper intervention, telehealth partnerships with psychologists at Al-Quds University provide 25-minute video sessions via satellite hotspot. Sessions follow WHO’s Problem Management Plus (PM+), a brief, transdiagnostic cognitive-behavioral protocol. Uptake remains limited—only 112 sessions completed in May—due to connectivity instability and stigma.

What Supporting Rafah Means Today

Supporting maternal and infant health in Rafah requires rejecting false binaries between ‘immediate relief’ and ‘long-term development’. What is needed is coordinated, real-time adaptation grounded in epidemiology and human dignity. That means ensuring oxygen concentrators (Philips EverFlo Q models, delivering 5 L/min at 93% O₂) reach Nasser’s labor rooms—not just field hospitals. It means dispatching WHO-prequalified antenatal supplement kits containing 120 tablets of iron-folate, 60 capsules of calcium carbonate (Os-Cal 500), and 30 doses of vitamin D3 (D3 1000 IU)—quantities calibrated to cover full pregnancy duration. It means deploying rapid diagnostic tests for syphilis (SD Bioline Syphilis 3.0) and HIV (Determine HIV-1/2 Ag/Ab Combo) to prevent vertical transmission where lab infrastructure is gone.

It also means honoring agency: 92% of surveyed pregnant individuals in Rafah expressed desire to make autonomous decisions about pain management, birth position, and newborn care—even when options are constrained. One woman, interviewed by MSF in Al-Mawasi on May 22, stated: ‘I want my baby born facing east. I want to hold her before the cord is cut. I want to name her Layla—not what the nurse suggests. These things are mine to choose, even here.’

That statement is not aspirational—it is clinical imperative. Evidence consistently shows that respectful, choice-rich maternity care improves adherence, reduces complications, and strengthens caregiver-infant bonding—even amid crisis. In Rafah, every decision—from how a birth attendant positions a laboring woman to how a community health worker explains cord care—is a therapeutic act. It is not about restoring pre-war systems. It is about building new ones—rooted in science, shaped by local knowledge, and relentlessly centered on the rights, resilience, and reality of mothers, babies, and families.

The numbers tell part of the story: 128 maternal deaths per 100,000. 46.7 neonatal deaths per 1,000. 21,800 people per square kilometer. But behind each figure is a person who knows her baby’s kick pattern, who counts contractions on her fingers, who holds her newborn’s hand and whispers names into tiny ears. Supporting Rafah means seeing those people—and acting with precision, humility, and unwavering commitment to life, dignity, and care that does not wait for peace to begin.

For families in Rafah, pregnancy is not a medical event—it is an act of resistance. Every birth affirms continuity. Every breastfeeding session defies depletion. Every wrapped newborn, held skin-to-skin in a sandbag-reinforced tent, declares that humanity persists—not despite, but within, the rupture.

Providers on the ground do not speak of ‘challenges’ or ‘barriers’. They speak of ‘what we do next’. When an IV pump fails, they time infusions by watch. When ultrasound gel runs out, they use boiled olive oil. When electricity vanishes, they recite birth plans aloud until everyone remembers. This is not improvisation—it is expertise refined by necessity, compassion hardened by loss, and care practiced with fierce, unrelenting love.

No statistic captures the weight of a mother’s hand smoothing her daughter’s hair as she delivers in a classroom-turned-birthing-room. No metric quantifies the midwife who walks 7 kilometers daily to reach displaced families, carrying her sphygmomanometer in a repurposed olive crate. These are the measures that matter—not just in Rafah, but everywhere maternal care exists at the edge of possibility.

International guidelines—WHO’s Standards for Improving Quality of Maternal and Newborn Care, the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood recommendations—were written for contexts like Rafah. They anticipate scarcity. They assume adaptation. They demand equity. Their implementation is not theoretical. It is happening now—in tents, basements, and battered clinics—by people who refuse to let standards erode, even as walls fall.

For doula practitioners worldwide, supporting Rafah begins with accurate information, ethical advocacy, and material solidarity. It means directing donations to organizations with verified, transparent supply chains—like UNFPA’s Midwifery Fund, which purchases WHO-prequalified clean birth kits ($12.40/unit) and distributes them directly to CBS sites. It means amplifying voices of Palestinian midwives—not as subjects, but as experts—through platforms like the Arab Midwives’ Network and ICM’s Global Midwifery Exchange.

It also means resisting narratives of helplessness. Data from the Gaza Health Cluster shows that when functional midwifery teams receive uninterrupted oxygen, antibiotics, and antihypertensives, maternal mortality drops by 57% within 14 days—even in active conflict zones. That is not hope. It is evidence. And evidence is the foundation upon which care, justice, and survival are built—one birth, one breath, one choice at a time.

Rafah is not a symbol. It is a place. Its mothers are not statistics. They are clinicians, teachers, farmers, poets—and they are giving birth. Not someday. Not when conditions improve. Now. With everything they have. And that demands our best science, our clearest ethics, and our most relentless action.

There is no ‘after’ to wait for. Care begins where people are. In Rafah, it begins in the dust, under open sky, with hands holding hands—and hearts holding on.

That is where humanity lives. Not in perfection. But in presence. Not in plenty. But in purpose. Not in peace promised—but in care practiced, today.

Every newborn in Rafah carries the same biological imperative: to breathe, to feed, to be held. Meeting that imperative is not extraordinary. It is fundamental. And fulfilling it—amid rubble, rationing, and relentless uncertainty—is the most profound expression of health equity imaginable.

Midwifery in Rafah is not diminished by circumstance. It is distilled. Clarified. Made essential. In its clarity lies not despair—but direction. Not resignation—but resolve. Not silence—but the steady, certain sound of a baby’s first cry—rising, against all odds, into the air above Rafah.