Under Israel’s Oct. 13 evacuation order, 1.1 million residents are forced to flee Northern Gaza, including 19,000 pregnant women. The International Planned Parenthood Federation says that stress and shock is causing many women to miscarry, and medical supplies are quickly running out.

Gaza is home to 2 million people, 40% of whom are under the age of 15. And this is ‘only the beginning,’ as Israel Prime Minister Netanyahu said in a televised statement. President Biden prepares to visit the country on Wednesday and 2,000 U.S. troops have been told to prepare to deploy to the surrounding region. Israel has been the largest recipient of U.S. foreign assistance since World War II. According to the Congressional Research Service, by March 2023 the U.S. had provided $158 billion to Israel, mostly for military assistance.

The Gaza strip has been labeled an open-air prison by the United Nations, apartheid by Amnesty International and a violation of International Humanitarian Law. On Oct. 7 Hamas, the Arabic acronym for what translates to the Islamic Resistance Movement, launched a surprise attack in Israel, killing 250. But the attacks on Oct. 7 were not the beginning of this crisis, as the Palestinian people have lived under Israeli occupation since 1967.

“When we look at it today, we have to look at what it was two weeks ago as well,” said Ammal Awadallah, executive director of the Palestinian Family Planning and Protection Association (PFPPA). “Because what it was two weeks before today is what’s making it [even more so] devastating today.

Videos of the aftermath of the bombings have spread across social media: footage of crying infants, covered in dust and blood; a mother holding their dead baby, begging him to wake up and nurse; people banding together to feed water through a tube to a man trapped under rubble.

Restricted travel, restricted access to medical services

The Gaza Strip and West Bank are the two parts of Palestine under military occupation kept segregated as Palestnians are not able to freely travel between the two unless given a permit, which few are able to obtain. Many of the region’s specialized hospitals are located in East Jerusalem, leaving some Palestinans unable to receive medical care even in dire situations.

Within the West Bank alone, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) reported 565 Israeli checkpoints and road obstacles earlier this year. In addition to 188 staffed or occasionally staffed checkpoints, this also included gates, earth mounds and other obstacles that restrict vehicles and pedestrians.

In 2022, 15% of permit applications by patients from the West Bank, and 20% of permit applications for their companions, were not approved by the time of their scheduled appointment.

The United Nations (UN) says that restricted movement causes access to maternity services to be unpredictable, influences decisions on labor inducement and c-sections and also discourages patients from seeking postnatal care, due to how difficult travel is.

“Mobility restrictions impede continuity of medical care throughout the cycle of pregnancy (prenatal care, a hospital for delivery and post-natal care may not be accessible in the same location) and thus the development of a relationship of trust between medical staff and patients,” reads one UN report.

Before Oct. 7

Israeli’s military occupation prevents residents from pursuing professional, creative, athletic and educational opportunities in the West Bank or abroad, according to Human Rights Watch.

Over half of the West Bank is under Area C designation, meaning it is under complete Israeli military control. Palestinians are not allowed to build permanent or even semi-permanent structures in Area C without an Israeli permit, says Medecins Sans Frontieres (MSF), an independent, humanitarian health organization. These are rarely granted, leaving virtually no options for new clinics to establish.

In 2021, MSF began visiting the area to provide healthcare services using a mobile clinic, and even that was at threat of being knocked down. A community leader in Khirbet Al-Fakheit told MSF his community’s lack of services or aid.

“For one year, no one came here, and our people had to go all the way to Yatta to get access to healthcare services,” explained Mohamad Ayoub Hamad, “It was a very difficult situation, especially for pregnant women. Put simply, families without a car really face a big problem.”

According to Google Maps, the distance between Khirbet Al-Fakheit and Yata is a 55 minute drive, or 9 hour walk. There is no public service transportation.

In Gaza, nearly all imports and exports are blocked – and have been for 16 years – which has caused the economy to be near collapse, according to World Bank. More than half of the population lives in poverty, with 63% experiencing food insecurity.

An estimated 94,000 Palestinian women were already without access to sexual and reproductive health services prior to Oct. 7, according to the United Nations Population Fund.

Organizations like PFPPA work to bridge the hole through service delivery points in the West Bank Areas of Ramallah, Bethlehem, Hebron and Halhoul, and another in the Gaza Strip.

What’s happening now

The PFPPA has worked in the West Bank and Gaza Strip since 1964, working to ensure accessibility and availability of sexual reproductive health services and information to all the Palestinians.

On Oct. 8, PFPPA’s only center in Gaza was destroyed by an Israeli airstrike on a nearby building, cutting off their ability to offer services. According to CNN, the Israeli government has dropped 6,000 bombs between October 7 and 12.

“I think right now maybe the best word to describe this is horrific, because we’re not talking about a situation where everything was all in place before all of this,” said Awadallah. “Being under blockade for over 15 years, having extreme difficulty obtaining materials or resources from outside of the Gaza Strip… Even sexual and reproductive health and rights, contraceptives or family planning methods also were very limited there beforehand.”

Awadallah says that according to the latest information PFPPA has from their health workers in Gaza, hospitals were not handling pregnant women until they were in active labor because hospitals are so overcapacity and resources are extremely limited.

“They are waiting for a certain level. They will not accept women until they reach the level of where, she said, the baby’s head is starting to start to come out,” said Awadallah.

PFPPA published a first-hand account of one of their healthcare providers, Wafa Abu Hasheish, who described what she’s experienced in her neighborhood in northern Gaza, where she has been sheltering since Oct. 10.

“I have dealt with two suspected cases of miscarriages already, where there was no movement for the fetus and the mother had hypotension, bleeding and back pain. There has been one case where a woman was referred to where I am staying, since they knew I was a health service provider in the neighborhood,” said Hasheish.

She said that fortunately that woman, who was 8 months pregnant, was able to reach a health center to safely deliver her baby.

By Oct. 14, about 40,000 Palestinians had taken refuge at Shifa Hospital in Gaza City. But this war is quickly revealing that hospitals and clinics in Gaza are no longer safe havens. On Tuesday an air strike hit Al-Ahli Baptist Hospital, killing 500 people.

Earlier reports on Tuesday said that Gaza hospitals were reaching a state of “actual collapse,” with the electricity cut off, extremely limited, if any, water supplies, and power from emergency generators draining. This morning US secretary of state Antony Blinken also announced an agreement with Israel to allow aid into Gaza, though details were not specified.

“Humanitarian assistance is what they need right now in the Gaza Strip… the basic components of humanitarian dignity – We’re talking about shelter, we’re talking about food, we’re talking about water, Awadallah said. “We’re talking about electricity, we’re talking about health… accessibility, to be able to move and reach these health services as well.”

An estimated 1,000 children have been killed in Gaza since Oct. 7, according to Defense for Children International Palestine, and hospitals warn that thousands more people will die with both hospitals and displaced Palestinians forced to run on extremely low resources.

And for expectant mothers – no promise of a hospital bed, or safe space to deliver their babies.

“I cannot imagine, maybe the most beautiful moments that they were looking forward to might be, right now, the thing that they’re fearing the most,” said Awadallah.