In the two weeks since Hamas’ horrific terror attacks, Israeli forces have carried out a brutal assault on Gaza, killing thousands of civilians and displacing nearly a million Palestinians. Air strikes targeting at least 59 health facilities have battered medical infrastructure that was already in shambles after 16 years of Israeli occupation. More than 60 percent of primary health care centers now are shut down, according to the U.N.’s Office for the Coordination of Humanitarian Affairs, and four hospitals in northern Gaza have been evacuated. Israeli authorities also have imposed a total siege on Gaza’s access to food, water, electricity, and fuel, plunging the territory into what one United Nations division called an “unprecedented catastrophe.” Among the civilians suffering: An estimated 84,000 pregnant women, some of whom have already delivered babies in these conditions, and Gaza’s substantial child population, which accounts for almost half the strip’s inhabitants.

On Wednesday, Israel agreed to let a small number of workers waiting at the Egyptian border cross into Gaza with food, water, and medicine. It’s unclear how much these resources will help; aid is not expected to reach northern Gaza, where most of Israel’s attacks have landed and where many are stranded in hospitals and unable to safely evacuate. Dr. Yara M. Asi, an assistant professor at the University of Central Florida’s School of Global Health Management who’s worked with Amnesty International on policy reform and outreach, has spent years chronicling the medical crisis in occupied Palestinian territory through focus groups and interviews on the ground. She shared with the Cut that she’s received harrowing updates in recent days from colleagues and students in Gaza. “Every bad outcome that you can imagine is going to befall these people,” she says. Here, she describes the dismal state of maternal and infant health in the strip right now.

Before the current humanitarian crisis, UNICEF estimated that one in four pregnant women in Palestine were considered high-risk (worldwide, the rate for high-risk complications is only 6 to 8 percent), and the infant mortality rate was 13 percent. What factors made maternal and infant health in occupied Palestinian territory so dismal before Israel’s siege started?

Gaza has stubbornly high infant and maternal mortality rates. In the pre-existing siege, Israel created a “dual use” list of items that they deemed potentially usable for military purposes, which severely limited goods entering the territory. That includes lumber and concrete for building facilities, so every time the health system gets attacked, it is never fully rebuilt. What’s left of the deteriorating health infrastructure is primary care services and some trauma-care services. Specialized reproductive maternal services and children’s health services are much more limited.

If you have any complications in a pregnancy, or if your newborn has complications, you’re facing a health system that doesn’t have the resources, the hospital beds, the medications, or even basic goods and supplies. People with really traumatic injuries or chronic illnesses would apply for medical permits, which are Israeli-issued, to get care in Israel or the West Bank. Those permits can be denied or delayed to the point where you’re missing your appointment. We frequently see a child’s permit get approved, but the parent is denied. Pregnancy lasts nine months, and these permits can take up to six months to get. The types of issues that a pregnant woman may have are often emergencies: She wakes up bleeding all of a sudden, for example. She doesn’t have time to apply for a permit.

Based on what you’re hearing from colleagues, how has the current siege escalated all these preexisting concerns?

The updates are harrowing. Hospitals are getting a thousand new patients per day, many with traumatic injuries. They’re running out of basic dressing and gauze, using cloths and rags and blankets to tourniquet people’s wounds. I’ve heard from physicians that they’re performing emergency surgeries without anesthetics because they don’t have any. They’re starting to worry about potential infection rates because their sterilization machines don’t have power. The conditions are unsanitary because people are splayed everywhere. Oftentimes health workers, who have family at home, are working 24-hour shifts for four or five days in a row. They’re also scared for their lives.

A lot of doctors have told me they receive children who are the lone survivors of an attack on their families. We’ll have a lot of orphans coming out of this. They’re triaging people who need immediate care, so we will undoubtedly see babies that could have been born, that could have thrived under different conditions, die.

A WHO spokesperson has estimated that there are 84,000 pregnant women in Gaza, and the UNFPA says 5,500 are expected to deliver in the next month. How are these conditions affecting them?

We’re going to see a significant increase in infant and maternal mortality, not just from airstrikes, but from inability to feed an infant and to deliver in safe, hygienic circumstances. During the last few months of pregnancy, you need not just medical care, but nutritional food, access to clean water, some feeling of mental safety. If the deprivation continues, pregnant women are going to start dying of malnutrition and lack of water. There’s an estimated 1 million people displaced, so most people are going from place to place — they sleep at a school one night, they sleep at an uncle’s house the next. The stress of going through this is going to have unquantifiable impacts on pregnant women.

I read an interview with a woman who said she could feel her baby moving excessively while she was hearing the bombing, as though the baby was also hearing and experiencing it. We don’t know how to quantify those kinds of effects on a growing fetus. This situation is not only going to make miscarriage more difficult, it will undoubtedly increase miscarriage rates as well. We’ll certainly see increased rates of postpartum depression.

What does delivering a baby in this environment look like?

Women who can get to a hospital to deliver are being discharged almost immediately because they need beds for trauma cases. They don’t get time to rest, recover, do skin-to-skin, or figure out nursing. They’re not reporting births because the health registry is completely non-functional right now. Many women are scared to leave their homes because there’s intermittent bombings, and we know hospitals are not safe. So they’re giving birth at home.

Delivering babies at home isn’t impossible, but in these conditions, with zero access to healthcare and, as of right now, to clean water, there will be infections and stunted growth. We’ve heard of women who had newborns, and they’re so stressed that their bodies are unable to produce milk, or the child is so stressed by the sound of airstrikes that they’re unable to latch. There’s no formula or diapers. Hospitals have no electricity and are running out of fuel for incubators, so newborns who would otherwise need extra support to help them leave the hospital in relatively good shape — even that moderate level of protection is gone.

What kind of medical care do women experiencing miscarriages need, and are they able to get any of that right now?

If a woman has a miscarriage at home, she may just need a checkup to make sure she’s not excessively bleeding. Physicians are not in a position to do those kinds of checks right now. If they’re miscarrying at a more advanced stage of their pregnancy, you may have women going into labor with stillborn babies. This is incredibly dangerous, especially if the baby is breech or if there is any issue with the umbilical cord. Women who miscarry have no time to mourn. They’ll probably have to go through the physical experience and then immediately reprioritize their own survival.

What other maternal health concerns can we expect?

Women are typically impoverished in Gaza to begin with. Most women don’t work because the unemployment rate is so high. If their partner dies — and we’re seeing a lot of men being targeted — then you have a woman who is not just alone, potentially pregnant or with a newborn, but has zero form of income if and when things slow down. So there’s also some economic aspects that are going to be a real challenge for women in the aftermath.

It seems like some humanitarian support might be trickling in — Israel has said it will allow some very limited supplies in from Egypt. Do you see that helping with any of these concerns?

The priority right now is trauma care and restocking the basics. It doesn’t seem like they’re going to funnel that aid to the north, where they have issued these evacuation orders. That’s where many of the Gaza Strip’s hospitals are, including the largest hospital, Al-Shifa, and one of the primary cancer centers. If aid is kept in the south to encourage people to congregate there, it’s not going to help those people at all. They’ve also mentioned that they’re going to ensure this aid is not used by Hamas or taken by any of the other militant groups. What does that mean in practice? Does that mean that they’re going to limit the kinds or types of aid that they’re going to let in?

Many hospitals, particularly in north Gaza, have received evacuation orders. How, realistically, can they do that?

You cannot just throw these people in a car and send them to a different hospital. For one, there’s no fuel, so cars aren’t going anywhere. Two, ambulances are often retrieving trauma patients from previous explosions. They’re not sitting outside the hospital able to transport patients. Three, when you leave the hospital, you’re also leaving that infrastructure. Other hospitals are full, so if you take a patient out of their initial hospital, they’re just not going to get care. Unplugging some of these patients and taking them out of the hospital environment will kill them, and many generators are running incubators that keep babies alive. There’s no alternative for a newborn. It is a death sentence — that’s not hyperbole. That’s why we’re seeing paramedics and physicians in Gaza saying, We are just going to stay.

We still don’t know definitively what was behind Tuesday’s explosion at al-Ahli hospital, though several other hospitals and care centers have been damaged by Israeli airstrikes. How does this destruction affect the few remaining health workers’ ability to help? 

Regardless of what happened at al-Ahli, there are several dozen documented incidents of Israel bombing or damaging hospitals. It kills and harms medical staff. There are already very few specialists in the territory, and many have fled to the south or sheltered at home with their families. There’s already a low bed-to-patient count in the Gaza Strip, and even if the airstrikes were to stop tomorrow, this infrastructure will take years to get back to the stage it was before October 7 — which was already insufficient. Every specialized machine is not only thousands of dollars but was likely weeks or months of paperwork and finagling just to get it imported. It also causes strain on other hospitals.

Half of Gaza’s population is under 18. What kind of help does that age group need most right now?

At this moment the biggest detriment to children is lack of access to food, water, and shelter. And secondary to that would be trauma care after airstrikes. At this point, children with chronic illnesses or who need dialysis are probably not getting any services at all.

Basically every child in Gaza has mental-health issues. There’s been some debate about whether it’s even appropriate to call it PTSD because it’s not post-traumatic. It’s chronic trauma. They’re not fearing something irrational that happened in the past; they’re fearing active circumstances and for good reason. Mental health is deprioritized everywhere in the world, even in the richest countries. When you layer onto that a really poor population with a bad health system, mental health is priority Z.

Is there any kind of mental-health care that can help children or postpartum or pregnant women at the moment?

Right now, the priority is physical survival. A lot of people lean on their faith as a form of mental self-care. I’ve heard recordings from mothers who say, “I’m trying to be strong and rely on God so that I can smile for my kids.” Mothers are doing what mothers always do, which is shoving their own needs aside and trying to deal with the needs of their children. I don’t even think they would have a conception of their own mental health because they’re worried about keeping themselves and their child alive. We have seen efforts, especially in the U.N. schools, where teachers are trying to play with the kids and give them mental-health support in the form of drawing classes or singing. Even amongst all this, they’re trying to give the children some semblance of normalcy.