When Tropical Cyclone Freddy slammed into Madagascar, Mozambique and Malawi, 32,000 pregnant women were due to give birth within the coming weeks.

The destruction of homes, health facilities and travel routes during the cyclone – which continued for weeks in February and March – made childbirth much more perilous.

Around 5,000 of the women could expect to experience complications in their final months of pregnancy or during childbirth, which, without access to skilled care, could prove fatal.

A climate crisis is an obstetric emergency.

[Pictured above] A young woman and child walk past damaged houses in the Chilobwe township of Blantyre, Malawi, after Tropical Cyclone Freddy hit. © UNFPA Malawi/Eldson Chagara

Eliza, 30, was nine months pregnant when the cyclone battered the city of Nsanje in Malawi, the country hardest hit by the storm.

“At first, it started as mere drizzle, but suddenly the intensity grew and it started pouring down in sheets,” she recalls. “I heard a huge thud from outside and immediately knew that part of the wall had collapsed.”

Eliza and her family left home and sought shelter at a makeshift camp, which had no running water. There, she went into labour.

Fortunately, despite disruptions to travel and services, an ambulance managed to make its way to her. “I arrived at the hospital around 10 p.m. At around 2 a.m., I gave birth to a baby girl,” says Eliza, now a mother of four.

[Pictured above] Eliza's newborn receives a checkup from Fainess Yobe, a UNFPA technical officer and a trained midwife and nurse. © UNFPA Malawi/Eldson Chagara

After a two-hour ambulance journey, Mercy, 37, gave birth to healthy twin boys, also in the city of Nsanje.

Mercy had been planning to deliver at her nearest health centre in Ndamera, but the electricity supply had been cut off by the storm.

“It was exciting and a bit scary at the same time,” she says, describing how it felt to learn she was having twins. “I am so grateful that I had a safe delivery. I don’t know what could have happened if the ambulance didn’t come in time.”

[Pictured above] Mercy at the maternity ward with her twin boys. © UNFPA Malawi/Eldson Chagara

Thanks to recent repairs of four ambulances, both Eliza and Mercy were able to make it to the hospital to deliver.

The repairs were supported by UNFPA in order to meet an increase in demand in the wake of the storm.

A staggering 87 health facilities were damaged in Malawi during the cyclone. The closure of local clinics means more emergency journeys.

[Pictured above] UNFPA supported the repair of four ambulances in southern Malawi. © UNFPA Malawi/Eldson Chagara

In the Zambezia province of Mozambique, where many local facilities have been damaged or destroyed, UNFPA installed temporary health facilities in six tents, including maternity wards.

Here, staff members are dealing with a triple crisis for thousands of pregnant women – cyclone, flood, and a cholera outbreak, which increases the risk of stillbirth.

“Managing cholera cases in pregnancy is very difficult because you need to prevent and treat both cholera and obstetric complications,” says Dr. Marilena Urso, a UNFPA maternal health specialist. “Time is of the essence, as healthcare providers must immediately intervene while monitoring fetal well-being and preventing the spread of cholera itself.”

[Pictured above] UNFPA tents being erected in Zambezia following storm damage. © UNFPA Mozambique/Helder Xavier

The first patients to be treated inside the new tents were Diana, 23, and her newborn baby.

Diana had given birth at home, but the following day the UNFPA tents opened, allowing her and her newborn son to receive postnatal care from skilled workers.

“Fortunately, mother and baby are in good health,” says nurse Lica Estevão, who provided assistance.

[Pictured above] Diana and her baby received postnatal care at a medical centre temporarily operating out of a tent. © UNFPA Mozambique/Helder Xavier

Rosana Henriques, a nurse in the city of Quelimane in Zambezia, describes the new tents as a “breath of fresh air.”

She explains that previously, there was a lack of privacy, as the storm damage had forced her team to work out of a single room in their facility. In the tent where she now works, there is a separate room for the maternity ward, giving people some space.\

[Pictured above] Rosana stands in a newly erected tent where women can give birth with the support of skilled staff. © UNFPA Mozambique/Helder Xavier

When Cyclone Freddy arrived in Madagascar, the country was busy recovering from another devastating storm – Cyclone Cheneso – which had hit a month earlier, in January.

Sadify, 18, was eight months pregnant when the first cyclone hit. 

“The rain fell for more than a week,” recalls Sadify, who received UNFPA support at a temporary site after being forced to leave home amid the crisis.

[Pictured above] Sadify received UNFPA support following Cyclone Cheneso. © UNFPA Madagascar/ Hanta Andremanisa

Part of UNFPA’s initial emergency response involves providing dignity and childbirth kits that include health and hygiene supplies to meet the most immediate of needs.

Sadify was unable to pack many belongings when she left her home after Cyclone Cheneso. “This kit that I just received will help us bounce back and better prepare for the arrival of our baby,” she says.

Dignity kits contain hygiene and washing items, a flashlight, a towel and a basin, while childbirth kits contain a plastic bag for the placenta, an umbilical cord tie, gauze tissue, a pair of disposable examination gloves and a razor blade and supplies for midwives.

[Pictured above] Dignity kits help meet the immediate needs of women and girls following a crisis. © UNFPA Madagascar/ Hanta Andremanisa

November to April is considered the cyclone season for East and Southern Africa – but cyclones are just one element of the region’s significant climate challenges.

The drought in Madagascar’s Grand Sud region, considered the worst in 40 years, has been going on since 2018. More than 70 per cent of the country’s land is used for agriculture, and cyclones, floods and drought have all caused food shortages.

Whether there’s too much water or not enough, there is an impact on women and girls’ sexual and reproductive health and rights – and their safety. During a crisis, incidences of gender-based violence increase, while at the same time, access to essential services is impeded. UNFPA works to close this gap and to provide support and safe spaces for women and girls.

[Pictured above] The drought in Madagascar’s Grand Sud region has been going on since 2018. © UNFPA Madagascar/Melvis Kimbi

Amid a crisis, it’s also crucial that family planning services remain accessible so that women are in control of their reproductive decisions.

For Pela Judith, 25, being able to choose not to have more children is one way to cope with the climate crisis in Madagascar.

“The droughts have changed many things. Now everything has become expensive,” she says. “I am not even able to feed my four children, so giving birth to another child is not in my plans anymore.”

[Pictured above] Pela Judith explains how the Grand Sud drought has changed her family planning decisions. © UNFPA Madagascar/ Hanta Andremanisa

After being uprooted by Cyclone Ana in 2022 in Malawi, Monica, who was six months pregnant with daughter Rehana at the time, is also using family planning services amid the crisis.

“We made the hard decision to abandon our land, which was owned by the family for generations,” she says. “The Cyclone Ana experience was a close shave with death, and we knew that next time, we wouldn’t be that lucky if we didn’t move.”

Monica accessed pre- and post-natal and sexual and reproductive health services supported by UNFPA. She opted for a contraception method that helps her plan her life around the crisis: “I got a five-year family planning method. This will allow us to raise our three children well and also to rebuild our lives.”

[Pictured above] Monica with daughter Rehana in the village of Jambo in Bangula, Malawi. © UNFPA Malawi/Eldson Chagara

UNFPA and its partners aim to provide sustained support for women and girls throughout a crisis.

We are also working toward long-term change, so that women and young people – those most affected by the climate crisis – can design solutions, and essential health services can continue to provide life-saving care.

[Pictured above] A young girl walks on waterlogged ground at a temporary camp following Cyclone Freddy in Blantyre, Malawi. © UNFPA Malawi/Eldson Chagara

“We suddenly woke up to the sound of the earthquake. My children had passed away in their beds, and my grandchildren were trapped under rubble,” says Kıymet.

“I was eight months pregnant. I was so scared. We couldn't stand up, our building was shaking so badly,” says Yonca.

“I woke up to realize that I lost everything in one minute – no home, no clothes, no money, nothing at all,” says Om Mohamed.

The moment of 4.17 a.m. on 6 February 2023 will be etched forever in the minds of millions of people across Türkiye and Syria. It’s when the first of two devastating earthquakes shook the region, with the second coming nine hours later. Thousands of aftershocks arrived in the weeks that followed.

[Pictured above] A woman looks over a scene of destruction in Jinderis, Syria. © UNFPA/Karam Al-Masri

As the scale of the disaster registered around the world, UNFPA launched an emergency response along with its partners.

The goal: to meet the immediate needs of women and girls in the aftermath of the crisis and to ensure the continuation of essential sexual and reproductive health services, including access to safe deliveries and contraception, as well as to protect displaced women and girls from abuse and violence.

Since the onset of this emergency, UNFPA has supported close to 500,000 people in affected areas.

[Pictured above] At a bazaar in Şanlıurfa, Türkiye, where people are sheltering in makeshift structures and vehicles, Gülsüm is among a team of psychologists, social workers and nurses who provide support. © UNFPA Türkiye/Eren Korkmaz

Three months on, the needs of women and girls remain stark.

Some 2.4 million earthquake survivors continue to live in camp settings in Türkiye, and some 1.9 million people in northwest Syria continue to live in camps or self-settled sites in dire conditions.

For millions of people, recovery is not happening quickly enough.

At this crucial stage, investment needs to be not only sustained, but ramped up. A protracted recovery will increase risks for women and girls as well as require more funds.

[Pictured above] A temporary camp on the outskirts of Diyarbakır, Türkiye. © UNFPA Türkiye/Eren Korkmaz

Lale, 22, is living with her family in a camp in Hatay, Türkiye. While she continues to wait for a tent of her own, she sleeps in a makeshift structure with her parents.

“We ran out barefoot in the rain; the babies had no jacket, no blanket,” says Lale, whose twins are six months old. “I have nothing left.”

Lale has received dignity and maternity kits with essential supplies but is still frequently running out of diapers, as well as food.

“I go to bed half full, half hungry, with my babies. We've been out in the rain too long.”

[Pictured above] Lale and her twin babies at an overcrowded camp in Hatay. © UNFPA Türkiye/Eren Korkmaz

For women and girls staying in camps, simply using the washroom can be a source of distress.

Many settlements lack adequate toilets and hygiene facilities. Adding to the problem, it can be difficult to make a bathroom trip after dark, when there is limited or no electricity.

Initially displaced from their hometown due to conflict, Salwa, 14, and Kholoud, 13, have lived for three years at the AlSekka camp in Idlib, Syria – an area affected by the earthquakes.

The two friends received dignity kits – which include supplies such as hygiene products and torches – provided by UNFPA partner Ihsan Relief and Development. “These things help us in maintaining personal hygiene,” says Salwa.

[Pictured above] Friends Kholoud (left) and Salwa look through the contents of a dignity kit. © UNFPA/Karam Al-Masri

In north-west Syria, the earthquakes are a crisis on top of a crisis.

After 12 years of conflict and human rights violations, people are living under untold strain. For many people uprooted by the earthquakes, this is yet another displacement.

“During the aftershocks, people were asking, ‘Is it a missile or another earthquake?’ If it was a mortar attack, people needed to go to the ground floor or basement; if it’s an earthquake, they needed to get out. People didn’t know what to do,” says Kinda Katranji, Communications Analyst in Syria who heard directly from women and girls affected.

[Pictured above] In the Syrian city of Maarat al-Numan, where many houses were damaged by war before the earthquakes compounded the destruction, mobile health teams are providing support. © UNFPA Syria/Massoud Hasan

Sex, periods and births do not stop during a crisis.

UNFPA has distributed tens of thousands of dignity kits and maternity kits since the onset of the crisis to women and girls in cities as well as in harder-to-reach rural areas.

[Pictured above] Dignity kits are distributed in the Sheikh Bahr camp in the countryside near the town of Armanaz in Syria. © UNFPA/Karam Al-Masri

Reports of gender-based violence, exploitation, abuse, child marriage and forced marriage have all increased following the earthquakes, at a time when services are overstretched.

In Syria, many safe spaces were damaged, like this one in Suran. So the teams went mobile, visiting women and girls at home and in temporary camps, to assess and support both psychological and practical needs.

UNFPA supports 52 safe spaces for women and girls across Syria, along with a helpline, as well as 23 safe spaces in Türkiye.

[Pictured above] A UNFPA safe space is no longer able to operate from its premises in Suran, Syria. It is among 12 safe spaces damaged in north-west Syria. © UNFPA/Karam Al-Masri

Hayfem and her husband and five children are Syrian refugees living in Şanlıurfa, Türkiye. They are sheltering in their vehicle, which they have parked at an outdoor bazaar for safety, along with other families.

A team dedicated to supporting migrant women and young people has mobilized to meet people’s needs following the earthquakes. The team includes psychologists, nurses and social workers.

[Pictured above] Hayfem and family have moved into their vehicle for safety. © UNFPA Türkiye/Eren Korkmaz

Mobile teams have also brought maternity services, including postnatal check-ups, to the camps.

Cahide gave birth shortly before the earthquakes struck. After being displaced, she arrived at a temporary camp in Şanlıurfa, where she was provided with a tent and received a medical check-up and maternity kit.

Across Türkiye and Syria, 60 mobile teams and 60 static clinics provide reproductive health and protection services, including emergency obstetric care, to some of the hardest-to-reach women and girls.

[Pictured above] In Şanlıurfa, Türkiye, UNFPA’s mobile team visits Cahide, who gave birth just before the earthquakes. © UNFPA Türkiye/Gözde Kumru

Baby Hala was born at Idlib Maternity Hospital in Syria. Her mother, Fatima, went into labour early.

“There are premature births due to anxiety, terror and psychological exhaustion that pregnant women experienced because of the earthquake,” says midwife Suad Muhiy-Aldeen. “There are cases of children with a very low weight.”

Hala was monitored in an incubator for the first few days of her life and thankfully now is healthy.

UNFPA-supported facilities have supported more than 1,350 safe deliveries and 400 C-sections in north-west Syria since the earthquakes.

[Pictured above] Fatima and her newborn daughter, Hala, at Idlib Maternity Hospital, run by the Syrian American Medical Society and fully funded by UNFPA. © UNFPA/Karam Al-Masri

Six days after the earthquakes, in the countryside around Aleppo, Syria, Khawla gave birth to quadruplets, who were all delivered safely at Al Fardous Hospital in Daret Azza.

Dr. Bushra Al-Khattab, who was trained by UNFPA, performed the Cesarean section.

As part of an inter-agency response, equipment and supplies have been delivered to health facilities, including equipment for C-sections.

[Pictured above] Khawla’s quadruplets are delivered by Cesarean section at Al Fardous Hospital, run by Syria Relief & Development with support from UNFPA.  © Ahmad Aljarban, SRD/UNFPA

“My joy is indescribable,” says Khawla. “I received services in this wonderful hospital for free. I thank the organization, the hospital and the medical staff for the services they provided me with and the warm welcome.”

The 25-year-old mother and her two older children, who are two and three years old, had been displaced by the earthquakes before she gave birth to her quadruplets. Khawla will be returning to tented accommodation – now with six children – and with uncertainty about what the future holds.

[Pictured above] Khawla with her four newborn babies. © Ahmad Aljarban, SRD/UNFPA

The immediate rescue efforts may be over, but there is still so much more that can and must be done.

With more clinics, mobile health teams, safe spaces and supplies, UNFPA can reach every woman and girl in need, but funding appeals for Türkiye and Syria remain woefully under target.

With additional funding, UNFPA will do whatever it takes to make sure that women affected by the earthquakes can give birth safely, manage their own reproductive choices, and live free from violence.

[Pictured above] UNFPA provides support at a temporary camp in Şanlıurfa, Türkiye. © UNFPA Türkiye/Eren Korkmaz