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

It’s common for pregnant women to have some anxieties about childbirth, but how they’ll be treated during labour should not be one of them.

Yet all around the world, an appalling number of women are subject to obstetric violence – the abuse and mistreatment of women during childbirth, including being forced into procedures against their will. In Latin America, it is estimated that around 43 per cent of women will experience this.

Specialist midwives are trained to provide more choices so women can have the delivery they want. Midwives increase safe births and make childbirth a more positive experience, among many other key services.

That’s why UNFPA provided human rights and leadership training to midwives in Brazil, Colombia and Mexico. The course is designed to recognize and strengthen the essential role of midwives in making services equitable and in delivering a high standard of care, free from violence and discrimination.

[Pictured above] Midwife Leonor attends to a pregnant woman during labour in São Paulo. © UNFPA/Tuane Fernandes

“I was hesitant to get pregnant again because the thought of going to hospital scared me,” says Erika, who had experienced obstetric violence with her first child in São Paulo, Brazil.

Her fears were making her reconsider her desire to grow her family.

When she discovered that there were alternatives to delivering in a hospital, Erika became pregnant with her second child, receiving care at a birthing centre.

“Here, they empower a woman in labour to know her own body. It is a more respectful approach, so this gives us a greater confidence,” she says. “The way you deliver a child into the world, a human being, a new life…it’s very important."

[Pictured above] Erika receives acupuncture, a safe and gentle way believed to possibly help turn a baby to the best position for birth, from Leonore at the Casa Angela birthing centre in São Paulo. © UNFPA/Tuane Fernandes

“I want every woman to feel respected in her pregnancy, birth and postpartum care,” says Leonor, who works at the Casa Angela birthing centre in São Paulo, where services are provided exclusively by obstetric specialists.

“Unfortunately, obstetric violence is very common; we hear many reports,” she says. “It hurts the woman not only physically, but also emotionally.”

Leonor believes there is a discriminatory element and that obstetric violence is linked to racism, which studies have confirmed.

[Pictured above] Leonor reviews ultrasound scans. © UNFPA/Tuane Fernandes

In Tumaco, Colombia, Elisa is head nurse of the delivery room at San Andrés Hospital. She, too, has observed that women who are more likely to face discrimination in daily life are also more adversely affected when it comes to childbirth, including people living in poverty and indigenous women.

“Tumaco is a remote area compared to other parts of Colombia and historically neglected. There is a lot of vulnerability, many social problems,” she says. “Political abandonment has increased the risks for indigenous women.”

“The human rights course is a great learning experience. Midwives have a very important place. It’s important to highly respect and value all women. Birth and care must be human, decent, and it must be intercultural.”

[Pictured above] Elisa says the human rights course is a “great learning experience.” © UNFPA/Carolina Navas

The long distances to reach specialist obstetric care from some rural areas means access is not currently equitable, and this can lead to crisis.

“If a woman has complications in our region, she may have to travel for five or six hours in an ambulance,” says Elisa. “We have had maternal deaths where mothers travelled for hours by boat. They arrived totally cold, hypothermic.”

UNFPA is committed to ensuring every woman has access to quality maternal and newborn care, and midwives are at the very heart of this mission. In addition to the human rights and leadership course, we have helped train more than 350,000 midwives to date.

[Pictured above] Elisa leads her team through a training exercise. © UNFPA/Carolina Navas

Erika, an intern of reproductive health and midwifery, grew up in the rural town of Tetetla, Mexico, seeing firsthand how people can struggle to access antenatal and midwifery services.

“I was motivated to become a midwife out of love and dedication to pregnant women and children in the community where I am from,” she says. “Learning that trained midwives could decrease maternal deaths was my greatest motivation.”

[Pictured above] Erika wants to help women in her hometown of Tetetla in Mexico. © Tomas Pineda

Erika is completing her training at the Tulancingo General Hospital in Hildago. Once qualified, her dream is to work with other professionals to make more life-saving support available to rural communities, including her hometown. “Maybe if the hospital is too far away, they will have another place closer,” she says.

[Pictured above] Erika takes a moment to reflect on her midwife training. © Tomas Pineda

Worldwide, 900,000 more specialist midwives are needed.

To close this gap, UNFPA is working in some 125 countries to strengthen quality midwifery training and to hold decision-makers, donors and health institutions accountable for their commitments to strengthen midwifery care and to protect maternal and newborn health.

Midwife Leonor says it is essential that midwives and obstetric nurses are recognized as the specialists that they are – and that more women have access to them.

“We have a [general] model in Brazil where a doctor leads most of the childbirths in the hospitals. So we are building this autonomy as midwives, in this leadership role for maternal health.”

[Pictured above] Midwives provide many crucial services that can save lives. © Andrea Murcia

Without specialist care, the decisions women make ahead of labour are not always respected.

For instance, in Brazil, 70 per cent of women in early pregnancy say they want a vaginal delivery, but more than half of babies (57.2 per cent) are born by Cesarean section. These C-sections are not all inevitable.

For women who did deliver naturally, only 5 per cent went through the experience without unnecessary interventions, as the Birth in Brazil study found.

[Pictured above] Leonor offers choices to women in her care. © UNFPA/Tuane Fernandes

In Mexico, Erika is also keen to decrease the number of C-sections for women who prefer a vaginal birth.

“We can make some manoeuvres so the baby is in the right position, helping the women try different positions, doing exercises such as psychoprophylaxis,” a method for coping with labor pain by using patterned breathing techniques and relaxation. She also offers options including aromatherapy, massage, music and water birth.

[Pictured above] Erika helps women exercise and find comfortable positions. © Andrea Murcia

Leonor says it’s not her role to be directive, but to assist women to be in control of their own labour, while providing knowledge, practical skills and support.

“Creating a bond during prenatal care is very important,” she says, explaining that this allows each woman to get to know the professional who will be with her during labour.

“We are women taking care of other women.”

[Pictured above] At a prenatal class, Leonor shares information with women and their birthing partners about the choices available to them. © UNFPA/Tuane Fernandes

It’s time for choices to be put into action.

Birthing plans are designed to be adaptable, with respect for women’s choices – from the lighting and temperature in the room, to the positions they want to try, to the way they want to manage pain.

[Pictured above] Leonor supports a woman through her labour. © UNFPA/Tuane Fernandes

Leonor helped to safely deliver baby Téo. He is 11 hours old.

[Pictured above] Baby Téo snuggles in his crib. © UNFPA/Tuane Fernandes

“It doesn’t look like you only gave birth [less than] 12 hours ago,” says Leonor, chatting with new mother Carolina.

Téo is Carolina’s third child. Like Erika, Carolina came to the Casa Angela birthing centre because she did not want another hospital birth.

This time, she says, “I felt my feminine strength much, much more. This was what I was looking for, to feel my freedom to do as I want; it felt exactly how it should feel. And that’s what makes the moment more special."

[Pictured above] Leonor provides postpartum support, including breastfeeding guidance. © UNFPA/Tuane Fernandes

“When the baby is born, we put the baby close to the mother’s chest to feel her heartbeat,” says Elisa, the head nurse of the delivery room at San Andrés Hospital in Colombia.

She describes doing the same with fathers, to promote bonding between newborns and parents, and she makes it possible for fathers or birthing companions to cut the umbilical cord if they wish.

[Pictured above] Yolimar holds newborn baby Brenda while partner Giovani looks on at San Andrés Hospital in Colombia. Yolimar is Venezuelan, Giovani is indigenous, and they live on a rural reservation. © UNFPA/Carolina Navas

“To bring a person into this world, born healthy, without complications, to present him to his mother, it's an incredibly happy moment to welcome that little baby,” says Erika, the midwifery intern in Mexico.

[Pictured above] A newborn baby is delivered safely in Mexico. © Andrea Murcia

Nurse Elisa says UNFPA training has helped empower obstetric specialists to establish sexual and reproductive health as a right. The “extraordinary courses,” she says, “have changed me as a human being.”

Midwife Leonor shares Elisa’s sentiment. “It is important for us to keep fighting for human rights,” she says. “When we do training like this, see what women are still going through; we see how much we still have to fight for.”

In a world where a woman dies during pregnancy or childbirth every two minutes, midwives save lives.

[Pictured above] Leonor holds baby Téo in his softly lit room. © UNFPA/Tuane Fernandes