Gaza City, Gaza Strip – On a mattress placed on the floor of a half-destroyed apartment, Duha Abu Yousef sits holding her newborn baby with great difficulty after an emergency caesarean section was performed following her arrival at a hospital the night before.

Abu Yousef, 24, who had entered her ninth month of pregnancy just a few days earlier, had hoped for a natural birth for her first child and to complete her final month of pregnancy.

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However, due to her severe anemia, doctors decided to perform a caesarean section to protect her baby.

Throughout her pregnancy, Abu Yousef endured physical and psychological pain due to Israel’s genocidal war on Gaza. What affected her the most was famine and the prolonged shortage of food and nutritional supplements, which severely weakened her body.

“Throughout my entire pregnancy, I didn’t taste meat, chicken or eggs, … only in the last three months when things improved slightly,” Abu Yousef, who is displaced, told Al Jazeera from her shelter.

“Even nutritional supplements were unavailable. I was constantly unable to move, suffering from headaches and continuous nausea due to lack of food.”

Famine and food shortages caused Abu Yousef to suffer from anemia throughout her pregnancy despite her attempts to improve her nutrition to raise her blood levels.

“Any pregnant woman generally suffers from low blood levels, but food helps improve her condition,” she said. “However, in Gaza, there is famine, iron deficiency and everything else.”

Compounding that was the psychological impact of events she had to face in the early months of her pregnancy, particularly the killing of her brother and his wife by an Israeli tank shell.

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“I was crying all the time, … completely lost and deeply sad.”

Rise in caesarean sections

April is Caesarean Awareness Month, which was designated to raise awareness about the procedure and support mothers who have gone through it.

In Gaza, the dangers that can accompany the operation are amplified by a wider health system collapse. And yet, as Dr Fathi al-Dahdouh, the head of obstetrics at Gaza City’s Al Helou International Hospital, explained, the number of caesarean sections has increased by about 2 percent since before the war, and now make up a quarter of all births.

Al-Dahdouh said difficulty in travel caused by the war means that some pregnant women arrive late to the hospital, reducing the possibility of natural births and increasing emergency surgeries.

He also noted a growing trend of pregnancy as a form of “compensation for loss”, especially among women who have lost children or family members.

“We see cases of women in their late 30s, even over 40, who decide to become pregnant despite the risks simply because they lost children during the war,” the doctor told Al Jazeera. Pregnant women who are older are more likely to have caesarean sections than younger women.

Dr Ruba al-Madhoun, an obstetrician-gynaecologist working at the International Medical Corps field hospital in Gaza, says many pregnant women arrive in critical condition with injuries due to bombardments. They can suffer placental abruptions, which pose a direct threat to both mother and fetus and require immediate surgery.

She added that shortages in medical equipment and supplies have played a major role in increasing reliance on caesarean sections, including the lack of continuous fetal monitoring devices and the absence of labour-inducing medications.

In some cases, this has eliminated the possibility of natural births altogether. Heavy pressure on hospital wards and shortages of staff have also made caesarean deliveries at times the fastest and safest available option.

Infection danger

The dangers from caesarean sections in Gaza often come after the procedure, particularly with the risk of infection.

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Displacement brought on by Israeli destruction of housing, malnutrition and deficiencies in essential nutrients, such as protein and iron, directly affect wound healing while overcrowded tents and contaminated water significantly increase infection risks, both for caesarean wounds and overall.

“This is further compounded by severe overcrowding in wards, where multiple patients often share a single room,” al-Madhoun said.

Al-Madhoun added that there have been a growing number of surgical wound infections at a time when hospitals face shortages of appropriate antibiotics and lack laboratory capacity to identify bacteria.

Sanaa al-Shukri, 35, returned to the hospital 10 days after giving birth due to a recurrent infection in her caesarean wound.

From her hospital bed, al-Shukri described the intense pain she experienced when doctors reopened the wound without anaesthesia and cleaned out the accumulated pus.

“I felt like my soul was leaving my body,” she said.

Doctors attributed al-Shukri’s infection to the lack of a proper healing environment despite her attempts to care for the wound.

She lives in a tent in Gaza City’s Tuffah neighbourhood, where she faces major difficulties in her postpartum recovery.

“The bathroom is terrible and unclean. … It’s a pit in the sand, full of flies and insects, far away,” al-Shukri said. “There is no wall in the tent to lean on, no bed. … I sleep on the ground.”

“I tried to clean the wound and change the dressing, but it became infected. The tents have become very hot lately, and doctors say the water is not clean,” she added.

Al-Shukri’s husband, Mohammed, 50, lost his entire family – his wife and seven children – in a bombing on their home in Jabalia at the beginning of the war.

He has since tried to rebuild his life with Sanaa.

The couple named their newborn Ahmed after Mohammed’s eldest son.

Despite her happiness at the birth, her recovery inside a tent has become a daily struggle against harsh environmental conditions.

“I started saying it is wrong to give birth in these tents. … Heat, mosquitoes, flies, rats, dogs, … everything is here,” she said.

“All night I hear rats on the tarps,” al-Shukri added. “I couldn’t even move. I stayed awake and woke my mother out of fear for the baby. I will never give birth in a tent again. … It is suffering.”