Deaths from violent conflict and lack of available care are major causes of mortality among pregnant women in war zones, warn doctors in an editorial published in The BMJ today.
More needs to be done to protect women from violence in conflicts, and to provide appropriate medical care required, they argue.
"In times of war, the focus is usually on the male soldiers", they explain, but an estimated 140,000 women die in conflict every year.
An unknown proportion of these women are pregnant at the time of death, and contribute to the estimated 303,000 women already expected to die in pregnancy and childbirth.
"In international humanitarian law, pregnant women should be protected," they explain, "but this rarely happens, and militant perpetrators are difficult to hold to account."
Violence is directed specifically against pregnant women, for example, through torture and rape--both used as weapons of war--in countries such as Syria, Nigeria, and Congo.
"Those lucky to survive are at risk of post-traumatic stress disorder, which negatively affects maternal functioning, parenting, and compliance with medical therapies," they explain.
Sexual health services are generally non-functioning, and prevent access to contraception, safe abortion, and treatment for sexually transmitted disease.
Furthermore, health services can be destroyed in wars, as seen in the recent massacre of 11 Médecins Sans Frontières health workers in Syria, and the bombing of Kunduz trauma hospital in Afghanistan.
"The cumulative effects of these problems can be devastating for women in war zones--and in turn take their toll on their children, families, and communities," they warn.
"All too often the only option is for women to attempt the dangerous escape from the war zone and seek refuge in other countries."
They suggest a number of solutions, but urge that "the final answer must lie in political settlements to resolve the root cause of the conflict. Warring parties should be educated about international humanitarian law to tackle the underlying ignorance."
"But while the conflict continues, care needs to be provided," and they outline the health services that are crucial for pregnant women, such as a safe place for birth, with emergency obstetric and neonatal care.
"A functioning operation theatre is also vital," they say. Of over 18,000 operations carried out 'in the field' by MSF Brussels in 2014, 21% were caesarean sections and 6% other gynaecological or obstetrical procedures.
But the authors conclude that "only peace will allow a true resumption of effective reproductive health services. A focus on women's health could, in some cases, provide an area of common interest between sides seeking to find political solutions."