All but a few hospitals in Sudan’s capital, Khartoum, have closed down because of the conflict raging there. Those that remain open often run out of power, making giving birth an even more stressful experience than usual for both the women and the healthcare workers trying to help them – especially if surgery is needed.
“We’re relying on lights from mobile phones to perform a Caesarean,” obstetrician Dr Howaida Ahmed al-Hassan said on a video shared with the BBC.
She recorded the footage as she was operating on a mother-to-be.
Her gloved hands can be seen applying pressure to the patient’s chest and stomach as the Caesarean takes place.
The medics present – all women – surround Dr Hassan and hold their phones up to illuminate the area where an incision has been made.
Dr Hassan was one of the handful of obstetricians who remained at Alban Jadeed Hospital, in the north of Sudan’s capital, Khartoum, for three consecutive weeks after heavy fighting erupted between military factions in April.
In the video she sent to the BBC, she showed wards with nurses assisting mothers giving birth under extremely tough conditions.
“The situation is really bad. We’ve stayed in the hospital for days and days. We’ve completely lost any sense of time. We don’t know if it’s day or night,” Dr Hassan said.
“There is minimum medical staffing in the hospital, and in many cases the electricity cuts out and we have no gasoline to operate the generators for Caesareans.”
She said the maternity ward in her hospital was packed with women in dire need of emergency obstetric care, many requiring Caesareans.
“We have taken high risks performing these Caesareans in dimly lit operating theatres. We do not have enough resources.
“We work in the absence of general anaesthesia consultants and specialists. We’ve had to discharge women only 10 hours after each Caesarean delivery.”
In April, the UN Population Fund estimated 219,000 pregnant women were believed to be at risk, as heavy fighting raged around Khartoum, interspersed by fragile and failed ceasefires.
Near the beginning of the fighting it said that around 24,000 would give birth “in the coming weeks”.
Bashayer al-Fadil was one of those women. She had a Caesarean just days after clashes erupted in Khartoum.
On a video call with the BBC she could be seen cradling her one-week-old baby girl, Omayma.
She said she was lucky to find a hospital that was still open and she was admitted amid sporadic gunfire.
“Explosions could be heard in the streets,” Ms Fadil said.
Most hospitals in her area were not functioning, so she was only able to give birth in a hospital thanks to her network of contacts.
Only one out of every six hospitals in Khartoum is working at full capacity, according to the World Health Organization (WHO).
“I was trying to look for any hospital that would admit me for a Caesarean and I was lucky enough to find the hospital with help from my doctor and friends.”
On the delivery day, Ms Fadil said she and her husband had to run through gunfire that swept across their neighbourhood, until they arrived safely at the hospital.
“I have given birth in tough circumstances. Even the simplest things, like water, were not available.”
The new mother has not been able to get a birth certificate for her baby, nor give her essential vaccinations, as the violence continues to rage.
Ms Fadil’s experience is not isolated. She said dozens of her pregnant friends had had difficulty getting to hospitals, and many had suffered miscarriages.
Omdurman Maternity Hospital, one of the largest of its kind in Sudan, closed its doors a few days after the clashes began.
Dr Kameel Kamal, a consultant gynaecologist there, told the BBC that most maternity hospitals in Sudan were now out of service. As a result, thousands of pregnant women faced dangerous complications, he said.
“Although there are no official statistics, we estimate large numbers of pregnant women are left to scream [in pain] in their homes.
“I’m sure there are lots of home deaths, haemorrhages, miscarriages, ectopic pregnancies, breech births, still births and many cases [of patients] who cannot get access to treatment,” he said.
Dr Kamal warned that the fighting was taking a “disastrous toll” on pregnant women in Sudan.
Even before the conflict began, Sudan had among the highest number of maternal deaths in the world, according to the WHO.
‘We create lives, they kill us’
Midwives are still playing a vital role with some continuing to make home visits.
Midwife Mawaheb, who did not give her surname, told the BBC she had helped around seven women have safe natural deliveries since fighting broke out.
“When I receive a phone call to be asked if I can help a woman in labour, I immediately head towards this woman’s house without hesitation.
“In most cases, labour goes smoothly. If there is a problem or complication, I send the woman to the nearest functioning hospital,” she said.
Despite the mounting odds in hospital, obstetrician Dr Hassan said medical staff try to keep spirits high and celebrate babies being delivered safely.
“We create lives, they kill us. We help two souls stay alive – a mother and a baby,” she said.
The United Nations Population Fund in Sudan has posted on its Twitter account a list of contacts for trained midwives who are able to offer pregnant women antenatal care and help those in labour have give birth safely.