State of the World’s Mothers is focused on the impact of humanitarian crisis on maternal and child survival in countries known to be the most dangerous and difficult places to be a mother. The 15th annual report by Save the Children documents why mothers and children are particularly vulnerable in war-torn countries in need of the most humanitarian assistance and increasing health-care where governments have failed in their responsibilities.

According to the report, almost one-third of child deaths happen in South Asia, with high mortality rates found in socially excluded communities that remain fragile with poor access to health-care, such as in Khyber Pakhtunkhwa in Pakistan and Indian states of Bihar, Uttar Pradesh and Orrisa.

Making sure mothers and children do not face high risks of death would imply that governments restore stability which entails challenging short-term goals. High risks of death makes the road to recovery even more challenging in situations of crisis where countries lack the capabilities to contend with extreme poverty, conflict displacement, weak infrastructure and poor governance.

It has been estimated that 80 million people are projected to be in need of humanitarian assistance globally in 2014, with majority living in impoverishment of which three-quarters are women and children.

According to this report, 56 per cent of maternal and child deaths happen in fragile and conflict-ridden countries in the developing world where the average refugee situation lasts 17 years. Countries that suffer conflict have lesser health workers and high mortality rates. Children and women die indirectly from diseases, medical complications and malnutrition.

This report focuses on four countries impacted by humanitarian emergencies, including Syria where the civil war in its fourth year has had a devastating impact on mothers and children with almost 1.4 million children and 690,000 women having left the country as refugees.

In December 2013, the United Nations put out a plea for $6.5 billion to deliver food, shelter and healthcare in Syria. Thousands die every month from malnutrition and lack of medical help as the conflict that has drawn militant fighters from all over continues to impact mothers and children where there is now evidence that because of the violence and collapsing health services, new-born deaths are on the rise and children in many parts of the country have limited or no access to vaccinations. In over a decade, polio and measles have been reported with the World Health Organization declaring Syria as one in three countries, alongside Pakistan, with a polio endemic.

Pakistan has the highest first-day mortality rate for babies in Asia making it the most dangerous place in the region to be born, says the report. About 60,000 Pakistani babies die within the first day of life, accounting for 30 per cent of all newborn deaths. Reasons include high rate of preterm births, low birth weight, poor nutritional status of mothers, poor family planning, lack of health workers and early childbearing.

The report also cited ‘horrific abuses against women and children’ as the civil war in the Democratic Republic of Congo causes mothers immense suffering. According to Save the Children, it is statistically more dangerous to be a woman or child than an armed fighter in the Democratic Republic of Congo, which ranked second to last in the rankings.

The Mothers’ Index that assesses the well-being of mothers and children ranks Somalia as the worse place to be a mother coming in last on a list which scores mothers’ and children’s health, education, economic and political status.

All 10 bottom ranking countries, including Chad, Niger and DR Congo, show a recent history of armed conflict where citizen expectations and basic needs are unmet.

At 147, Pakistan is ranked as one of the more difficult countries to be a mother, falling behind India. Finland ranks as the best place to be a mother.

Childbirth during conflict

Findings by the Centre for Research on the Epidemiology of Disasters state that those affected by conflict in 2012 were residents of conflict zones rather than refugees who had fled the war.

Pakistan with 28 million and Nigeria at 19 million both had the largest numbers of people affected by conflict.

More than half of all maternal deaths occur in fragile states because women living in conflict-ridden areas cannot access proper health facilities to give birth safely. They cannot travel to health facilities and may have to give birth on the run without access to clean facilities. The key causes of maternal death – obstructed labour and hemorrhage included – that are preventable and treatable are not accessible in areas of conflict.

When women die they leave behind families and children. Older children will drop out of school to look after younger babies. It is this devastating cycle of poverty and lack of access to basic rights that causes malnutrition in families, all pointing to the failure of the state. Poor governance and provision of services is the direct result of scare resources and inadequate planning but corruption and lack of administrative interest are also contributing factors.

Lack of access to health care

Health care, when disproportionate and unaffordable, results in malnutrition and increased vulnerability to disease. In Pakistan, skilled health workers available during pregnancies and birth in villages and communities where access to larger health facilities is not possible form a cadre that can minimise deaths and birth complications. Conflict-ridden states are seen to employ less than half the health workers required with many working long hours for little compensation and with few medical supplies as is the case of Pakistan’s lady health workers. Their job is crucial; while providing medicines and raising health awareness, they link women to the health system. Protecting health workers from attack and training an increased force is crucial in developing countries where health facilities and medical supplies are not reachable.

Pakistan’s lady health workers traditionally working within communities on population control mechanisms and awareness campaigning are under threat having the responsibility for administering polio vaccinations.

Last year, health workers were killed in Pakistan, Nigeria and Syria by militant groups: in the case of Pakistan, health workers remain targets because they work with the countrywide polio immunisation programme as are the police that accompany them to volatile parts of the country.

With many countries in South Asia taking strides to reduce maternal and child mortality, Pakistan is ranked as one where progress has been 25-50 per cent slower, says the report.

Bangladesh, China and Nepal have improved their record in saving women and children’s lives despite natural disasters which points to how they have achieved progress and .

Gender-based and sexual violence

Much still needs to be done to address the needs of women and children in humanitarian emergencies where trauma caused by upheaval and displacement because of conflict is not uncommon. Refugees and internally displaced people are at greater risk of gender-based violence and sexual abuse because of the cycle of poverty and helplessness that characterises their situation. Rape is used as weapon of war as found in African countries and Syria, more lately, where women must not only suffer the violent abuse but perpetrators operate with impunity.

The report points out that sexual violence against children is ‘shocking’ with research revealing that many victims are under the age of 18. It recommends that prevention of violence must be high on the agenda when it comes to improving reproductive health in crisis situations where prevention strategies include educating community members to reject gender-based violence and identify high-risk individuals.

Family planning and early marriages

Family planning is known to save women’s lives and preserve their health in developing countries where a woman’s ability to limit her pregnancies also depends on her education, her access to family planning information and the consent of her husband. The ability to limit and space pregnancies is a human right and in conflict areas lack of family planning services and patriarchal attitudes make it even more difficult for women to gain access to birth control measures.

The report says that 70,000 adolescents in developing countries die each year because of maternal causes. Girls who become pregnant under the age of 15 in low-income communities in Africa and South-Asia are at double the risk of maternal death than older women. Tackling child marriages is imperative when reducing maternal and child mortality though where it remains the traditional norm despite legislation it has limited women’s opportunities, made life more difficult and unhealthy for women and their children.

When poverty in larger families struggling to cope and feed children remains the problem in most developing countries, healthcare is not a primary priority for women. Pregnant women give birth alone without a doctor because they cannot afford the trip to the hospital or a midwife. Mother neglect their own health to feed their children and health care facilities discriminate in countries like Pakistan when it comes to the poor finding it unaffordable to make payments for essential health care. Worse is the crisis of care and facilities in a conflict zone where emergencies are not addressed and women find it hard to leave homes and visit the nearest hospital.

However, there are signs of progress in countries such as Afghanistan where the conflict had limited basic services and health care accessibility for women and children. It has cut maternal death rates by 60-70 percent since 2000 along with Nepal, Bhutan and Bangladesh. In 2010 and 2011, Afghanistan was ranked as one of the worse places to be a mother but has now risen considerably in the Mothers’ Index with the help of international donor funded programmes focused on training midwives, improving immunisation coverage raising girls’ education levels – all of which have contributed to women and child health and progress.