Delivering essential maternal, newborn, and child health care during crisis in Sudan 

When war erupted in Sudan on April 15, 2023, the tranquility of Khartoum was shattered. The once-safe sanctuary transformed into a battleground, with clashes erupting in its heart. Amidst the deafening roar of gunfire and the smoke of explosions, my small family and I were forced to flee our home, which had become a pawn in the deadly conflict. We sought refuge in the northern city of Ad-Damar, leaving behind the familiar streets and comforting routine of our lives. However, personal and professional obligations compelled me to return to Khartoum within days.  

The sight that greeted me was one of utter devastation—buildings reduced to rubble, streets littered with debris, and a haunting silence that echoed the city’s loss. My thoughts turned to our stores of vaccines and the vaccine cold chain—the lifeline that safeguarded the health of countless children. As I approached the cold chain facility in southern Khartoum, a wave of relief washed over me—despite the chaos that engulfed the city, guards and several employees of the facility remained steadfast at their posts, ensuring the uninterrupted operation of the refrigeration systems. Their unwavering commitment to their duty, even in the face of unimaginable adversity, was a testament to the indomitable spirit of the Sudanese people and the resilience of our health system, but I knew more issues were bound to arise as the conflict continued on.

Worldwide, roughly 1.8 billion people live in areas affected by humanitarian crises. In places like these, the need for maternal, newborn, and child health (MNCH) services—including antenatal care, childbirth care, emergency obstetric and newborn care (EmONC), small and sick newborn care, and childhood vaccinations—is ever-present, yet tragically unmet. Currently, countries with a UN Humanitarian Appeal account for 58% of global maternal deaths, 38% of newborn deaths, and 36% of stillbirths. 

Sudan stands as a stark example.  We are facing a complex humanitarian crisis—escalating armed conflict, the collapse of essential health services with multiple disease outbreaks, an unprecedented malnutrition crisis, and mass displacement. Sudan has the largest internally displaced population in the world. According to the International Organization for Migration (IOM), an estimated 7.9 million people have been internally displaced since mid-April 2023, including those who experienced secondary displacement. The surge of newly displaced people across Sudan has overwhelmed public services and resources in the areas of arrival, creating appalling living conditions for millions of people who face a daily struggle to survive. The situation is further exacerbated by significant damage to infrastructure, the collapse of banking and financial services, frequent interruptions to the internet, telecommunications and electricity supply and the destruction of health facilities. 

The ongoing crisis in my country has had a devastating impact on MNCH. In conflict areas, where all health institutions are either closed or lack the necessary medicines and equipment for childbirth, mothers who need institutional delivery are forced to travel long distances, sometimes on foot, in unsecure conditions to reach a functional EmONC facility in a safe area. On the other hand, at the area of arrival, quality of service provision is extremely affected by huge displacement that outstretches available resources.  

The conflict has also fueled violence against women and girls, including during childbirth and when seeking basic healthcare. Sudan’s National Reproductive Health Program estimates that over 328,000 births are expected in the next three months. Malnutrition among pregnant and breastfeeding women has reached alarming levels—1.2 million were acutely malnourished as of March 2024. This, combined with the significant mental health impact of ongoing insecurity, has led to an increase in preterm births, further straining already overwhelmed health care services and the absence of optimal neonatal critical care. The UN estimates that 220,000 children could die of malnutrition in the coming months. 

Despite the immense challenges, we remain steadfast in our commitment to improving MNCH outcomes. We are working tirelessly with local and international partners to: 

• Ensure community midwives are fully equipped to respond to home and community childbirth: The conflict has emphasized the importance of community midwives who should be optimally empowered and supported. Midwives have played a heroic role in Sudan since April 15, 2023. They have saved the lives of hundreds of thousands of mothers and newborns by providing maternity services at home and through their presence in primary health care units in the community. Provision of midwifery kits, clean delivery kits, and essential medications together with strengthening the in-service training and supervision systems are the focus areas in the current MNCH contingency plan. 

• Prevent a looming malnutrition crisis: A detailed famine prevention plan that addresses food insecurity and provides targeted nutrition interventions for pregnant and breastfeeding women was developed last March. Access negotiation to ensure therapeutic and supplementary food supplies and the Severe Acute Malnutrition (SAM) kits reach the last mile are successfully has led to implement the critical maternal and child nutrition interventions in conflict affected states. 

• Ensure safe access to health care facilities: Security measures and collaboration with local communities are crucial to guarantee safe passage for pregnant women reaching health care facilities.
• Protect health care workers: Safeguarding the midwives, nurses, and doctors who provide life-saving services is paramount. We must advocate for international support to ensure their safety and well-being so they can continue their critical work without fear. 
• Ensure functionality and readiness of EmONC facilities: With an extreme shortage of government funding to provide the operational costs for these facilities and provide the staff salary along with cessation of the National Health Insurance, it is critical to innovate alternative solutions. Refocusing the external support and the communities to ensure EmONC services continuity.   
• Ensure continuity of family planning strategy: With great support from UNFPA and IPPF, family planning commodities are constantly maintained and provided as part of the primary health care package at health facilities and within communities by midwives. 
• Strengthen the clinical management of rape protocols and related GBV guidelines: Continuous training on rape management protocols and prepositioning of essential GBV kits in facilities are regularly monitored. 
• Prioritize data management: We continue to prioritize RMNCH data management including maternal and perinatal death surveillance and response (MPDSR) to facilitate a responsive health system. 
• Coordinate amongst all national and international responders: We are strengthening the coordination and capacity to manage a complex network of actors and relationships, internally and externally, to ensure the MNCH agenda is not overlooked. 
• Ensure meaningful community participation and engagement: Sudanese communities and civil society organizations have been at the forefront of responding to the current crisis. Meaningful engagement between communities and national actors is critical to the resilience of the health system and meeting the health needs of the women and children affected by conflict.   

Local leadership and support are key to reaching all women and newborns in our country, but international support and collaboration are also crucial. Our humanitarian response plan is currently severely underfunded. We urge the global community to recognize the urgency of the situation in Sudan and prioritize investment in MNCH services within the broader humanitarian response. 

Sudan is just one example where progress toward the SDGs for MNCH must be addressed within the context of humanitarian and fragile settings. The WHO estimates that by 2030, over half of the world’s poorest people will reside in these very areas, making this an essential issue.  

I still think of that moment when I saw staff at their posts at the vaccine facility in Khartoum. It was a flicker of hope within the despair and a reminder of the resilience of the Sudanese people and their unwavering commitment to protecting their children. With our collective concerted efforts, together we can create a future where every mother and child, regardless of circumstance, can survive and thrive.