Sub-Saharan Africa, home to the world’s fastest-growing population, accounts for 70% of global maternal deaths. Each year, about 180,000 women on the continent die from pregnancy-related causes, along with roughly 1 million newborns.

The crisis is especially acute in conflict zones like the Central African Republic, where war, displacement and shrinking aid have turned childbirth into a deadly gamble.

For Maude Ahmad Fadala, the danger began shortly after sunset. Her baby was coming. She was in a refugee camp near the Sudan border, weakened by typhoid. There were no facilities for delivery and she had no money for transport to the hospital. She struggled to her feet and started walking, stopping every few minutes as contractions gripped her, until she could go no farther.

"I gave birth in the street,” she said. "There was no doctor, no midwife, and no one holding my hand.”

Nearly two-thirds of maternal deaths worldwide occur in countries affected by conflict or "fragility,” the World Health Organization said this year.

For women like Fadala, who fled Sudan’s war to the Central African Republic, the danger does not end at the border. Displacement often means missed prenatal appointments, risky journeys and collapsing health systems in remote areas.

Women in the Central African Republic are 40 times more likely to die in pregnancy or childbirth than women in the U.S., according to the United Nations. For every 100,000 births in the impoverished country, 829 women die.

Years of internal conflict have left the health system shattered. Despite large gold reserves, basic services are scarce outside major cities, and one in three people live on less than $2 a day.

The government announced a plan in 2024 to increase spending on skilled birth attendants and other resources, but officials did not respond to questions about its impact.

Risk of maternal death up

At the same time, sweeping cuts in humanitarian funding by top donor countries, including the United States, have made care even harder to reach. In the remote town of Birao, where Fadala now shelters, four local midwives who were supported by the U.N. Population Fund (UNFPA) lost their jobs last year after the Trump administration cut all U.S. funding agreements with the agency.

Opposite Fadala’s tent stands a shuttered UNFPA-funded "safe space” that once provided transport for pregnant women to the district hospital. It was one of four such spaces in Birao serving nearly 50,000 women. All have closed without U.S. support, along with two U.S.-backed health facilities.

Now, "some women run the risk of dying in pregnancy situations that are not medically managed,” said UNFPA program officer Marie Justine Mamba Ibingui.

UNFPA’s budget in the Central African Republic has been halved over the past two years to $6.5 million, country director Victor Rakoto said. In Birao, the agency had been the only provider of reproductive health products. "The risk of maternal death is going to increase if there is no solution,” he warned.

Conflict-affected settings like Birao account for six in 10 maternal deaths globally, the U.N. estimates.

The district hospital that Fadala tried to reach is just a few kilometers away over rutted dirt roads. On a recent day, birthing assistant Delphine Zanabe moved between patients as dozens of women waited, packed thigh-to-thigh on hard benches in the heat. Some had walked for hours; others had bounced on motorbikes over rough ground.

"They only come when they are about to give birth,” Zanabe said. "It’s a struggle and it’s either the baby or the mother who suffers.” WHO guidelines call for at least eight prenatal consultations, but for refugees living in "survival mode” in an unfamiliar, impoverished setting, poverty and lack of education compound the risks.

In the tiny maternity ward, eight beds almost touch, serving about 70,000 local residents and 22,000 Sudanese refugees. Doctors said 12 staffers have lost their jobs because of aid cuts, most from the maternity department.

One patient, Amna Adam Hessen, arrived burning with malaria-induced fever. Her unborn child was in a breech position, discovered late because she had missed prenatal visits.

Brought by motorbike from the camp, she bled heavily during labor and lost her baby. "Giving birth here is exhausting,” her mother, Salet, said, fanning her as Amna writhed on a bare foam mattress, crying out, "Mama, mama.”

Over 40% of births in Central African Republic already take place outside medical facilities, the U.N. says, a traditional practice that now increasingly means preventable deaths.

'Abandoned them like that'

Former midwife Clara Abessende, one of the four who lost their jobs in Birao, said the number of women arriving daily tripled after Sudan’s war erupted in early 2023, even as supplies like antibiotics and malaria treatments ran out. "As a result, there were more cases of infant and maternal deaths,” she said. Losing her post has left her feeling "heavy with guilt.”

"The children born in my hands ... I abandoned them like that,” she said.

Among those she can no longer help is Katidje Idrisse Tahire, nine months pregnant, walking slowly through the camp to fetch water, one child on her back and two at her side.

She fled Sudan on foot four months ago. At the border, armed men robbed her of everything; her husband has not been seen since they escaped Darfur.

"My whole body aches,” she said. "I am very tired and unwell.”

She has no money and does not know if care will be there when her baby comes.