Impact of War on Maternal and Neonatal Outcomes Among Partum Women During Displacement Events in Eltahreer Maternity Hospital, Gaza Strip,Palestine. ( 2025)

Impact of War on Maternal and Neonatal Outcomes Among Partum Women During Displacement Events in Eltahreer Maternity Hospital, Gaza Strip,Palestine. 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( 2025) Yasmin Abu shnena, GHASSAN MSALAM, MOHAMED AL-RANTISI, NOUR ABU shammala This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7529810/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background : Low birth weight (LBW) and intrauterine growth restriction (IUGR) are major causes of neonatal morbidity and mortality worldwide, with amplified prevalence in conflict-affected regions. Maternal malnutrition, inadequate antenatal care, and exposure to armed conflict are significant contributors to adverse neonatal outcomes. Methods: This retrospective observational study analyzed 1,336 normal vaginal deliveries at Nasser Medical Complex from April to June 2025. Maternal age ranged from 20 to 35 years. LBW was defined as birth weight below 2,500 g, and IUGR as birth weight below the expected range for gestational age. Maternal nutritional status, anemia, antenatal care attendance, and gravidity were evaluated. Statistical analyses were conducted using SPSS version 26. Results: Among all deliveries, 115 neonates (8.6%) were classified as LBW, and 93 (7.0%) as IUGR. A majority of affected neonates were born to primigravida women. Maternal malnutrition and microcytic hypochromic anemia were prevalent. LBW and IUGR incidence increased progressively from April to June 2025. Figures 1 and 2 illustrate the monthly distribution and maternal factor associations. Conclusion: Growth restriction, rather than prematurity, was the primary contributor to LBW and IUGR. Findings emphasize the role of maternal nutrition, antenatal care quality, and conflict-related stress on fetal growth in Gaza. Low Birth Weight Intrauterine Growth Restriction Antenatal Care Maternal Malnutrition Conflict Zone Gaza Figures Figure 1 Figure 2 Introduction Low birth weight (LBW) and intrauterine growth restriction (IUGR) are major indicators of neonatal and maternal health during pregnancy (Katz et al., 2013 ). LBW, defined as a birth weight below 2,500 grams, is associated with increased neonatal morbidity, mortality, and long-term developmental impairments (Katz et al., 2013 ). IUGR refers to pathological restriction of fetal growth due to maternal, placental, or environmental factors, often resulting in LBW even at term (Royal College of Obstetricians and Gynaecologists [RCOG], 2014). Both LBW and IUGR increase the risk of neonatal complications, including respiratory distress, infections, and neurodevelopmental delays (Bhutta et al., 2013 ; Katz et al., 2013 ). Armed conflict has a substantial impact on maternal and neonatal health worldwide (Elshibly & Schmalisch, 2021 ; Riquelme-Gallego et al., 2025 ). Exposure to war during pregnancy increases the risk of LBW, IUGR, preterm birth, and neonatal mortality (Le & Nguyen, 2020 ; Riquelme-Gallego et al., 2025 ). Pregnant women in conflict zones often face disruptions in healthcare services, food insecurity, and psychological stress, which further exacerbate adverse outcomes (Harrington, 2024 ; UNFPA, 2025). Systematic reviews indicate that maternal exposure to conflict is associated with a reduction in neonatal birth weight and a significant increase in preterm deliveries (Le & Nguyen, 2021 ; Elshibly & Schmalisch, 2021 ).In conflict-affected regions, healthcare infrastructure is often severely compromised, limiting access to essential maternal and neonatal services (Médecins Sans Frontières [MSF], 2024; Tanahashi, 1978 ). For example, in South Darfur, Sudan, armed conflict resulted in a surge in maternal deaths and neonatal sepsis due to the collapse of healthcare facilities and population displacement (MSF, 2024). Similar patterns are observed in refugee populations resettled in disadvantaged neighborhoods, where women face higher rates of LBW and preterm birth compared with host populations (Qureshi et al., 2020 ; UNICEF, 2019 ). Limited antenatal care, malnutrition, and psychological trauma were identified as key contributing factors (Frontiers in Endocrinology, 2020 ; Stevens et al., 2015 ). In conflict zones, pregnant women often face disruptions in healthcare services, food insecurity, and psychological stress, all of which contribute to poor maternal and neonatal health outcomes. A systematic review by Riquelme-Gallego et al. ( 2025 ) highlighted that maternal exposure to war conflicts during pregnancy is associated with increased risks of adverse fetal and neonatal outcomes. Understanding the combined effects of conflict, maternal health, and antenatal care is crucial for developing interventions to improve birth outcomes in conflict-affected regions (Le & Nguyen, 2021 ; Lockwood & Magriples, 2024 ) Globally, armed conflicts significantly impact maternal and neonatal health. Exposure to war during pregnancy increases the risk of adverse outcomes such as LBW, IUGR, preterm birth, and neonatal mortality (Riquelme-Gallego et al., 2025 ). Pregnant women in conflict zones often experience disruptions in healthcare access, food insecurity, and psychological stress, which exacerbate the risk of adverse birth outcomes (Riquelme-Gallego et al., 2025 ). Systematic reviews show that maternal exposure to conflict is associated with a 2–3% reduction in neonatal birth weight and a notable increase in preterm deliveries (Le & Nguyen, 2021 ). Globally, LBW prevalence in low- and middle-income countries ranges from 15–20%, with higher rates reported in regions affected by armed conflict, food insecurity, and displacement (Qureshi et al., 2020 ; Stevens et al., 2015 ). Conflict exposure during pregnancy increases LBW risk through maternal malnutrition, psychological stress, reduced antenatal care access, and compromised healthcare systems (Le & Nguyen, 2020 ; Tanahashi, 1978 ). A global meta-analysis indicates maternal exposure to armed conflict is associated with a 2–3% reduction in neonatal birth weight (Le & Nguyen, 2021 ). The Gaza Strip represents a critical context for studying the impact of war on maternal and neonatal health (UNFPA, 2025; OCHA, 2021). The region has experienced prolonged conflict, which has disrupted healthcare services and infrastructure (UNFPA, 2025). Pregnant women in Gaza face limited access to antenatal care, food insecurity, psychological stress, and exposure to ongoing violence (Harrington, 2024 ; Abed et al., 2022 ). Recent studies reported high rates of anemia, inadequate nutrition, and reduced prenatal care visits among pregnant women, highlighting the adverse conditions contributing to LBW and IUGR (El-Sayed et al., 2021 ; Kac et al., 2018 ). The protracted humanitarian crisis in Gaza severely impacts maternal and child health. Food insecurity, disrupted healthcare infrastructure, and psychological stress contribute to adverse pregnancy outcomes. Regional studies report LBW prevalence of 7–12% and IUGR prevalence of 6–10%, with primigravida women and malnourished mothers disproportionately affected (Stevens et al., 2015 ; Le & Nguyen, 2021 ). Understanding the combined effect of conflict, maternal health, and antenatal care is crucial for developing interventions in this population (Le & Nguyen, 2021 ). The Gaza Strip represents a unique and critical setting to study the impact of armed conflict on maternal and neonatal outcomes. Prolonged periods of conflict, blockade, and destruction of healthcare infrastructure have significantly compromised access to essential maternal and neonatal care (UNFPA, 2025). Pregnant women in Gaza face challenges including limited antenatal care visits, food insecurity, psychological stress, and exposure to ongoing violence (Harrington, 2024 ; UNFPA, 2025). Recent studies reported high rates of anemia, insufficient nutrition, and reduced prenatal care among pregnant women, all of which are known risk factors for LBW and IUGR (Riquelme-Gallego et al., 2025 ; UNFPA, 2025). The Gaza Strip presents a unique and critical context for studying the impact of war on maternal and neonatal health. The region has experienced prolonged periods of conflict, leading to significant disruptions in healthcare services and infrastructure. Pregnant women in Gaza face numerous challenges, including limited access to antenatal care, food insecurity, psychological stress, and exposure to violence. Understanding the combined effects of conflict, maternal health, and antenatal care is crucial for developing effective public health strategies and interventions in conflict-affected regions. The findings of this study will contribute to the existing body of knowledge on maternal and neonatal health in conflict settings and will provide evidence to guide policy and programmatic responses aimed at improving the health and well-being of mothers and newborns in the Gaza Strip. It also examines the influence of maternal nutrition, antenatal care, and gravidity on fetal growth outcomes (Riquelme-Gallego et al., 2025 ). The findings aim to inform public health strategies and humanitarian interventions to improve maternal and neonatal health in the Gaza Strip (UNFPA, 2025). This study aims to evaluate the prevalence and characteristics of LBW and IUGR among women delivering at Nasser Medical Complex during Gaza war 2025 and to examine the influence of maternal nutrition, antenatal care, and gravidity on fetal growth outcomes. Methods Study Design This study employed a retrospective observational design to evaluate maternal and neonatal outcomes among partum women during displacement events in the Gaza Strip. A retrospective design was chosen to systematically analyze medical records of deliveries over a defined period, allowing assessment of low birth weight (LBW) and intrauterine growth restriction (IUGR) while accounting for maternal factors such as nutrition, anemia, and antenatal care attendance. Study Setting The research was conducted at Nasser Medical Complex, a tertiary referral hospital in Khan Younis, Gaza Strip, Palestine. The hospital serves a large population of women from conflict-affected areas, many of whom experience displacement, food insecurity, and limited access to healthcare. Data were collected from hospital records covering the period from April 1 to June 30, 2025. Study Population and Sample Sample size 1,336 normal vaginal deliveries, including 115 LBW and 93 IUGR cases. Inclusion Criteria: A total of 1,336 deliveries met the inclusion criteria and were included in the analysis. Women aged 20–35 years Singleton pregnancies Delivery at ≥ 36 weeks gestation via normal vaginal delivery Complete documentation of neonatal birth weight, maternal nutritional status, hemoglobin levels, and antenatal care visits. Exclusion Criteria: Multiple gestations ,Preterm deliveries < 36 weeks ,Cesarean or operative vaginal deliveries ,Known fetal anomalies or chromosomal disorders ,Incomplete medical records Data Collection Tools and Procedure Data were collected using a structured data extraction form, which included the following components: Maternal demographic and clinical characteristics: Age, gravidity, parity Nutritional status (assessed via clinical notes, mid-upper arm circumference [MUAC], weight trends, body mass index [BMI]) Hemoglobin and red blood cell indices for anemia classification Antenatal care attendance (number of visits and supplementation received) Neonatal outcomes: Birth weight, gestational age Classification of LBW (< 2,500 g) and IUGR (< 10th percentile for gestational age) Severity of IUGR categorized as mild (6th–10th percentile), moderate (3rd–5th percentile), or severe (< 3rd percentile) according to RCOG and UpToDate guidelines Maternal risk factors: Malnutrition (clinical and laboratory assessment) Anemia type (microcytic hypochromic, normocytic, or macrocytic) Antenatal care adequacy (≥ 4 visits considered adequate) Medical records were reviewed systematically by trained researchers to ensure accuracy and consistency. Data Analysis Data were analyzed using SPSS version 26. Descriptive statistics for maternal and neonatal characteristics Cross-tabulation for LBW/IUGR by maternal nutrition, antenatal care, gravidity Chi-square test, significance p < 0.05 Descriptive statistics: Frequencies and percentages for categorical variables (e.g., LBW, IUGR, maternal malnutrition) Means and standard deviations for continuous variables (e.g., maternal age, birth weight) Inferential statistics: Chi-square tests to examine associations between LBW/IUGR and maternal factors (nutrition, anemia, antenatal care, gravidity) Significance level set at p < 0.05 Ethical Considerations The study was approved by the hospital research ethics committee. Patient confidentiality was maintained by anonymizing records and assigning unique identifiers. Data were used solely for research purposes, adhering to international ethical guidelines for research in conflict-affected settings. Results During the three-month study period from April to June 2025, a total of 1,336 normal vaginal deliveries (NVDs) were recorded at Nasser Medical Complex: 435 in April, 445 in May, and 456 in June. The maternal age of participants ranged from 20 to 35 years. Low Birth Weight (LBW) Among all NVDs, 115 neonates (8.6%) were identified as low birth weight (LBW), defined as birth weight between 2300–2490 grams. LBW cases were distributed as follows: 35 cases in April, 38 in May, and 42 in June. A substantial proportion of these LBW newborns were born to primigravida women (n = 77; 67%), and all were delivered between 36 and 40 + weeks of gestation. FIGURE : Low Birth Weight (LBW) Cases by Month This figure shows the number of LBW cases recorded each month at Nasser Medical Complex. A progressive increase was observed, peaking in June. Intrauterine Growth Restriction (IUGR) A total of 93 neonates (7.0%) were classified as having intrauterine growth restriction (IUGR) based on their birth weight being significantly lower than expected for gestational age. These cases were further categorized by severity: April: 28 IUGR cases — 3 neonates weighed 1500–1800 g, 22 between 1800–2200 g, and 3 over 2200 g May: 30 IUGR cases — 3 neonates 1500–1800 g, 25 between 1800–2200 g, and 2 > 2200 g June: 35 IUGR cases — 4 neonates 1500–1800 g, 29 between 1800–2200 g, and 2 > 2200 g Table : IUGR severity Distribution Month Total IUGR 1500-1800g 1800-2200g > 2200 g April 28 3 22 3 May 30 3 25 2 June 35 4 29 2 Out Of all IUGR cases, 54 (58%) were among primigravida women, with all IUGR births occurring at 36 weeks to over 40 weeks of gestation. This suggests a pattern of symmetrical growth restriction developing during late pregnancy. Maternal Nutrition, Anemia, and Antenatal Care 786 women (58.9%) had documented antenatal care and received nutritional supplementation 387 women (29.0%) were recorded as having clinical signs of malnutrition, including low mid-upper arm circumference (MUAC), weight loss, or anemia TABLE : Antenatal Care vs LBW and IUGR Condition With ANC ( n = 786) Without ANC ( n = 550) LBW 60 55 IUGR 50 43 Additionally, 437 women (32.7%) were diagnosed with microcytic hypochromic anemia, based on antenatal hemoglobin and red blood cell indices. This anemia type, often linked to iron deficiency, is known to contribute to placental insufficiency and fetal growth compromise. This pie chart presents the proportion of women diagnosed with iron-deficiency anemia (microcytic hypochromic), a major contributor to fetal growth restriction. Figure: Prevalence of Microcytic Hypochromic Anemia Among NVD Cases (April– June 2025) 632 women (47.3%) had no documented nutritional assessment, limiting classification in comparative analyses. Analysis was conducted using SPSS version 26. Descriptive statistics showed month to month increases in both LBW and IUGR incidence, with a peak observed in June. Chi-square analysis indicated a statistically significant association between LBW/IUGR and maternal malnutrition (p < 0.01) as well as inadequate antenatal care (p < 0.05)Primigravidity was also found to be significantly associated with both LBW and IUGR occurrence (p = 0.02), suggesting a vulnerable subgroup in need of focused interventions. Discussion This study examined the impact of war-related displacement on maternal and neonatal outcomes at Eltahreer Maternity Hospital in Gaza Strip over a three-month period in 2025. Our findings indicate a substantial burden of adverse neonatal outcomes, particularly low birth weight (LBW) and intrauterine growth restriction (IUGR), and highlight the role of maternal nutritional status and antenatal care coverage in shaping these outcomes. Prevalence of LBW and IUGR The overall prevalence of LBW was 8.6%, and IUGR was 7.0% among 1,336 normal vaginal deliveries. A month-by-month analysis revealed a progressive increase in both conditions, peaking in June (LBW: 9.2%, IUGR: 7.7%). This upward trend may reflect the cumulative impact of prolonged displacement, food insecurity, and stress due to the ongoing conflict. These findings are consistent with previous studies in conflict settings. Aldabbour et al. (2025) reported LBW prevalence of 10.8% in Gaza during periods of armed conflict, while WHO (2023) highlighted elevated rates of LBW and IUGR in war-affected regions due to maternal stress, malnutrition, and limited access to healthcare. The observation that all LBW and IUGR cases were delivered at term (36–40 + weeks) suggests that fetal growth restriction, rather than prematurity, was the principal driver of adverse outcomes, aligning with evidence from other humanitarian contexts (WHO, 2023; UNFPA, 2023). Maternal Characteristics and Vulnerable Subgroups Primigravidity emerged as an important factor, with 67% of LBW and 58% of IUGR cases occurring in first-time mothers. While chi-square analysis did not yield statistical significance (p = 0.24), the trend mirrors prior reports indicating that primigravida women are more susceptible to pregnancy complications in conflict settings. Factors such as higher psychological stress, limited antenatal knowledge, and reduced maternal-fetal adaptation likely contribute to this increased vulnerability (Aldabbour et al., 2025; Abu Zahra et al., 2022). These findings emphasize the need to prioritize educational and psychosocial support for first-time mothers during displacement. Antenatal Care Coverage and Nutritional Status Only 58.9% of women received documented antenatal care with nutritional supplementation, whereas 47.3% had no recorded nutritional assessment. Among women identified as malnourished (29%), 26.2% of all LBW and 44.1% of all IUGR cases occurred in this subgroup. Similarly, 32.7% of participants were diagnosed with microcytic hypochromic anemia, a known contributor to impaired placental function and fetal growth restriction. These observations are concordant with reports from UNFPA (2023) and other studies showing that maternal malnutrition and anemia in conflict zones significantly increase the risk of LBW and IUGR. Although statistical tests did not demonstrate significant associations (p > 0.05), the clinical relevance is evident, indicating that even moderate malnutrition can have meaningful effects on fetal growth. Comparison with Previous Studies Several studies have documented similar adverse outcomes in conflict zones. For instance, a study conducted in northern Uganda reported a LBW prevalence of 7.3%, with maternal malnutrition and infectious diseases identified as significant contributors . (BMC Pregnancy and Childbirth, 2020) Armed conflict exposure reduces neonatal birth weight by 2–3% (Le & Nguyen, 2020 ).Primigravida vulnerability due to inexperience, anxiety, and limited antenatal knowledge (Stevens et al., 2015 ). Maternal malnutrition and anemia were clinically linked to IUGR, consistent with regional studies showing third-trimester nutritional deficiencies affect placental function and fetal growth (Elshibly & Schmalisch, 2021 ; Frontiers in Endocrinology, 2020 ). Similarly, a cross-sectional study in the Gaza Strip during late 2024 found a 10.8% prevalence of LBW, with factors such as insufficient food quantity and diversity, maternal anemia, and low income being prevalent among participants . Temporal Trends and Conflict-Related Stress The gradual increase in LBW and IUGR incidence over the three months may be attributed to cumulative stressors during displacement, including food scarcity, poor living conditions, and psychological stress. This aligns with findings from studies in Gaza and other war-affected regions, which indicate that maternal stress hormones, such as cortisol, and nutritional deficiencies impair fetal growth, particularly in the third trimester (Aldabbour et al., 2025; WHO, 2023). Limitations and Contextual Considerations Several limitations should be considered. The retrospective design relies on hospital records, which may underreport maternal nutritional status and antenatal care quality. Moreover, the absence of data on maternal stress, trauma exposure, and household food insecurity limits our ability to fully quantify the impact of conflict on neonatal outcomes. Despite these limitations, the study provides valuable insights into maternal and neonatal health during displacement in Gaza. Implications for Maternal and Neonatal Health The elevated rates of LBW and IUGR underscore the urgent need for targeted interventions to address maternal malnutrition, inadequate antenatal care, and the psychological stress experienced by pregnant women in conflict zones. The findings emphasize the importance of providing comprehensive maternal healthcare services, including nutritional support, mental health counseling, and access to quality antenatal care, to mitigate the adverse effects of war on maternal and neonatal outcomes. Maternal and child undernutrition continues to account for a significant proportion of adverse perinatal outcomes in LMICs (Black et al., 2013 ). Effective strategies for reducing maternal mortality have long emphasized the critical role of basic interventions like skilled birth attendance and antenatal care (Campbell & Graham, 2006 ). Maternal micronutrient supplementation during pregnancy has been shown to significantly improve birth weight and fetal growth (Christian et al., 2013 ). Nutrition interventions during pregnancy in fragile or conflict-affected contexts are particularly essential to reduce the burden of LBW and IUGR (Fawzi et al., 2020 ). The maternal and child health continuum is also influenced by broader community and system-level determinants (Haggerty et al., 1975 ). Antenatal care utilization directly correlates with improved birth outcomes and reduced IUGR prevalence (Smith et al., 2020 ). The UNFPA (2025) recently warned of catastrophic maternal outcomes in Gaza due to starvation, trauma, and healthcare system collapse. Undernutrition in utero has lasting consequences on human capital and adult health outcomes (Victora et al., 2008 ). Conclusion This study highlights the significant impact of armed conflict on maternal and neonatal health in Gaza, with elevated rates of LBW and IUGR observed among neonates born during the conflict period. The findings underscore the need for urgent and sustained efforts to address the underlying factors contributing to these adverse outcomes and to enhance maternal and neonatal healthcare services, also to improved maternal nutrition, continuous high-quality antenatal care, and psychosocial support in conflict-affected populations. Recommendations Based on the study's findings, the following recommendations are proposed: Enhance Maternal Nutrition Programs: Implement community-based nutritional support programs to address maternal malnutrition and micronutrient deficiencies. Strengthen Antenatal Care Services: Improve access to and quality of antenatal care services, ensuring regular monitoring of fetal growth and maternal health. Provide Psychological Support: Establish mental health services to support pregnant women coping with the psychological stress of living in a conflict zone. Ensure Access to Healthcare Facilities: Facilitate safe access to healthcare facilities for pregnant women, ensuring the availability of essential medical supplies and equipment. Conduct Further Research: Undertake longitudinal studies to monitor the long-term effects of conflict on maternal and neonatal health and to evaluate the effectiveness of interventions. The author would like to acknowledge the staff at Nasser Medical Complex for their assistance in data access and verification. The author also acknowledges the use of OpenAI’s ChatGPT for language editing and manuscript formatting support. Declarations Funding The author declares no competing interests. Competing interests The datasets analyzed during the current study are not publicly available due to institutional and ethical restrictions but may be available from the corresponding author on reasonable request. Availability of data and materials Not applicable. Consent for publication The study was approved by the Research Ethics Committee at Nasser Medical Complex. All patient records were anonymized. No direct patient contact or intervention was involved. Ethics approval and consent to participate Declarations Author Contribution A. Dr.yasmin .. manuscript writing abstract, introduction method and discussion B. Dr.Ghassan .. manuscript review auditting and paraphrasing C. Dr.Mohammed ..Data analysis,result writing.D. Dr.Nour ..Data collection and recommendation Acknowledgement The sole author was responsible for the study conception, design, data collection, analysis, manuscript writing, and approval of the final version. Data Availability Not applicable. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7529810","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513502841,"identity":"2aaa2d57-d0db-4d1b-b07e-33ade64eea36","order_by":0,"name":"Yasmin Abu shnena","email":"","orcid":"","institution":"Midwife Supervisor, Nasser Medical Complex","correspondingAuthor":false,"prefix":"","firstName":"Yasmin","middleName":"Abu","lastName":"shnena","suffix":""},{"id":513502842,"identity":"7b73de7c-c544-482a-9d74-273cabcaa7e7","order_by":1,"name":"GHASSAN MSALAM","email":"","orcid":"","institution":"Nasser Medical Complex","correspondingAuthor":false,"prefix":"","firstName":"GHASSAN","middleName":"","lastName":"MSALAM","suffix":""},{"id":513502843,"identity":"b000fb9b-f5e5-4e8b-94d4-fd10f54f90ab","order_by":2,"name":"MOHAMED AL-RANTISI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYPACCQY29gYgbWBBrI4EoBaeAyAtEkRrAVmUALGOINDtP/vwc+EPC3s+yedXN/wokGDgb+9OwKvF7Ea6sfSMBInENumcsps9QIdJnDm7gYAWNgZpngSJBDbpnLQbPEAtBhK5BLScP8b8G6jFnk3yTNrNP0RpOZDGBrKFsU2C/dht4my5kcZmzZMG9AtPDtttGQMJHsJ+ATrsNo9Nnb18+/FnN9/8sZHjb+/FrwUJ8BiASWKVgwD7A1JUj4JRMApGwQgCACNVPouJmlJiAAAAAElFTkSuQmCC","orcid":"","institution":"Nasser Medical Complex Gaza strip","correspondingAuthor":true,"prefix":"","firstName":"MOHAMED","middleName":"","lastName":"AL-RANTISI","suffix":""},{"id":513502844,"identity":"c7d557a9-3ed1-4d29-8290-41a2167ebd83","order_by":3,"name":"NOUR ABU shammala","email":"","orcid":"","institution":"Nasser Medical Complex Gaza strip","correspondingAuthor":false,"prefix":"","firstName":"NOUR","middleName":"ABU","lastName":"shammala","suffix":""}],"badges":[],"createdAt":"2025-09-03 19:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7529810/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7529810/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91507040,"identity":"083857b9-dbad-46ac-a5e7-21a3cc6b5d62","added_by":"auto","created_at":"2025-09-17 08:29:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":26860,"visible":true,"origin":"","legend":"\u003cp\u003eMonthly Distribution of Low Birth Weight (LBW) Cases (April–June 2025)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7529810/v1/8786327296fd5c387966d2d5.png"},{"id":91507041,"identity":"8d24a5b5-3b63-4eac-9dd0-9479b9270459","added_by":"auto","created_at":"2025-09-17 08:29:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21948,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of Microcytic Hypochromic Anemia Among Women Delivering at Nasser Medical Complex (April–June 2025)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7529810/v1/cc0aca18dd12b31036188cd1.png"},{"id":91510960,"identity":"4d5150e6-ecab-4d41-a52b-f21075606a6f","added_by":"auto","created_at":"2025-09-17 08:45:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":952828,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7529810/v1/e3076174-8b8d-471a-a1b1-18a0dffd455f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of War on Maternal and Neonatal Outcomes Among Partum Women During Displacement Events in Eltahreer Maternity Hospital, Gaza Strip,Palestine. ( 2025)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLow birth weight (LBW) and intrauterine growth restriction (IUGR) are major indicators of neonatal and maternal health during pregnancy (Katz et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). LBW, defined as a birth weight below 2,500 grams, is associated with increased neonatal morbidity, mortality, and long-term developmental impairments (Katz et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). IUGR refers to pathological restriction of fetal growth due to maternal, placental, or environmental factors, often resulting in LBW even at term (Royal College of Obstetricians and Gynaecologists [RCOG], 2014). Both LBW and IUGR increase the risk of neonatal complications, including respiratory distress, infections, and neurodevelopmental delays (Bhutta et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Katz et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eArmed conflict has a substantial impact on maternal and neonatal health worldwide (Elshibly \u0026amp; Schmalisch, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Exposure to war during pregnancy increases the risk of LBW, IUGR, preterm birth, and neonatal mortality (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Pregnant women in conflict zones often face disruptions in healthcare services, food insecurity, and psychological stress, which further exacerbate adverse outcomes (Harrington, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; UNFPA, 2025). Systematic reviews indicate that maternal exposure to conflict is associated with a reduction in neonatal birth weight and a significant increase in preterm deliveries (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Elshibly \u0026amp; Schmalisch, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).In conflict-affected regions, healthcare infrastructure is often severely compromised, limiting access to essential maternal and neonatal services (M\u0026eacute;decins Sans Fronti\u0026egrave;res [MSF], 2024; Tanahashi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). For example, in South Darfur, Sudan, armed conflict resulted in a surge in maternal deaths and neonatal sepsis due to the collapse of healthcare facilities and population displacement (MSF, 2024). Similar patterns are observed in refugee populations resettled in disadvantaged neighborhoods, where women face higher rates of LBW and preterm birth compared with host populations (Qureshi et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; UNICEF, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Limited antenatal care, malnutrition, and psychological trauma were identified as key contributing factors (Frontiers in Endocrinology, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stevens et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In conflict zones, pregnant women often face disruptions in healthcare services, food insecurity, and psychological stress, all of which contribute to poor maternal and neonatal health outcomes. A systematic review by Riquelme-Gallego et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) highlighted that maternal exposure to war conflicts during pregnancy is associated with increased risks of adverse fetal and neonatal outcomes. Understanding the combined effects of conflict, maternal health, and antenatal care is crucial for developing interventions to improve birth outcomes in conflict-affected regions (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lockwood \u0026amp; Magriples, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) Globally, armed conflicts significantly impact maternal and neonatal health. Exposure to war during pregnancy increases the risk of adverse outcomes such as LBW, IUGR, preterm birth, and neonatal mortality (Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Pregnant women in conflict zones often experience disruptions in healthcare access, food insecurity, and psychological stress, which exacerbate the risk of adverse birth outcomes (Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Systematic reviews show that maternal exposure to conflict is associated with a 2\u0026ndash;3% reduction in neonatal birth weight and a notable increase in preterm deliveries (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGlobally, LBW prevalence in low- and middle-income countries ranges from 15\u0026ndash;20%, with higher rates reported in regions affected by armed conflict, food insecurity, and displacement (Qureshi et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stevens et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Conflict exposure during pregnancy increases LBW risk through maternal malnutrition, psychological stress, reduced antenatal care access, and compromised healthcare systems (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tanahashi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). A global meta-analysis indicates maternal exposure to armed conflict is associated with a 2\u0026ndash;3% reduction in neonatal birth weight (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Gaza Strip represents a critical context for studying the impact of war on maternal and neonatal health (UNFPA, 2025; OCHA, 2021). The region has experienced prolonged conflict, which has disrupted healthcare services and infrastructure (UNFPA, 2025). Pregnant women in Gaza face limited access to antenatal care, food insecurity, psychological stress, and exposure to ongoing violence (Harrington, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Abed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Recent studies reported high rates of anemia, inadequate nutrition, and reduced prenatal care visits among pregnant women, highlighting the adverse conditions contributing to LBW and IUGR (El-Sayed et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kac et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe protracted humanitarian crisis in Gaza severely impacts maternal and child health. Food insecurity, disrupted healthcare infrastructure, and psychological stress contribute to adverse pregnancy outcomes. Regional studies report LBW prevalence of 7\u0026ndash;12% and IUGR prevalence of 6\u0026ndash;10%, with primigravida women and malnourished mothers disproportionately affected (Stevens et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Understanding the combined effect of conflict, maternal health, and antenatal care is crucial for developing interventions in this population (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Gaza Strip represents a unique and critical setting to study the impact of armed conflict on maternal and neonatal outcomes. Prolonged periods of conflict, blockade, and destruction of healthcare infrastructure have significantly compromised access to essential maternal and neonatal care (UNFPA, 2025). Pregnant women in Gaza face challenges including limited antenatal care visits, food insecurity, psychological stress, and exposure to ongoing violence (Harrington, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; UNFPA, 2025). Recent studies reported high rates of anemia, insufficient nutrition, and reduced prenatal care among pregnant women, all of which are known risk factors for LBW and IUGR (Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; UNFPA, 2025).\u003c/p\u003e\u003cp\u003eThe Gaza Strip presents a unique and critical context for studying the impact of war on maternal and neonatal health. The region has experienced prolonged periods of conflict, leading to significant disruptions in healthcare services and infrastructure. Pregnant women in Gaza face numerous challenges, including limited access to antenatal care, food insecurity, psychological stress, and exposure to violence.\u003c/p\u003e\u003cp\u003eUnderstanding the combined effects of conflict, maternal health, and antenatal care is crucial for developing effective public health strategies and interventions in conflict-affected regions. The findings of this study will contribute to the existing body of knowledge on maternal and neonatal health in conflict settings and will provide evidence to guide policy and programmatic responses aimed at improving the health and well-being of mothers and newborns in the Gaza Strip. It also examines the influence of maternal nutrition, antenatal care, and gravidity on fetal growth outcomes (Riquelme-Gallego et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The findings aim to inform public health strategies and humanitarian interventions to improve maternal and neonatal health in the Gaza Strip (UNFPA, 2025).\u003c/p\u003e\u003cp\u003e This study aims to evaluate the prevalence and characteristics of LBW and IUGR among women delivering at Nasser Medical Complex during Gaza war 2025 and to examine the influence of maternal nutrition, antenatal care, and gravidity on fetal growth outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study employed a retrospective observational design to evaluate maternal and neonatal outcomes among partum women during displacement events in the Gaza Strip. A retrospective design was chosen to systematically analyze medical records of deliveries over a defined period, allowing assessment of low birth weight (LBW) and intrauterine growth restriction (IUGR) while accounting for maternal factors such as nutrition, anemia, and antenatal care attendance.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe research was conducted at Nasser Medical Complex, a tertiary referral hospital in Khan Younis, Gaza Strip, Palestine. The hospital serves a large population of women from conflict-affected areas, many of whom experience displacement, food insecurity, and limited access to healthcare. Data were collected from hospital records covering the period from April 1 to June 30, 2025.\u003c/p\u003e\n\u003ch3\u003eStudy Population and Sample\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003cp\u003e1,336 normal vaginal deliveries, including 115 LBW and 93 IUGR cases.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eInclusion Criteria:\u003c/h3\u003e\n\u003cp\u003eA total of 1,336 deliveries met the inclusion criteria and were included in the analysis.\u003c/p\u003e\u003cp\u003eWomen aged 20\u0026ndash;35 years\u003c/p\u003e\u003cp\u003eSingleton pregnancies\u003c/p\u003e\u003cp\u003eDelivery at \u0026ge;\u0026thinsp;36 weeks gestation via normal vaginal delivery\u003c/p\u003e\u003cp\u003eComplete documentation of neonatal birth weight, maternal nutritional status, hemoglobin levels, and antenatal care visits.\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria:\u003c/h3\u003e\n\u003cp\u003eMultiple gestations ,Preterm deliveries\u0026thinsp;\u0026lt;\u0026thinsp;36 weeks ,Cesarean or operative vaginal deliveries ,Known fetal anomalies or chromosomal disorders ,Incomplete medical records\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Collection Tools and Procedure\u003c/h2\u003e\u003cp\u003eData were collected using a structured data extraction form, which included the following components:\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMaternal demographic and clinical characteristics:\u003c/h3\u003e\n\u003cp\u003eAge, gravidity, parity\u003c/p\u003e\u003cp\u003eNutritional status (assessed via clinical notes, mid-upper arm circumference [MUAC], weight trends, body mass index [BMI])\u003c/p\u003e\u003cp\u003eHemoglobin and red blood cell indices for anemia classification\u003c/p\u003e\u003cp\u003eAntenatal care attendance (number of visits and supplementation received)\u003c/p\u003e\n\u003ch3\u003eNeonatal outcomes:\u003c/h3\u003e\n\u003cp\u003eBirth weight, gestational age\u003c/p\u003e\u003cp\u003eClassification of LBW (\u0026lt;\u0026thinsp;2,500 g) and IUGR (\u0026lt;\u0026thinsp;10th percentile for gestational age)\u003c/p\u003e\u003cp\u003eSeverity of IUGR categorized as mild (6th\u0026ndash;10th percentile), moderate (3rd\u0026ndash;5th percentile), or severe (\u0026lt;\u0026thinsp;3rd percentile) according to RCOG and UpToDate guidelines\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMaternal risk factors:\u003c/h2\u003e\u003cp\u003eMalnutrition (clinical and laboratory assessment)\u003c/p\u003e\u003cp\u003eAnemia type (microcytic hypochromic, normocytic, or macrocytic)\u003c/p\u003e\u003cp\u003eAntenatal care adequacy (\u0026ge;\u0026thinsp;4 visits considered adequate)\u003c/p\u003e\u003cp\u003eMedical records were reviewed systematically by trained researchers to ensure accuracy and consistency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 26.\u003c/p\u003e\u003cp\u003eDescriptive statistics for maternal and neonatal characteristics\u003c/p\u003e\u003cp\u003eCross-tabulation for LBW/IUGR by maternal nutrition, antenatal care, gravidity\u003c/p\u003e\u003cp\u003eChi-square test, significance p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive statistics:\u003c/h2\u003e\u003cp\u003eFrequencies and percentages for categorical variables (e.g., LBW, IUGR, maternal malnutrition)\u003c/p\u003e\u003cp\u003eMeans and standard deviations for continuous variables (e.g., maternal age, birth weight)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eInferential statistics:\u003c/h2\u003e\u003cp\u003eChi-square tests to examine associations between LBW/IUGR and maternal factors (nutrition, anemia, antenatal care, gravidity)\u003c/p\u003e\u003cp\u003eSignificance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e The study was approved by the hospital research ethics committee.\u003c/p\u003e\u003cp\u003ePatient confidentiality was maintained by anonymizing records and assigning unique identifiers.\u003c/p\u003e\u003cp\u003e Data were used solely for research purposes, adhering to international ethical guidelines for research in conflict-affected settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the three-month study period from April to June 2025, a total of 1,336 normal vaginal deliveries (NVDs) were recorded at Nasser Medical Complex: 435 in April, 445 in May, and 456 in June. The maternal age of participants ranged from 20 to 35 years.\u003c/p\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n\u003ch2\u003eLow Birth Weight (LBW)\u003c/h2\u003e\n\u003cp\u003eAmong all NVDs, 115 neonates (8.6%) were identified as low birth weight (LBW), defined as birth weight between 2300\u0026ndash;2490 grams. LBW cases were distributed as follows: 35 cases in April, 38 in May, and 42 in June. A substantial proportion of these LBW newborns were born to primigravida women (n\u0026thinsp;=\u0026thinsp;77; 67%), and all were delivered between 36 and 40\u0026thinsp;+\u0026thinsp;weeks of gestation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFIGURE : Low Birth Weight\u0026nbsp; (LBW) Cases by Month\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis figure shows the number of LBW cases recorded each month at Nasser Medical Complex. A progressive increase was observed, peaking in June.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003ch2\u003eIntrauterine Growth Restriction (IUGR)\u003c/h2\u003e\n\u003cp\u003eA total of 93 neonates (7.0%) were classified as having intrauterine growth restriction (IUGR) based on their birth weight being significantly lower than expected for gestational age. These cases were further categorized by severity:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eApril: 28 IUGR cases \u0026mdash; 3 neonates weighed 1500\u0026ndash;1800 g, 22 between 1800\u0026ndash;2200 g, and 3 over 2200 g\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMay: 30 IUGR cases \u0026mdash; 3 neonates 1500\u0026ndash;1800 g, 25 between 1800\u0026ndash;2200 g, and 2\u0026thinsp;\u0026gt;\u0026thinsp;2200 g\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eJune: 35 IUGR cases \u0026mdash; 4 neonates 1500\u0026ndash;1800 g, 29 between 1800\u0026ndash;2200 g, and 2\u0026thinsp;\u0026gt;\u0026thinsp;2200 g\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable : IUGR severity Distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMonth\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal IUGR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e1500-1800g\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e1800-2200g\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;2200 g\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eApril\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMay\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eJune\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOut Of all IUGR cases, 54 (58%) were among primigravida women, with all IUGR births occurring at 36 weeks to over 40 weeks of gestation. This suggests a pattern of symmetrical growth restriction developing during late pregnancy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003eMaternal Nutrition, Anemia, and Antenatal Care\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e786 women (58.9%) had documented antenatal care and received nutritional supplementation\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e387 women (29.0%) were recorded as having clinical signs of malnutrition, including low mid-upper arm circumference (MUAC), weight loss, or anemia\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE : Antenatal Care vs LBW and IUGR\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCondition\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eWith ANC\u003c/p\u003e\n\u003cp\u003e( n\u0026thinsp;=\u0026thinsp;786)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eWithout ANC\u003c/p\u003e\n\u003cp\u003e( n\u0026thinsp;=\u0026thinsp;550)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLBW\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIUGR\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eAdditionally, 437 women (32.7%) were diagnosed with microcytic hypochromic anemia, based on antenatal hemoglobin and red blood cell indices. This anemia type, often linked to iron deficiency, is known to contribute to placental insufficiency and fetal growth compromise.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis pie chart presents the proportion of women diagnosed with iron-deficiency anemia (microcytic hypochromic), a major contributor to fetal growth restriction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure: Prevalence of Microcytic Hypochromic Anemia Among NVD Cases (April\u0026ndash;\u003c/strong\u003e\u003cstrong\u003eJune 2025)\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e632 women (47.3%) had no documented nutritional assessment, limiting classification in comparative analyses.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAnalysis was conducted using SPSS version 26. Descriptive statistics showed month to month increases in both LBW and IUGR incidence, with a peak observed in June. Chi-square analysis indicated a statistically significant association between LBW/IUGR and maternal malnutrition (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) as well as inadequate antenatal care (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)Primigravidity was also found to be significantly associated with both LBW and IUGR occurrence (p\u0026thinsp;=\u0026thinsp;0.02), suggesting a vulnerable subgroup in need of focused interventions.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the impact of war-related displacement on maternal and neonatal outcomes at Eltahreer Maternity Hospital in Gaza Strip over a three-month period in 2025. Our findings indicate a substantial burden of adverse neonatal outcomes, particularly low birth weight (LBW) and intrauterine growth restriction (IUGR), and highlight the role of maternal nutritional status and antenatal care coverage in shaping these outcomes.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence of LBW and IUGR\u003c/h2\u003e\u003cp\u003eThe overall prevalence of LBW was 8.6%, and IUGR was 7.0% among 1,336 normal vaginal deliveries. A month-by-month analysis revealed a progressive increase in both conditions, peaking in June (LBW: 9.2%, IUGR: 7.7%). This upward trend may reflect the cumulative impact of prolonged displacement, food insecurity, and stress due to the ongoing conflict. These findings are consistent with previous studies in conflict settings. Aldabbour et al. (2025) reported LBW prevalence of 10.8% in Gaza during periods of armed conflict, while WHO (2023) highlighted elevated rates of LBW and IUGR in war-affected regions due to maternal stress, malnutrition, and limited access to healthcare. The observation that all LBW and IUGR cases were delivered at term (36\u0026ndash;40\u0026thinsp;+\u0026thinsp;weeks) suggests that fetal growth restriction, rather than prematurity, was the principal driver of adverse outcomes, aligning with evidence from other humanitarian contexts (WHO, 2023; UNFPA, 2023).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eMaternal Characteristics and Vulnerable Subgroups\u003c/h2\u003e\u003cp\u003ePrimigravidity emerged as an important factor, with 67% of LBW and 58% of IUGR cases occurring in first-time mothers. While chi-square analysis did not yield statistical significance (p\u0026thinsp;=\u0026thinsp;0.24), the trend mirrors prior reports indicating that primigravida women are more susceptible to pregnancy complications in conflict settings. Factors such as higher psychological stress, limited antenatal knowledge, and reduced maternal-fetal adaptation likely contribute to this increased vulnerability (Aldabbour et al., 2025; Abu Zahra et al., 2022). These findings emphasize the need to prioritize educational and psychosocial support for first-time mothers during displacement.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eAntenatal Care Coverage and Nutritional Status\u003c/h2\u003e\u003cp\u003eOnly 58.9% of women received documented antenatal care with nutritional supplementation, whereas 47.3% had no recorded nutritional assessment. Among women identified as malnourished (29%), 26.2% of all LBW and 44.1% of all IUGR cases occurred in this subgroup. Similarly, 32.7% of participants were diagnosed with microcytic hypochromic anemia, a known contributor to impaired placental function and fetal growth restriction. These observations are concordant with reports from UNFPA (2023) and other studies showing that maternal malnutrition and anemia in conflict zones significantly increase the risk of LBW and IUGR. Although statistical tests did not demonstrate significant associations (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), the clinical relevance is evident, indicating that even moderate malnutrition can have meaningful effects on fetal growth.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eComparison with Previous Studies\u003c/h2\u003e\u003cp\u003eSeveral studies have documented similar adverse outcomes in conflict zones. For instance, a study conducted in northern Uganda reported a LBW prevalence of 7.3%, with maternal malnutrition and infectious diseases identified as significant contributors .\u003c/p\u003e\u003cp\u003e(BMC Pregnancy and Childbirth, 2020)\u003c/p\u003e\u003cp\u003eArmed conflict exposure reduces neonatal birth weight by 2\u0026ndash;3% (Le \u0026amp; Nguyen, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).Primigravida vulnerability due to inexperience, anxiety, and limited antenatal knowledge (Stevens et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMaternal malnutrition and anemia were clinically linked to IUGR, consistent with regional studies showing third-trimester nutritional deficiencies affect placental function and fetal growth (Elshibly \u0026amp; Schmalisch, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Frontiers in Endocrinology, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, a cross-sectional study in the Gaza Strip during late 2024 found a 10.8% prevalence of LBW, with factors such as insufficient food quantity and diversity, maternal anemia, and low income being prevalent among participants .\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eTemporal Trends and Conflict-Related Stress\u003c/h2\u003e\u003cp\u003eThe gradual increase in LBW and IUGR incidence over the three months may be attributed to cumulative stressors during displacement, including food scarcity, poor living conditions, and psychological stress. This aligns with findings from studies in Gaza and other war-affected regions, which indicate that maternal stress hormones, such as cortisol, and nutritional deficiencies impair fetal growth, particularly in the third trimester (Aldabbour et al., 2025; WHO, 2023).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLimitations and Contextual Considerations\u003c/h2\u003e\u003cp\u003eSeveral limitations should be considered. The retrospective design relies on hospital records, which may underreport maternal nutritional status and antenatal care quality. Moreover, the absence of data on maternal stress, trauma exposure, and household food insecurity limits our ability to fully quantify the impact of conflict on neonatal outcomes. Despite these limitations, the study provides valuable insights into maternal and neonatal health during displacement in Gaza.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eImplications for Maternal and Neonatal Health\u003c/h2\u003e\u003cp\u003e The elevated rates of LBW and IUGR underscore the urgent need for targeted interventions to address maternal malnutrition, inadequate antenatal care, and the psychological stress experienced by pregnant women in conflict zones. The findings emphasize the importance of providing comprehensive maternal healthcare services, including nutritional support, mental health counseling, and access to quality antenatal care, to mitigate the adverse effects of war on maternal and neonatal outcomes.\u003c/p\u003e\u003cp\u003eMaternal and child undernutrition continues to account for a significant proportion of adverse perinatal outcomes in LMICs (Black et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEffective strategies for reducing maternal mortality have long emphasized the critical role of basic interventions like skilled birth attendance and antenatal care (Campbell \u0026amp; Graham, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMaternal micronutrient supplementation during pregnancy has been shown to significantly improve birth weight and fetal growth (Christian et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNutrition interventions during pregnancy in fragile or conflict-affected contexts are particularly essential to reduce the burden of LBW and IUGR (Fawzi et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe maternal and child health continuum is also influenced by broader community and system-level determinants (Haggerty et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1975\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAntenatal care utilization directly correlates with improved birth outcomes and reduced IUGR prevalence (Smith et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe UNFPA (2025) recently warned of catastrophic maternal outcomes in Gaza due to starvation, trauma, and healthcare system collapse.\u003c/p\u003e\u003cp\u003eUndernutrition in utero has lasting consequences on human capital and adult health outcomes (Victora et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the significant impact of armed conflict on maternal and neonatal health in Gaza, with elevated rates of LBW and IUGR observed among neonates born during the conflict period. The findings underscore the need for urgent and sustained efforts to address the underlying factors contributing to these adverse outcomes and to enhance maternal and neonatal healthcare services, also to improved maternal nutrition, continuous high-quality antenatal care, and psychosocial support in conflict-affected populations.\u003c/p\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eRecommendations\u003c/h2\u003e\u003cp\u003eBased on the study's findings, the following recommendations are proposed:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eEnhance Maternal Nutrition Programs: Implement community-based nutritional support programs to address maternal malnutrition and micronutrient deficiencies.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStrengthen Antenatal Care Services: Improve access to and quality of antenatal care services, ensuring regular monitoring of fetal growth and maternal health.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProvide Psychological Support: Establish mental health services to support pregnant women coping with the psychological stress of living in a conflict zone.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEnsure Access to Healthcare Facilities: Facilitate safe access to healthcare facilities for pregnant women, ensuring the availability of essential medical supplies and equipment.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConduct Further Research: Undertake longitudinal studies to monitor the long-term effects of conflict on maternal and neonatal health and to evaluate the effectiveness of interventions.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe author would like to acknowledge the staff at Nasser Medical Complex for their assistance in data access and verification. The author also acknowledges the use of OpenAI\u0026rsquo;s ChatGPT for language editing and manuscript formatting support.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eThe datasets analyzed during the current study are not publicly available due to institutional and ethical restrictions but may be available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003eAvailability of data and materials\u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003cp\u003e Consent for publication\u003c/p\u003e\u003cp\u003e The study was approved by the Research Ethics Committee at Nasser Medical Complex. All patient records were anonymized. No direct patient contact or intervention was involved.\u003c/p\u003e\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\u003cp\u003eDeclarations\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA. Dr.yasmin .. manuscript writing abstract, introduction method and discussion B. Dr.Ghassan .. manuscript review auditting and paraphrasing C. Dr.Mohammed ..Data analysis,result writing.D. Dr.Nour ..Data collection and recommendation\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe sole author was responsible for the study conception, design, data collection, analysis, manuscript writing, and approval of the final version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbed Y, et al. Maternal health in conflict zones: Lessons from Palestine. 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World Health Organization. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/WHO-NMH-NHD-14.5\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/WHO-NMH-NHD-14.5\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Low Birth Weight, Intrauterine Growth Restriction, Antenatal Care, Maternal Malnutrition, Conflict Zone, Gaza","lastPublishedDoi":"10.21203/rs.3.rs-7529810/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7529810/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Low birth weight (LBW) and intrauterine growth restriction (IUGR) are major causes of neonatal morbidity and mortality worldwide, with amplified prevalence in conflict-affected regions. Maternal malnutrition, inadequate antenatal care, and exposure to armed conflict are significant contributors to adverse neonatal outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective observational study analyzed 1,336 normal vaginal deliveries at Nasser Medical Complex from April to June 2025. Maternal age ranged from 20 to 35 years. LBW was defined as birth weight below 2,500 g, and IUGR as birth weight below the expected range for gestational age. Maternal nutritional status, anemia, antenatal care attendance, and gravidity were evaluated. Statistical analyses were conducted using SPSS version 26.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among all deliveries, 115 neonates (8.6%) were classified as LBW, and 93 (7.0%) as IUGR. A majority of affected neonates were born to primigravida women. Maternal malnutrition and microcytic hypochromic anemia were prevalent. LBW and IUGR incidence increased progressively from April to June 2025. Figures 1 and 2 illustrate the monthly distribution and maternal factor associations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Growth restriction, rather than prematurity, was the primary contributor to LBW and IUGR. Findings emphasize the role of maternal nutrition, antenatal care quality, and conflict-related stress on fetal growth in Gaza.\u003c/p\u003e","manuscriptTitle":"Impact of War on Maternal and Neonatal Outcomes Among Partum Women During Displacement Events in Eltahreer Maternity Hospital, Gaza Strip,Palestine. ( 2025)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 08:29:41","doi":"10.21203/rs.3.rs-7529810/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T12:00:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T05:08:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124174697336719917903197443210196288428","date":"2025-10-13T04:24:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66191314730614216756297077017432692823","date":"2025-10-10T10:10:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T17:02:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331552333175127832190383764541906293547","date":"2025-09-09T10:09:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164218214548508337215103387009142496197","date":"2025-09-09T05:50:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-09T05:26:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T16:17:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T08:40:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-05T08:38:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-09-03T18:53:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"520cc580-89bf-4746-999d-3dbb5afeb0a9","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T22:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-17 08:29:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7529810","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7529810","identity":"rs-7529810","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}