At 9am on a Wednesday, 20-year-old Zanat sits on her single iron bed, a thin green mattress and a white sheet thrown over it. Dressed in mustard yellow with a matching headscarf, she looks at her newborn daughter, who sleeps beside her. She shares the cramped room with three other mothers in the maternity unit of a primary health center inside Cox’s Bazar refugee camp in southeastern Bangladesh. Zanat gave birth only yesterday. 

“When my labor pain started, I felt some fear about whether the baby would be delivered normally; but when I delivered the baby, I felt happy,” she told More to Her Story.

Today, Zanat feels well enough to travel the 20 minutes by car through the narrow and dusty roads back to her one-bedroom home in her part of the camp where her husband and three-year-old son await. 

Although a refugee camp indicates the contrary, these women could be considered the lucky ones. They have endured childbirth and survived. Inside the world’s largest refugee camp, many women in the camps of Cox’s Bazar don’t live to see their children grow. In 2023, 295 women died out of every 100,000 who gave birth, one of the worst rates globally. Elsewhere in Bangladesh, the rate is significantly lower at 85, highlighting the vast difference in conditions. 

The camp, which is broken down into smaller camps and districts, hosts almost one million Rohingyas, a minority Muslim ethnic group, the majority of which fled neighboring Myanmar in 2017 amid violent persecution from the Burmese military. As with most refugee camps, resources, such as food, water, and medicine, are scant, and healthcare is sparse and mostly dependent on aid organizations. 

With no means for these refugees to integrate into local Bangladeshi life or to return home where a civil war wages on, the camp has turned into a playground for violence and gangs. All of this makes it unsafe, particularly for women and girls. 

Kidnapping and trafficking are frequent occurrences, as is gender-based violence (GBV). Then there are the high rates of child marriage, an increasingly common practice among the Rohingya. But for the parents of a daughter, it can mean freeing up more space in an impoverished household. Early marriage significantly raises the likelihood of adolescent pregnancy, which is considered high-risk. Religious beliefs discouraging contraception contribute to consistently high pregnancy rates across all age groups. According to 2018 UNICEF data, an estimated 60 babies were born in the camp every day.

“Among Muslims, even Bangladeshi people, there is a significant misconception that using contraception is not supported by the religion of Islam,” Nuruzzaman Khan, a global health research fellow at the University of Melbourne whose research focuses on maternal and child health in refugee settings, told More to Her Story. “Many want big families to access more food from aid agencies or to create a big cohort to fight against Myanmar in the future,”

But the increased birth rate, lack of decision-making about their own bodies in a patriarchal community, and stigma around formal medical care mean that women and girls bear the brunt of the protracted crisis. According to UNICEF, only one in five mothers gives birth in a health center, with traditional beliefs dictating that a home birth is best. Yet hypertension, infection, and haemorrhage are the biggest causes of maternal death, all of which could be more immediately managed with adequate health care provided in a health center.

Trying to remedy that, the United Nations Agency for Sexual and Reproductive Health (UNFPA) in partnership with NGOs such as Ipas and RTM International, has set up a collection of maternity units inside the primary health centers within the camp. UNFPA has also trained nearly 500 Bangladeshi women through their international midwife mentorship program to work in these centers and educate the community on the benefits of access to health services.

26-year-old Shakila Arfin, who lives outside the camps and has been a midwife for four years, is one of UNFPA’s midwife supervisors, working to ensure the midwives are well-trained to deal with complications. Dressed in a pink tunic and head scarf with matching pink lipstick, she shares how she opted to work in this context instead of elsewhere in Bangladesh because of the dire need inside the camp. 

The biggest challenge, she said, is in getting women to come to such centers in the first place. Community beliefs dictate that a home birth must be the norm; this, said Arfin, is what drives up the high numbers of maternal mortality alongside the inability to diagnose issues such as preeclampsia or hypertension beforehand. 

This means a lot of midwives like Arfin’s time is spent convincing not the mothers themselves but, often, the husbands, mothers-in-law, and imams to allow the expectant mother to receive care and deliver in a hospital. 

“We communicate with the head of the community and also imam… because in their community their [word] is easily accepted,” Arfin shared, from inside one of the small patient rooms where a lone fan whirrs and flutters the pink curtains that do little to block the sunshine from seeping through.

Today, though, she’s on duty inside a center in the Ukhia area of the camp. More pink curtains hang outside each door frame, marking a transition from the general medical ward to maternity, where five small rooms, void of any air conditioning, make up a cramped yet efficient ward. The catchment area of the facility is over 12,000 people, and 245 are currently pregnant. Arfin will spend her day giving antenatal and postnatal care in between stints in the labor room, but also, in her role as a supervisor, it is among her responsibilities to deliver UNFPA training to the other midwives when she can. 

Despite the somewhat early hour, the waiting areas are already full. Women, the majority of whom are dressed in black burqas, wait patiently outside for their appointment, babies in arms and toddlers at their feet. These are the women whose families have been convinced by midwives and community health workers like Arfin, that there is value in seeking formal medical care. Making sure no time is wasted, a member of Arfin’s team delivers an educational session to the waiting women. Sometimes, it’s on family planning; other times, it’s on breastfeeding, birth, or adolescent pregnancy, said Arfin. 

“It’s important all women understand what’s available to them and feel comfortable in seeking support,” she said. A big part of that is having some of UNFPA’s midwives stationed inside designated women’s friendly spaces in the camps. These are often nestled in between houses, offering classes on embroidery or talks on nutrition. They simultaneously act as a safe space for women to seek advice on family planning, support for GBV, and access to maternal health care. Midwives then refer the women to the PHCs as the pregnancy progresses.

Such is the work that Arfin and colleagues have done through spaces like these. When Zanat became pregnant the first time, community members encouraged her to go to the center, she shared, rather than discouraging her. This meant she gave birth to both her babies with a skilled birth attendant present, something the UN stipulates is necessary to reduce the global maternal mortality rate. Refugee camps in Bangladesh report some of the highest maternal mortality rates in the world.

However, aside from community barriers, these midwives face other challenges. There are constant threats of funding cuts. Seven years on, the Rohingya crisis has been eclipsed by other global conflicts, leading to a decline in aid. In 2023, food assistance was cut by a third, while the 2024 Joint Response Plan for the Rohingya refugee response was only 53 percent funded as of the end of September. All of this puts what services there are, including those for women and girls, at risk. 

Prior to COVID-19, access to health services had been improving, said Khan, but since then, they’ve rapidly declined.

“After the COVID-19 pandemic, I know some local NGOs stopped providing services to the Rohingya refugee community because of funding issues. I know some other organizations that are still providing services in the refugee community, but their volume of providing services or their coverage area significantly reduced because of funding issues,” he told More to Her Story.

At the same time, midwives have to deal with the constant onslaught of floods and storms that make their work harder to do. “When the floods occur, our health workers and patients cannot easily come to the facilities,” said Arfin, adding that this increases the level of maternal mortality. Bangladesh is one of the most vulnerable countries to disasters and climate change, according to the 2023 World Risk Report. In 2024 alone, the camp has had to withstand landslides, floods, and waterlogging. What would help, Arfin said, is more maternity centers to provide more options for care in the event that climate disasters destroy major infrastructure or much-needed material care elsewhere. 

But Khan doesn’t believe that will happen any time soon. “It is only going to be more challenging in the coming days,” he said.

In the meantime, Zanat will leave the center with her unnamed baby girl, hoping that when she’s older, the situation will change for the better.