In order to continue providing maternity care during air raids and bombings, medical staff at the regional maternity hospital in Poltava, central Ukraine, built a fully functioning operating theatre in the basement in a matter of weeks after the start of Russia’s invasion of Ukraine. It’s been invaluable – numerous babies have been delivered there and major surgeries successfully carried out.

It’s also one of the health clinics fully equipped with a gynaecological suite provided by the International Planned Parenthood Foundation (IPPF) via its Ukraine partner organisation, the NGO Woman Health and Family Planning Charity Foundation (WHFP).

According to IPPF, the sexual and reproductive health impacts, both immediate and long-term, of Russia’s invasion of Ukraine are numerous and widespread. They include an increase in sexual violence (mainly against women but also some men) and a rise in demand for abortions.

Birth rates were worryingly low before the war, but are now decreasing further: between January and November 2022, 195,000 babies were delivered in the country, a 30% decrease on the previous year. There are also concerns about what happens after the war, and the likelihood of a repopulation push and what that will mean for women’s choices.

All this at a time when healthcare services across the country are depleted and under immense strain, with Russia’s invasion having led to a lack of facilities, personnel and equipment.

To help with the country’s most urgent sexual and reproductive health needs, WHFP has been providing hospitals and healthcare clinics with medication and equipment, including emergency obstetric kits, emergency contraception, and pills for medical abortions.

“[Ukrainian doctors] have been delivering babies in the metro because [of the bombings],” WHFP executive director Galyna Maistruk, who is also an obstetrician-gynaecologist and is based in Kyiv, told openDemocracy.

“If you speak to women about what we need – we need victory. We need Russia to leave our territory and to stop bombing us,” she added. But in the meantime, she said, “we’re trying to minimise the losses.”

Maistruk emphasised the importance of providing psychological – as well as medical – care for those traumatised by the war, adding that most pregnant women worry about how stress and panic could affect their pregnancies. The charity, which also operates in Kyiv, Kirovohrad, Odesa and Vinnytsia, trains medical professionals in being trauma-informed when speaking with women, especially survivors of rape.

Prioritising women’s choices

Nadiia*, who lives in a village near Poltava, decided to have an abortion in April after discovering she was pregnant unexpectedly. Her husband is earning less because of the war, they already have two children – she’s still on maternity leave for her youngest – and she is also caring for two elderly relatives who escaped from Russian-occupied territory.

“My husband and I agreed that if the war wasn’t happening, we would have this baby. But to give something to our unborn child, we would have to take something away from our two children,” Nadiia told IPPF in an interview shared with openDemocracy. “Normally, we would have been able to cope – but there is no certain end point to this war.”

A local doctor recommended that she have the termination at the Poltava regional maternity hospital, specifically the WHFP suite. She went to the hospital, where she was consulted, counselled, checked via ultrasound, and then asked if she was confident with her decision. She had the abortion and said she was pleased with the medical care she received.

The displacement of millions of Ukrainians since the Russian invasion has disproportionately affected women and children – they make up 90% of the eight million Ukrainian refugees in Europe.

But although the war is still raging, many people have now returned home – either from abroad or after being internally displaced. Tamara Zaiva is one of them. She fled to Poland with her husband and six-year-old son soon after the invasion last year. They remained for six months, but once she became pregnant, they decided to return to their home village of Dobroslav, an hour’s drive from Odesa.

“There were some nuances with the health system in Poland that I couldn’t navigate,” Zaiva, who is due to give birth by the end of May, said in an interview shared with openDemocracy. These included language and financial barriers. “I wanted to come back to Ukraine to see my own doctor, who I can rely on and understand.”

WHFP’s Maistruk hopes that more women who have left Ukraine will return, but for this to happen there needs to be high-quality reproductive and sexual healthcare. “People need good services. This is a big attraction, even for people who left Ukraine as refugees,” she said.

Sexual violence in wartime

From the very start of the war, there have been numerous reports of sexual violence by Russian troops in Ukraine. Iryna Didenko, from the Ukrainian prosecutor’s general office, said in January: “Russian invaders have a clear pattern of behaviour when seizing territory. Ground forces arrive and rapes start on the second or third day.”

This was echoed by Nerida Williams, IPPF’s senior humanitarian communications adviser, who told openDemocracy: “Russia is using sexual violence as a tactic of war.”

Ukrainian investigators have recorded widespread sexual abuse by Russian troops, with victims ranging in age from four to 82. According to Radio Free Europe, documented cases skyrocketed last year after parts of the Kharkiv region were liberated in September and the city of Kherson was liberated in November.

However, there is an information blackout about Russian-occupied regions such as the so-called ‘people’s republics’ of Donetsk and Luhansk in eastern Ukraine. “These people are under occupation by a terrorist state, which means all kinds of criminal things go on,” said Maistruk from WHFP.

Cases of intimate partner violence against women have also escalated in Ukraine since the start of the invasion.

“The curfew imposed by the war means that people aren’t outside at night, but rather stuck inside with people they know,” said Anzhelika Yatsenko, one of the leading clinical psychologists in Poltava and a medical trainer for WHFP. “The stress and pressure of the war have a direct impact on the increase of sexual and gender-based violence rates.”

Men have also suffered from sexual violence, with reports of Russian soldiers castrating captured Ukrainian troops.

Yatsenko told IPPF that she is treating two male patients who were castrated by the Russian army while they were prisoners of war. “These cases have really touched me,” she said. “These soldiers do not want pity but are in severe need of psychological care.”

The prosecutor’s general office has interviewed hundreds of survivors of sexual violence, but by early March this year, only 155 had agreed to testify in court.

Maistruk believes that if Russia is to be held accountable, earning the trust of survivors is crucial so that they will report the crimes committed against them to the International Criminal Court (ICC).

The ICC held a training session in Kyiv in March, on witness protection and support for victims of conflict-related sexual violence in Ukraine. Maistruk said: “It’s extremely important to [preserve] the memory of the victims… so we’re grateful for help from international investigators who know international law. ”

* Names have been changed