Attacks on sexual, reproductive, maternal and newborn healthcare in armed conflict: Accountability for the gendered reverberating effects

Attacks on sexual, reproductive, maternal and newborn healthcare are an increasingly prominent feature of contemporary armed conflict, yet their gendered effects remain underexamined. This narrative review synthesizes evidence from global health, humanitarian practice, conflict studies, and international law, drawing on examples from Gaza/occupied Palestinian territory, Ukraine, Sudan, and Ethiopia. It argues that attacks on health care produce reverberating harms that extend beyond immediate destruction, disrupting reproductive autonomy, maternity care, neonatal services, referral pathways and health-seeking behavior. Building on the three-delays model of maternal mortality, the article proposes a "fourth delay" to capture situations in which the healthcare destination itself is destroyed, displaced or rendered non-functional. It further examines how such harms intersect with gender-based and reproductive violence and existing protections under international humanitarian, human rights, and criminal law. The article concludes that stronger medico-legal analysis, accountability, reparations, and prevention are needed to recognize and address these gendered harms in conflict and improve maternal outcomes.