Barriers to effective antenatal care coverage in conflict-affected settings: Evidence from the Gaza Strip.

BackgroundMaternal health services were severely disrupted during the war in Gaza due to damage to health infrastructure, supply shortages, workforce disruption, and large-scale displacement, compromising access to and continuity of antenatal care.ObjectivesTo assess antenatal care coverage in the Gaza Strip during active hostilities and characterize gaps across availability, accessibility, acceptability, contact, and quality-adjusted effective coverage.DesignA mixed-methods study combining a cross-sectional, community-based household survey with qualitative key informant interviews.MethodsThe quantitative component included 671 women aged 16 to 48 years who had been pregnant between October 2023 and October 2025 and were surveyed across accessible governorates of the Gaza Strip during September and October 2025. The qualitative component comprised 14 key informant interviews with health care providers, policymakers, and other stakeholders conducted between October and November 2025. Quantitative data were analyzed using descriptive statistics, bivariate analysis, and multivariable logistic regression, while qualitative data were analyzed using inductive thematic analysis.ResultsOverall, 65.1% of pregnant women reported receiving any antenatal care, compared with 99.2% pre-war coverage. Although services remained geographically available, access was constrained by insecurity, damaged infrastructure, transportation barriers, disrupted information systems, and limited outreach. Among women who received antenatal care, 28.6% initiated care after the first trimester. Delayed antenatal care initiation was significantly associated with educational level, health insurance status, and pre-war area of residence, among other factors. Qualitative findings further identified fragmented continuity of care, reliance on informal information sources, reduced trust, and gaps in service quality.ConclusionAntenatal care coverage in Gaza was severely disrupted during the conflict, affecting timely access, continuity, and quality of care. Restoring and scaling up antenatal care services, strengthening coordination, and embedding continuity and quality into emergency preparedness are critical to humanitarian response and recovery.