“I was three months pregnant and worried about what this trip would do to my baby, but I didn’t have a choice. We had to go,” says Leyla Ashur, one of the few hundred Syrians allowed to cross into the former Yugoslav Republic of Macedonia from Greece one day in August.

Ashur, 35, says she, her husband and their four sons had fled fighting in their home town of Dayr Az-Zawr, Syria, in 2012 and lived for about a year in Iraq. But the fear of violence from the self-proclaimed Islamic State in Iraq and the Levant, or ISIL, drove them across yet another border, into Turkey, where they stayed for three years until even that situation became untenable. She says not only were they afraid of escalating violence along the border, but they also felt exploited and unwelcome in their host community.

“When they saw we were Syrians, we had to pay three times the rent everyone else was paying,” she says. “And everyone kept telling us, ‘Go away, go away.’”

And so the family of six left with a few belongings crammed into backpacks. The journey across Turkey took 10 days, with little rest and very little to eat along the way. “We didn’t receive help from anyone,” Ashur says.

When she and her family reached the Turkish coastal city of Bodrum, they and about 20 others together paid a smuggler €10,000 to carry the group in a rubber raft across the Aegean Sea to the Greek island of Ios. From there, they made their way to the former Yugoslav Republic of Macedonia.

From the southern city of Gevgelija, Ashur and her family began the next leg of their journey north, with the aim of crossing through Serbia and Hungary and then on to Belgium, where her husband’s sister lives.

“We will reach our destination or die on the way”

While hundreds piled onto overcrowded trains and buses, or simply walked the 178 kilometres to the northern frontier city of Kumanovo, Ashur and her family found a taxi to take them for €100. Her two younger sons waved goodbye from the back window.

Syrians like Ashur and her family account for about 80 per cent of the people transiting through the country. Afghans and Iraqis each account for about 5 per cent. The others are from Pakistan, Somalia, Palestine and five countries in sub-Saharan Africa.

Between June and August 2015, an average of 700 refugees and migrants followed the same path to northern Europe through the former Yugoslav Republic of Macedonia every day. Of that number, about one in four is a woman, and on average, 6 per cent of those women are pregnant.

Many of the pregnant women have health concerns stemming from walking long distances in the heat, poor nutrition, dehydration and the absence of sanitation, all of which can lead to pregnancy complications or even miscarriage. And many are traumatized, says Suzana Paunovska of the Red Cross in the capital, Skopje. “You see it immediately in their faces.”

The Government in June declared that refugees and migrants could access health care, including obstetric and gynaecological services, for free from public health centres and hospitals, including the one in Gevgelija.

But because refugees and migrants are in a hurry to reach the border with Serbia within the 72 hours the Government allows for transiting through the country, most choose not to take advantage of free services rather than risk missing one of the few trains or buses traveling north.

Pregnant women will only use services that are fast and within easy reach of transit hubs near border crossings, says Bojan Jovanovski, who heads the Association for Health Education and Research, or HERA, in the capital, Skopje.

HERA deploys its only mobile health clinic to the border with Greece, a few hundred metres from Gevgelijia, one day a week to provide free, quick, basic gynaecological services for refugees and migrants. UNFPA, the United Nations Population Fund, helps cover the clinic’s operating expenses.

Lidija Jovcevska is an obstetrician-gynaecologist based in Kumanovo. She volunteers one day a week for the mobile clinic. The five or six women she sees in a day mostly want to know whether their foetuses are healthy. She uses an ultrasound machine to reassure most expectant mothers but also lets them know about any potential complications. Some women who have traveled for days and sometimes months also ask for vitamin supplements to increase the chances they will deliver healthy babies. Vaginal and urinary tract infections are common. Jovcevska prescribes antibiotics and other medications.

On occasion, there is a serious problem requiring attention at a hospital. Jovcevska refers these cases to the nearby hospital, which can handle emergencies as well as deliveries. Jovcevska says the risks of traveling under such extreme conditions while pregnant are high. “It is unclear to me, as a mother of two myself, how they can even contemplate such a trip,” she says, while acknowledging the desperation that many of these women feel. “One woman I saw today told me, ‘It’s all right if I die on the way.’”

The mobile clinic also offers contraception, though few take advantage of it, says Vesna Matevska, a programme coordinator for HERA. The refugees and migrants she sees tend to be very private people who are reluctant to ask for or accept condoms or the pill, even though they are free of charge and available from non-judgmental service providers. She says this sense of privacy, along with language barriers, also make it difficult for many women to talk about or report gender-based violence.

In addition to services provided by nongovernmental organizations and the country’s ministry of health, there are those offered informally by individuals like Lence Zdravkin, 48, a self-described activist, who says she has helped hundreds of pregnant women as they walked north across the country to reach the Serbian border.

Until June 2015, it was illegal for refugees and migrants to use trains, buses or taxis, so most simply walked the distance, usually along the main railway tracks, which pass 10 metres from Zdravkin’s home.

Zdravkin began offering refugees and migrants food and water and opened her home to people who simply needed a rest. She brought pregnant women to a local clinic for checkups or to treat the injuries that are inevitable when walking for days in the summer heat.

“Everything was happening right in front of me,” Zdravkin says. “I couldn’t just close my eyes.”

* This story was featured in UNFPA's State of World Population 2015: "Shelter From the Storm: A transformative agenda for women and girls in a crisis-prone world"