Babies in Ethiopia’s embattled Tigray region are dying in their first month of life at four times the rate before the war cut off access to most medical care for more than five million people, according to the most sweeping study yet of how mothers and children are suffering.

Women are dying during pregnancy or within 42 days of giving birth at five times the rate before the war, and children under the age of five are dying at twice the pre-war rate, often because of easily preventable reasons, according to the yet-unpublished study shared by its authors with The Associated Press.

Almost two years have passed since the war started and Ethiopia’s government isolated the Tigray region from the rest of the world, severing basic services such as electricity, phone, internet and banking.

While United Nations-backed investigators last month said all sides including the Tigray forces have committed abuses, they said the Ethiopian government is using “starvation of civilians” as a weapon of war.

Both sides have been invited to African Union-mediated peace talks this weekend in South Africa.

A lull in the war earlier this year allowed thousands of trucks of humanitarian aid into Tigray, but renewed fighting in August has again stopped deliveries to a region where critical medical supplies like insulin and childhood vaccines have run out. There is an “extreme shortage” of medicines and equipment, the UN-backed investigators found.

Pregnant women and young children, least to blame for the fighting, are among the most vulnerable.

The new study was carried out in May and June by local health authorities with financial support from two UN agencies and studied more than 189,000 households in six of the region’s seven zones via cluster sampling. With limited fuel for transport, researchers at times walked for hours to reach rural areas.

Maternal mortality was at 840 deaths per 100,000 live births, up from a low of 186 before the war, with obstetric haemorrhage and hypertension the most common causes.

“This level is unacceptably high and is comparable to the level which was 22 years back,” the study said.

More than 80% of mothers died outside a health facility, another stark contrast, it added.

More than 90% of mothers in Tigray before the war had prenatal care and more than 70% benefited from skilled delivery, according to an analysis published in the BMJ Global Health journal last year.

The increase in maternal mortality in Tigray has been “phenomenal,” the UN Population Fund said this year.

Neonatal mortality, or children dying in the first 28 days of life, was at 36 in 1,000 live births, the new study said. That is a four-fold increase from pre-war levels, and more than half of the deaths occurred at home without medical intervention.

The most common causes were prematurity, infections and perinatal asphyxia, or the inability to establish breathing at birth.

Under-five mortality was 59 in 1,000 live births, double the rate before the war. “Vaccine-preventable diseases like diarrheal disease, pneumonia and pertussis account for the majority of causes,” the study said.

In images shared with the AP this week from Tigray’s flagship hospital in the capital, Mekele, a health worker pinched the thin stomach of a small child, two-year-old Selam Mulu. The skin stayed pinched after the hand was removed, a sign of dehydration in malnutrition.

The study calls for more medical supplies including painkillers, antibiotics, anticonvulsants, vaccines, IV fluid and drugs to induce labour after foetal death.

“For women here, it’s hell,” a gynaecologist in Mekele who was part of the research team told the AP.

“They get pregnant, they cannot access care,” he said. “I’m talking about the rural women. And if she’s in labour and if she lives in the mountains, which is the case for most pregnant mothers in the outskirts, they cannot travel. They cannot call an ambulance. There is no money to pay for private transportation. Even if they arrive at a health facility, there is nothing.”

Before the war, a woman’s pregnancy was a joyous matter, the gynaecologist said. Now it is a bad omen, with people feeling sorry for her.

“I haven’t heard of such things in other parts of the world,” he said.

This occurs as the UN-backed investigators found that some Tigrayans are resorting to transactional sex to survive.

It remains difficult to estimate the war’s death toll because of the widespread constraints, the gynaecologist added. Thousands of people have died. Independent journalists have been barred from the region.

The researchers plan to share their results with the international community and Ethiopia’s health minister, Lia Tadesse, who is also a gynaecologist. The minister, told of the findings and asked for comment, did not reply to the AP.

The war has devastated Tigray’s once well-funded health system, the gynaecologist said. “People would ask you ‘Are you going to help us? What’s after the data collection? Are you going to solve our problems?’ It was haunting.”