This is the worst winter for women in quake-hit areas of Kashmir. Many are shelter-less, poor and without access to healthcare. In fact, the fragile and inadequate health system of the state has been thoroughly exposed in the recent months.

The October 8, 2005 quake killed over 73,000 people in Pakistan and around 1,300 in India. Hundreds of people are still homeless after the quake, and with many mountain roads still blocked by landslides, aid has yet to reach many in remote areas in Pakistan and India, say media reports.

Aid workers say many women in the quake areas are pregnant and urgently need high protein food and medicines. Recently, the UNFPA appealed for US$ 3.2 million to meet the needs of pregnant women in the quake zone. Media reports quoted UNFPA saying "that the physical and psychological shock may increase the number of women needing emergency medical care to prevent maternal or infant death".

The earthquake destroyed two main hospitals in Uri and Tanghdhar districts (in Kashmir), and some primary health centers (PHCs) in remote villages. Dr Arif from Uri says that the harsh winter, coupled with disruption of normal life, has made many children and women vulnerable to diseases like pneumonia. In fact, several pregnant women, who live in tents and are exposed to the bitter winter, are suffering from pneumonia.

Poor sanitation facilities have also exposed women to urinary tract infections (UTIs). Says Dr Sitara, a gynecologist, "We are getting women in their third trimester suffering from pneumonia. In such situations, both mother and the child are at risk. Lack of nutrition is also a problem for expectant mothers. Direct exposure to cold, in the absence of proper shelters, is making women, and children, vulnerable to cold-related diseases."

A local politician from Uri admitted that the state's health system almost collapsed in quake-hit areas. "Very few doctors have come forward to help in remote mountainous areas. There has been tremendous reluctance on the part of the doctors to go to places like Karnah and other remote locations in Uri, despite being offered the best possible living conditions under prevailing circumstances," stated a senior Jammu and Kashmir health officer.

Since October, over 300 cases of miscarriages or threatened abortions have been reported from Uri district. Many women, hurt during the quake, later developed major complications because of "very limited" access to basic health services and emergency obstetric care. Many pregnant women deliver at home, without any medical assistance.

Dr Shahida Mir, Head of the gynecology department at Srinagar's Lal Ded Maternity Hospital, says their biggest challenge has been taking care of pregnant women who suffered multiple fractures during the quake or during the aftershocks. In fact, a large number of women have delivered babies who had fractured bones and serious injuries. Some women also reported problems of bleeding and hypertension.

"The reasons are both psychological and physiological. Many women would run in panic during the 1,000 aftershocks that struck after the deadly quake," says Sitara.

According to Dr Mehmooda Dar, a leading gynecologist who runs a private clinic in Srinagar, "I see 400-500 patients (women with pregnancy complications) in a month, and I can tell that there are about 50 per cent abortions among the normal patients as well."

Dar says many pregnant women even suffer from the trauma of not being able to access basic health services and emergency care. "My wife developed pregnancy-related complications a month after the quake. Also, each time a post-quake tremor occurred, she refused to enter the house. She would run out in panic and one day she stumbled, fell down, and lost the baby," says Nisar Farooqi, a pharmacist from Srinagar. That would have been the couple's first child.

Aid workers and doctors warn that the ongoing winter will bring more loss to the state.