"Her name is Amirah and she is clueless about her age. She must be forty-something I guess. When I ask her about the number of children she has, she smiles and says 'jaam' meaning 'a lot' in Sindhi. Still, how many, I persist. 'Fifteen or sixteen!' she tells me. When asked how many more she wants, Amirah looks up to the sky and says resignedly: 'Allah ji marzi [It's up to God],' which to me, translates to 'till death do us part'." Dr. Nighat Shah, secretary-general of the Society of Obstetrics and Gynecologists, Pakistan (SOGP), wrote this in one of her daily diaries last month during her visits to the relief camps in Khairpur district, one of the 23 districts comprising Sindh province.

Khairpur alone has seen an influx of some 1,50,000 internally displaced persons (IDPs) due to the recent floods. It has been almost two months since the rising river waters submerged one-fifth of Pakistan and affected nearly 21 million people. Now, after the waters have receded, the death toll stands at 1,750 and more than 1.8 million homes are estimated to have been either damaged or destroyed. Receding waters also means that people have to now gear up for another battle - against diseases that become rampant post-floods because of stagnating waters, poor sanitation, hygiene and an over-stretched healthcare system. In this dismal scenario, imagine the plight of expectant women and new mothers. According to the United Nations Population Fund (UNFPA), of the 18 million displaced by floods, 70 per cent are women. Almost 1.5 million are in their reproductive age and some 52,500 women are estimated to give birth in the coming days. 

When Shah visited the camps she observed that most women there were malnourished. "The sad part was that many were still breast-feeding, even though there was no milk," she recalls. Whichever camp she and her team visited, between 20 to 25 per cent women were pregnant. Dr Sajjad Ahmed, who is managing a battalion of midwives that have been deputed by the Pakistan Medical Association's (PMA) Karachi chapter across the 22 camps in Karachi, concurs with Shah. He says, "They were already in poor health, but in the face of displacement, disease and hunger, their health problems have been further exacerbated."

According to him, there is an urgent need for folic acid supplements for pregnant women and milk for nursing mothers. "We need milk for nursing mothers. Giving powdered formula milk will only complicate matters as the women will not know how to prepare it, and getting clean water is a huge challenge." The thinking is that if nursing mothers are provided milk they will, in turn, be able to breastfeed.

In the face of a broken down health system it has been difficult to provide these women with even the basics, but efforts are on. The PMA, in collaboration with the SOGP and United Nations Children's Fund (UNICEF), has formed teams comprising two midwives, one male nurse and one doctor to visit these camps. Nagina Ilyas, who supervises these teams, says, "If the camps are bigger, like the 500 Quarters in Hawkesbay tented camp, some 20 kilometres from the Karachi city centre, which has almost 10,000 displaced people, then two or even three teams go there."

But there are problems aplenty. Like a shortage of doctors, especially female doctors. "Female doctors are badly needed as women IDPs refuse to get checked by male doctors," says Ahmed. One midwife, who is a part of these care teams, offers an explanation for this hesitation to volunteer, "It's not easy to come here every day. It's hot; there is no washroom and the ones setup for the community are filthy." 

Working in schools-turned-camps is tougher. "The classrooms are packed with about 30 or 40 people and flies are swarming all around. Most of the displaced are ill. A lot of them have scabies; others have eye-infections or open wounds; many have Hepatitis C and even tuberculosis (TB). Most children are suffering from diarrhoea," says Ilyas, overwhelmed by so much suffering around her. 

Around 70,000 are lodged in the 22 camps in Karachi and the numbers are only increasing. "Our team has seen more than 28,000 patients in the last two weeks," says Dr Samrina Hashmi, PMA general-secretary, "This means every third or fourth person is in need of some medical attention." In the last two weeks, the healthcare teams have carried out 1,285 antenatal checkups and 43 safe deliveries. The PMA has also identified three referral tertiary care hospitals nearby for maternal and child health care. They are providing 24X7 services, including investigation into all referral cases free of cost. In addition, one of the referral hospitals, the Murshid Hospital, is providing DOT (Directly Observed Therapy) for drug-resistant TB infection.

The UNFPA also has established 36-fully equipped service delivery points for pregnant women. These include 23 mobile service units and 14 existing government health facilities across Pakistan. It also plans to strengthen 40 basic health facilities and 12 referral health facilities to deal with the increased demand for medical services all over the country. 

Direct interventions apart, the UNFPA is also conducting reproductive health training and offering supplies to non-governmental service providers. "It is vital to provide life-saving reproductive health facilities for the benefit of mothers and babies. We only need six million dollars to cover 5,00,000 births, and only 20 per cent of this has been financed. What we need is, in fact, just $12 per birth. Only $12, to ensure the health and safety of a mother and her baby," says Maurizio Giuliano, spokesperson for the Office for the Coordination of Humanitarian Affairs (OCHA) in Islamabad.

Adds a young midwife who visits the 500 Quarters camp daily, "For those who are pregnant or have just delivered, sometimes all we need is bedding or even a clean sheet for them to sleep on. There have been many instances when we have seen mothers sleeping on the floor without even a straw mat. Naturally, she and even her new born baby will catch infections."

While morbidity and mortality were tragically high even before the floods, calamities often put women at a much greater risk of getting pregnant, says Dr Shershah Syed, a noted gynaecologist in Karachi. "But if we can provide these women with timely low-cost reproductive health services and emergency obstetric care, we can lower the number of maternal mortalities and morbidities."

According to Ilyas, "It's quite normal to see women with 10 to 11 kids." Take Roza Barkat, who hails from a village in Jacobabad. It is her 11th pregnancy and she is in her seventh month. The 30-something, who is camped in a government school in Kemari area of Karachi, looks extremely anaemic. "I'm always tired because I can't get enough sleep; the mosquitoes just don't let us take any rest," she says.

But Shah sees a "silver lining" in all this chaos. It has brought women like Amirah and Roza to healthcare professionals, thereby providing them with an opportunity to break the cycle of frequent pregnancies. "We can provide them the much-needed family planning (FP) services," she says.

"We are cajoling women who have between 10 and 14 children, to go in for a tubal ligation, but it is an uphill task. Apart from the language barrier, they just freak out when we tell them it's an operation. The next job is convincing the husband, which is a time-consuming task," says Ilyas. 

These are tough times for the average Pakistani woman, on whom falls the responsibility of keeping the family together even as she tries to rebuild her life from scratch. As for those who are expecting or have given birth recently, what would otherwise have been a happy time has become a nightmare today.    
 
By arrangement with WFS