It has been more than two years since the devastating floods of 2022 ravaged one-third of Pakistan, affecting approximately 33 million people, including 8.2 million women falling in the reproductive age.

The United Nations Population Fund (UNFPA) had estimated then that more than 650,000 women with expectant mothers needed maternal assistance to ensure safe pregnancies and deliveries. The numbers also showed that nearly 73,000 women were due in the month following the onset of the floods. Sindh, Balochistan, KP, and Southern Punjab were badly affected, and the consequent displacement affected the already limited healthcare available.

Climate change is known for amplifying already existing vulnerabilities, including gender disparity. There is no doubt that climate change disproportionately affects women and girls, and women, whose needs are often ignored when conditions are relatively normal, are further exposed to health crises.

Pregnant women, new mothers and those who had to give birth during the floods or when the water had not yet receded were amongst the most vulnerable groups present. However, one does wonder whether the floods during August and September 2020 in Sindh may have prepared and equipped the country for the future, but 2022 as well as 2024 have proven that Pakistan still has a long way to go in understanding the health crises that befall women.

One organization among others which has actively worked towards women’s health, especially maternal and neonatal care, is Mama Baby Fund under Neha Mankani, who is a midwife herself.

In 2022, Neha was present in the affected areas of Sindh, trying to assist women who had arrived in hordes, some in their last trimesters, and others holding out their feeble babies who clutched onto their mothers.

As shown in a documentary focusing on non-urban Sindh by Push campaign, which is a movement that centres midwives and their vital role in sexual and reproductive health (SRHR), Neha revealed that many women gave birth in tents while being submerged in the flood water.

“I mean, we saw infections and maternal deaths. The sheer amount of tragedy that had happened, I think it’s something that you couldn’t comprehend until you were on the ground to understand what was happening and what it was that I could do in my capacity as a midwife,” she shares in the documentary.

Sanitation appeared to be a major concern, which also leads to various other ailments later, so providing them with birth kits was a priority. She was able to hand out around 13000 kits to the women, while the number of women who would need similar aid was more than 70000.

The camp set up by Neha and her team was in a small village, yet so many women showed up that there was a stampede: “At any given clinic we would see around 200 to 300 women at full capacity per day but one day we had at least 1000 people show up, and many who had come from distant villages returned home empty handed.” Neha can be seen comforting a mother who cannot stop crying and feels that empowering midwives in midwifery schools is very important.

“I’ve been speaking to a lot of midwives and engaging with them, having discussions with them on how we could advocate for them better so that they’re able to mobilize in future emergencies. But also sharing with respective ministries who may not know the kind of impact that midwives can have in these kinds of disasters and humanitarian situations. So, we have used it as a pivotal advocacy moment to highlight what the gaps are and how they can be filled by midwives as a solution,” she explains.

Dr Ghazala, an OBGYN from Jacobabad who has witnessed at least three major floods in the last 14 years, explained that while women in the first trimester can manage themselves, those who are about to deliver or have just delivered are at a higher risk.

“Having a normal delivery is a miracle at that point, but what we fear most is the postpartum haemorrhage (PPH) because it becomes very tough to stop the bleeding and procure the necessary medication, more so because anaemia is very common. In such cases, mothers who lose their lives don’t even make it to the official records due to the chaos and mass destruction.” She also believes that empowering lady health workers and midwives is necessary so that more women can handle delivery and post-natal care.

“Training can at least prepare women even when tools are not available, as we have witnessed in the past. Many times, trained midwives would help women give birth without any tools, as they passed by someone who was about to give birth. Those are desperate times, but this should not be taken lightly. Sometimes the birth attendants need to be trained again and again because they tend to forget the learnings, so I feel the competency needs to be in line with the best practices. Unfortunately, in the wake of the disaster, we hardly receive assistance from the state as quickly as we should, so we rely on ourselves to help women in need,” she said.

Dr Ghazala also shared that, given floods are neither a recent phenomenon nor would be recurring due to climate change, the government should allocate lands or spaces which would cater to people escaping the calamity. “Right now, we do not have a specified space. People often rush to schools for shelter because they are off to children. But when children return to resume their studies, the furniture has been burned to be used as firewood. So, deputy commissioners should look into this because it would be easier to reach one area and help all those affected instead of waiting for the water to recede. Another aspect is community building, which is for the locals to trust those coming to help them from nearby places so that the entire process is smooth and there can be some access points for health instead of none,” she explained.

The climate activist behind Madat Balochistan, Maryam Jamali, spoke about how her community is severely impacted by the floods: “Maternal healthcare access gets disrupted. Local clinics, often more reliable than district hospitals, became inaccessible due to infrastructure damage. This, coupled with power outages that disabled essential medical equipment, severely impacted access to basic medications and emergency care. The displacement and trauma of living in flood camps, coupled with the stress of food insecurity and the loss of livelihoods, significantly impacted women’s physical and mental health.”

She added that overcrowded camps and limited access to clean water and sanitation led to increased risks of infections, including those affecting reproductive health. The scarcity of resources also limited access to critical care during pregnancy and childbirth, resulting in tragic outcomes for some mothers and infants: “The long-term consequences include increased rates of malnutrition, delayed or denied access to essential reproductive healthcare services, and the ongoing psychological impact of the disaster on women’s mental and physical well-being.”

Maryam also believes that empowering midwives and lady health workers can be an important step in this regard: “I think that there’s less focus on community healthcare services. Just basic primary healthcare service delivery is available for pregnant women and infants.”

She added that improving maternal and child health requires an approach that does not exist in a vacuum: “This includes enhancing health literacy among women, equipping midwives with essential birthing kits and providing them with updated training to address harmful practices.

Furthermore, strengthening the healthcare system is crucial. Basic health units must be adequately staffed and resourced to effectively respond to disasters and meet the community’s needs. Midwives, as front-line responders, require consistent support and training to effectively address the unique challenges faced by women in these situations.“

Recalling the time during floods, she said there was a dispenser from her village who had to administer medical care to women on the canal bank because there was no other option.

She feels that equipping midwives with all the resources they need is crucial because they do phenomenal work, teaching people about birth control, contraceptives, and helping women through their pregnancies: “The midwife in my village stays with women for two, three days after their baby is born. This one girl, perhaps 19 or 20, lost her mother shortly after giving birth. The midwife in our village went above and beyond, staying with her for a week, providing not just medical care but also essential support like food and assistance with childcare. This highlights the invaluable role midwives play in these communities. While establishing clinics and deploying doctors everywhere is not always feasible, investing in and empowering existing midwives within communities offers a cost-effective and sustainable solution. Midwives possess deep-rooted connections and an understanding of local challenges, enabling them to provide culturally sensitive and effective care. By supporting their efforts and equipping them with the necessary resources, we can significantly improve maternal and child health outcomes in these underserved areas.”

Delving into the long-term impacts faced by women, Maryam explains that immediate disasters, like floods, displace families, forcing them to endure harsh conditions, increasing stress, and disrupting access to essential services.

“However, conditions which persist like droughts and heatwaves also pose significant risks. For pregnant and postpartum women, extreme heat increases health vulnerabilities. Heat stress can directly impact maternal and foetal health. Moreover, displacement, food insecurity, and the psychological stress of climate change can lead to increased risks of malnutrition, infectious diseases, and adverse pregnancy outcomes. The vulnerability of pregnant and postpartum women is further exacerbated by limited access to healthcare, inadequate nutrition, and the psychological stress of climate-related disasters,” she said.

Speaking about the inability to learn from disasters that have occurred previously, Maryam thinks that the exclusion of marginalized communities, particularly those directly impacted by climate change, from decision-making processes is a major obstacle to effective climate action.

“In the context of flooding, landless farmers and small-scale farmers, who are disproportionately affected by these disasters, are often excluded from policy discussions. This lack of representation leads to the development of climate policies that fail to address the specific needs and vulnerabilities of these communities. Also, the absence of personal experience with the devastating impacts of climate change can hinder empathy and understanding among policymakers. Without firsthand knowledge of the suffering caused by floods, droughts, and other climate-related disasters, it becomes difficult to prioritize and effectively address these issues. This disconnect between those who make decisions and those who are most affected by climate change hampers the development of truly effective and equitable solutions.”

Echoing similar thoughts in the documentary, Neha also feels that despite their vital role, midwives are conspicuously absent from the discussions around health: “Despite the existence of numerous frameworks and strategies for improving maternal and child health, midwives are often excluded from the policy-making processes. This top-down approach, where policies are formulated without the input of those who are directly involved in providing care, often misses crucial aspects of the realities on the ground. Our approach focuses on amplifying midwives’ voices, allowing their thoughts and experiences to inform the necessary changes in their work.”

Mariyam Nawaz of UNFPA in Pakistan said that the displacement in any humanitarian situation further compounds vulnerabilities and restricts access to essential healthcare services. This results in higher risks of maternal complications due to lack of access to ante-natal care, delivery, and post-natal care, compounded by malnutrition and poor hygiene: “Restricted access to maternal healthcare, particularly the Emergency Obstetric and Newborn Care (EMONC), forces women to deliver without skilled birth attendants. Research indicates that floods are associated with adverse pregnancy outcomes, including preterm birth, low birth weight, and complications such as gestational diabetes.”

Mariyam added that disruptions in contraceptive supplies lead to an increase in unintended pregnancies: “Displacement and loss of livelihoods heighten vulnerability of women and girls to face gender-based violence, including sexual violence and child marriages. Temporary shelters often lack privacy, safety, and hygiene due to overcrowding.”

Speaking about UNFPA’s role, she said that the organisation has been working closely with governments, local NGOs, UN agencies and other partners to ensure that sexual & reproductive health and responses to gender-based violence are integrated into preparedness and response to emergencies: “We provide hygiene supplies and reproductive health kits and deploy trained personnel and provides other crucial support to affected populations. Major challenges to meet the reproductive health needs of women and girls include funding gaps, including insufficient resources to cater for the needs of women and girls in underserved areas, as well as the need for more collaboration and coordination among government agencies and stakeholders.”

Zoya Anwer is a freelance multimedia journalist who writes about culture and socio-political issues and is greatly interested in relationships between public spaces, gender, faith and class. She can be found on Twitter @ZoyaAnwerNaqvi