Upon arrival at Peshawar Women’s Hospital, I am greeted by lots of smiles, which seems to be an unspoken custom in health facilities run by Médecins sans Frontières / Doctors Without Borders (MSF) around the world.
I am but one of the scores of women on the receiving end of those smiles today.
Tucked away from the crowded, dusty heart of Khyber Pakhtunkhwa’s capital, this maternity hospital allows more than 400 women to give birth in the presence of skilled medical staff – every month, free of charge.
Behind the registration desk sits a young lady with a headscarf, impeccable English and a businesslike demeanour. Spread out in front of her is an enormous patient register, in which women’s data is recorded at admission.
She tells me that while all women in labour are accepted here, many of the patients come from the rural areas surrounding Peshawar. Many are Afghans who have fled into and settled in Pakistan’s western provinces. Others hold Pakistani citizenship but have been no less affected by the armed conflict along the country’s western border with Afghanistan.
An incredible story
As we are chatting, a stout woman with rose-coloured hair, covered with a sheer black scarf, bursts into the reception area through the swing doors.
The henna-reddened palms of her hands are all over the place – she is gesticulating wildly at my male colleague, Zahir Gul. She talks at him through a huge smile of small teeth, tinted brown by the passage of time and many cups of strong black tea. Her eyebrows are pulled up in excitement, carving deep lines in her forehead.
She needed medical attention, but there was no clinic located closer to home. Taking public transport was not an option, as very few drivers will face the mountain roads after dark.
This goes on for a while, as Zahir Gul responds with encouraging nods. She then turns her attention to me.
The lady leans in as if telling me a spectacularly exciting bit of gossip. I don’t understand a thing as she’s speaking in Pashto, but her gestures say it all...
She has an incredible story to tell.
In the wintery dead of night
Zahir Gul translates for me.
This woman has travelled the 70-odd kilometres to Peshawar from Khyber Agency in the wintry dead of night.
Khyber Agency is in the north of the province, right on the border with Afghanistan. It is an area in the former Federally Administered Tribal Agencies (FATA), where there are very little in the way of public services. MSF had two medical projects in this region until they were both forcibly closed in 2017.
Last night, the woman’s daughter-in-law gave birth at home.
Having babies in the community without a skilled birth attendant is not uncommon in the farther-flung regions of this province. Patients have told me that this is often preferable, as local health facilities may not have heating, water, or electricity, and in any case, close at 2pm. Many healthcare workers in these areas run their own private practices after hours, but they charge whatever they see fit for services.
After labour, the woman’s daughter-in-law fell ill. She needed medical attention, but there was no clinic located closer to home. Taking public transport was not an option, as very few drivers will face the mountain roads after dark.
The condition is common here, the nurse tells me. It can kill a woman very quickly and many sufferers do not survive.
With 5000 rupees – approximately 40 US dollars, depending on the day – the family was able to convince a taxi driver to transport them to hospital, against the odds.
Travelling these routes means navigating checkpoint after checkpoint. People nonetheless fear what might be waiting for them after each bend in the road.
Eyes wide and still chattering away, the woman waves me into the delivery room. I leave Zahir Gul at the entrance and she whisks me inside, where a young woman is lying on a labour table.
She is alert and very beautiful, with fine features, curly dark hair tied back and a delicate silver ring in her nostril. Her skin is pallid, almost grey. Her lips have no colour. She has that glow of someone regaining their strength, though. She seems buoyant with relief.
“Congratulations”, I say.
The young lady smiles – “may God be with you”, she replies.
The nurse attending to her explains that she has had a massive post-partum haemorrhage, pointing to the wall behind us which is smattered with fresh blood. The condition is common here, the nurse tells me. It can kill a woman very quickly and many sufferers do not survive.
What I think – but it seems unhelpful now to say – is that there are drugs that could have prevented this young woman’s ordeal if they had been accessible to her back home.
When administered to a woman following the birth of her child, uterotonics – drugs that bring about contractions of the uterus – greatly reduce the risk of excessive post-partum bleeding. Some of these drugs, for example, oxytocin and misoprostol, are easily available in Pakistan and are on "essential drugs" lists, meaning that they should theoretically be available in healthcare facilities.
Still, this woman didn’t have access to them, and it could have ended in tragedy.
The other side of the story
As is so often the case, though, there is another side to the story.
At MSF’s healthcare facilities in Khyber Pakhtunkhwa, our medical teams treat many pregnant women experiencing complications due to the misuse of these same drugs.
Because they are so widely available, enterprising healthcare practitioners or traditional birth attendants administer them to pregnant women in order to speed up their births, and on the pretext that the drugs will help to reduce labour pains.
She approaches a hospital bed and carefully draws back a few layers of a fleece blanket to reveal two pinkish masses…
However, those women are then often referred to MSF hospitals, suffering from contractions that are too strong and frequent, fatigue of the uterus and sometimes excessive bleeding.
These are all too often tales that end in sterility for the mother, a lifetime of disability for the newborn baby, or death for both.
Clearly, just because a drug is accessible does not mean that it will have only the intended effect.
In the remotest areas of Pakistan, skilled healthcare can be hard to access, regulatory frameworks are weakly enforced and folk remedies are in high demand - creating a perfect storm that promotes the inappropriate use of life-saving drugs.
That’s why, since 2013, MSF has been working with outreach teams and local authorities to collect data on this topic, train health staff, and educate communities about the benefits and inherent risks in the use of these medicines.
Creased little faces
The rose-haired woman is still buzzing around the labour room. She wants to show me something.
She approaches a hospital bed and carefully draws back a few layers of a fleece blanket to reveal two pinkish masses: tiny babies, twin boys, only a few hours old.
The nurses, other patients and I gather around to see them: their round, creased little faces and their tiny fingers that waggle and grope at nothing in particular.
The woman holds the fleece back, beaming. No one speaks, not even her.
This is where this story of hers ends. And a happy ending it is.