Zainab Kulsoom lives in the Lotar village in the Upper Kohistan district of Khyber Pakhtunkhwa. She is on the cusp of giving birth to her sixth child, even though she is just 27 years old.
Residing in a shared home with her husband and his 14 brothers, the heavily pregnant Kulsoom has to share a single room with two co-wives and a total of 16 children. Despite being in the final days of her pregnancy, she still tends to household chores such as preparing meals, herding and grazing animals. The situation is not too different from when she gave birth to her first five children.
Of all her children that Kulsoom gave birth to, two of them were delivered at home without consulting a medical practitioner, while she had the luxury of assistance from a local midwife for her remaining three children.
The lack of access to medical care for pregnant women almost cost Kulsoom her life. She told [The Friday Times] that on the morning of January 13, 2023, when she was cutting grass for her animals on a steep hill, she started feeling intense labour pains and fell unconscious into a nearby ravine. Thankfully, someone from the village quickly spotted her and rushed her to the local health centre, where she received fluids to improve her condition.
"This labour pain was distinct from what I had felt during my previous deliveries," Kulsoom said, expressing that it evoked fear of imminent death. Given her condition, Kulsoom said her mother-in-law directed her brothers-in-law to take her to a nearby midwife. Recognising the complexity of the situation, the midwife referred her to a hospital.
"I was then transported in a 4x4 local jeep to a nearby basic health unit (BHU), where a female medical technician provided initial treatment and arranged for my transfer to a more advanced hospital," she asserted.
Kulsoom described the journey over unpaved mountainous roads in a rickety jeep while in labour as nothing short of "a nightmare".
During their journey, Kulsoom said their jeep lost its brakes and plunged into a ravine. Trapped and unconscious, she was rescued by villagers and transported to neighbouring Mansehra district, where doctors performed surgery to save the mother and the child. A baby boy was born but, unfortunately, did not survive. Kulsoom was luckier and lived to tell the tale.
She regrets losing her child the last she was pregnant, noting that all her other children are girls. In this patriarchal segment of Pakistani society, girls and women are still not considered equal to boys and are looked down upon when it comes to inheriting title, land, wealth and power.
Worried about her husband's dislike for surgical procedures such as cesarean sections — which saved her life, Kulsoom is still contemplating whether she should visit a large hospital for what could be the birth of her sixth child. Even though she has been under the knife once, Kulsoom fears that surgery may affect her chances of having more children and fulfilling the desires of her husband and his family to have male heirs, a concern strongly echoed by her mother-in-law.
For this reason, Kulsoom says she hides the severe labour pains she feels from her husband and considers that it is inappropriate to share this information with him. Instead, she chooses to confide in her mother-in-law. Contraceptives and family planning are unmentionable concepts.
Kulsoom prays for the strength and ability to deliver her sixth child naturally at home without needing surgery.
The digital census conducted by the Pakistan Bureau of Statistics (PBS) shows that the population of Upper Kohistan rose from 305,451 in 2017 to 422,947 in 2023. These people are accommodated within 71,543 households, with an average household size of 5.91 and a population growth rate of 5.59.
Factors contributing to high population growth in the province include a male-dominated society where large families are expected to be part of religious and cultural duties.
When asked about the high population rate in the distrct, Kohistan Population Officer Muhammad Suleman said the government has attempted to create awareness about the location of health facilities and the importance of keeping birth rates low. However, they face challenges in countering the deep-rooted beliefs, ignorance and widespread illiteracy.
"Despite the establishment of awareness centres, their impact remains minimal," he conceded, adding that they have made extensive efforts to enlighten the public about the hazards of a large population.
Among the major challenges they confront, Suleman listed that locals believed the use of contraceptive measures was un-Islamic and unethical. He added that locals are influenced by clergy who are unaware of the hazards of a high population and exploit the religious sentiments of locals for personal gain. He criticised their opportunism, highlighting their acceptance of incentives from the department while disregarding requests for certain actions for broader community welfare.
Haroon Tanoli, a civil society activist who has worked in different parts of Kohistan, stated that the government provides the Population Welfare Department with a large budget for educating the public in Kohistan. Despite that, he claimed that the department has failed to achieve the desired results. He believes that the department has failed to plan properly, which is why it has been unable to achieve its objectives.
Other issues, he highlighted, included the lack of healthcare facilities and other amenities, which further aggravate the problems faced by women in the district.
Early marriages, Tanoli said, were another issue in the district. He claimed that it is a common practice for girls to get married at the tender ages of 14 or 15. As a result, many families have a high number of children, with the mothers often being 35 years of age or younger. The enrollment level for girls in Kohistan between the ages of six and 16 is at a dismal 38% in government schools and 37% in private schools (ASER Pakistan Report 2021)
Despite the early marriages, Tanoli noted that the divorce ratio in the district was quite low. Moreover, if a man dies, his widow is expected to remarry within her husband's family as soon as permissable. He believed there was a belief that women could not live without remarrying.
Regarding the dismal state and availability of health facilities in the area, Tanoli pointed out that the government built basic health units on inaccessible hilltops. If anyone does manage to reach these units, they find them without adequate staff.
In Kolai Palas—which was carved out of the larger district of Kohistan in 2017—Tanoli said that a large Tehsil Headquarters Hospital is operational in Pattan. However, he claimed that it was severely understaffed and lacked resources to serve the district's large population. He also claimed that there was a shortage of emergency medical facilities in the area.
On the population levels recorded in the 2023 digital census by the PBS, Tanoli expressed doubts over the recorded figures, claiming that the reported average family size in the three Kohistan districts (Kolai Palas: 6.94; Lower Kohistan:6.50; Upper Kohistan: 5.91) does not reflect reality.
He insisted that the true average household size was higher since it was common for families to have 12 to 15 children.
At a basic health unit (BHU) located on the banks of the Indus River in Shalkhanabad, just northeast of Pattan, Consultant Gynecologist Dr Sadia Muzaffar shares her experience of treating patients. She said since they lack advanced facilities to treat patients who arrive in a critical or emergency condition. Maternal, Newborn and Child Health (MNCH) programme said the best they can do is to provide them with life-saving intravenous fluids, some medicines and a blood transfusion before sending them off on an arduous six-hour-long journey to large settlements such as Manshera or Abbottabad to get the critical care they need at secondary or tertiary healthcare facilities.
Due to the challenging state of transportation in the hilly district, Dr Muzaffar said there is an urgent need to significantly enhance emergency healthcare facilities in the region, even at basic healthcare facilities such as the BHU where she works, acknowledging that the risks faced by mothers and infants greatly increases due to delayed care.
She stressed the need to establish an emergency healthcare centre in the area to save the lives of women living in the hilly region.
Responding to queries, Dr Faisal Khanzada, the Additional Director General for Health Services in the Hazara Division, admitted there was a shortage of health facilities in Kohistan due to numerous factors.
To bridge this gap, he said that the provincial health department, in collaboration with international and local non-governmental organisations, was actively working to safeguard maternal and child health through the MNCH programmes in KP.
Dr Khanzada assured that he would raise the matter before the district's MNCH programme project director and ensure a thorough examination by District Health Officers before establishing healthcare facilities in the region.