In Kurram district, the patriarchy, broken health care leaves women like Gul Rukh struggling for survival
35-year-old Gul Rukh Bibi still remembers the silence that followed the birth of her eighth child: There were no congratulations, no whispered prayers, no relatives arriving with sweets. Only the quiet certainty that her life was about to change.
Her husband had warned her months earlier that another daughter would cost her a marriage. “When the midwife said it was a girl, I closed my eyes,” Gul Rukh recalled, sitting on a woven charpoy inside her mud-brick home in Khyber Pakhtunkhwa’s newly merged Kurram district.
“Here a woman is blamed for what she gives birth to, even though it’s not in her hands,” she told me.
Within weeks of giving birth, Gul Rukh’s fears materialized, she said, when her husband took another wife and withdrew financial support for her medication and postnatal care. Weak from repeated pregnancies and complicated births, she was left to recover alone while raising eight daughters in a district where access to reproductive health care remains severely limited.
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An endemic problem
Health workers say her story is not an exception but a reflection of entrenched gender norms, high fertility and systemic neglect in the merged districts of Khyber Pakhtunkhwa. Since the former tribal areas were merged into KP in 2018, administrative changes have been slow, but for women like Gul Rukh, access to maternal and reproductive health care has not improved, according to Kurram district resident Shahid Hussain.
He further added that Kurram and other merged districts have limited health centers for women and due to the security situation, sometimes there is curfew in tribal areas and women have to give birth at home without any facilities. Female health visitors and midwives are few and far between in tribal areas, he added.
Lack of education, especially for women and girls, prevents them from making informed decisions about their reproductive health and the use of contraceptives, he said.
Dr. Ali Mohammad Mir, senior director of programs at the Population Council, said there was a shortage of trained female staff, contraceptives, postnatal services and functional maternal health facilities in the merged districts.
Population data underscores the scale of the challenge. According to the 2023 population census, KP’s population has crossed 40.8 million and is growing at an annual rate of 2.38%. A significant portion of this growth has occurred in the merged districts, where fertility rates remain well above the provincial average due to limited access to family planning.
Bajaur district’s population now stands at over 1.28 million, while North Waziristan’s has crossed 693,000. The 2023 census notes that local health infrastructure was never designed to support these numbers.
The crisis is exacerbated by wider population pressures, as Pakistan is now the world’s fifth most populous country with an estimated population of 234 million in 2023 and the highest population growth rate in South Asia at 2.4%. According to World Development Indicators, Pakistani women have the highest average number of children in the region, with a total fertility rate of 3.6, compared to 2.2 in Bangladesh and 1.7 in Iran.
Health outcomes in KP and particularly in the merged districts remain alarming, according to the Pakistan Demographic and Health Survey (PDHS). While the national maternal mortality rate is estimated at around 186 deaths per 100,000 live births, experts say the rate is significantly higher in remote districts due to home births, a lack of skilled birth attendants and delayed emergency care. In the combined districts, the fertility rate stands at 4.8 compared to 4.0 for KP overall, while contraceptive prevalence remains low at 21.8%.
Female health worker Aisha Khan in Mohmand district explained how frontline health workers see daily struggles that often turn fatal. “Most women give birth at home because there is no female doctor, no midwife, no functioning delivery room nearby,” she said. “By the time complications arise and families decide to move, it’s often too late.”
According to national estimates, Pakistan sees about nine million pregnancies each year: five million intended and four million unintended. Of these, 1.4 million result in unwanted births, while 2.2 million end up in induced abortions, added Dr. Mir.
He said decision-making power remains overwhelmingly skewed against women, as only about 10% of Pakistani women can independently make decisions about their own health care, while choices about family size and birth control are largely controlled by men.
Dr. Mir said that due to this imbalance, our population is severely affected, which in turn has adverse effects on climate change and financial situations, adding that the government should expand the budget and contingency planning for population control.
Educational gaps further entrench these vulnerabilities, according to Qamar Naseem, a campaigner for girls’ education. He cited the Global Gender Gap Index 2024, which ranks Pakistan 139 out of 146 countries in terms of education. “Pakistan has over 26.2 million out-of-school children, the second highest number globally,” he said. “KP alone accounts for 4.9 million and almost 60% of them are girls.”
Health professionals say social pressure for male children is a silent driver of repeat pregnancies. A gynecologist at Bajaur District Headquarters Hospital, Dr. Abdul Basit, said many women arrive severely anemic after multiple pregnancies close together. “Families push women to keep trying for a boy,” he said. “These mothers face greater risk of complications and even death, yet very few husbands or relatives stand by them.”
UNFPA provincial coordinator in KP Mah Jabeen Qazi noted that limited government resources, donor hesitancy due to security concerns and past attacks on health workers have limited outreach. “Curfews, mobility restrictions and fear make it difficult for women to reach health facilities or for workers to provide services,” she said.
KP secretary for the Population Welfare Department Dr. Aneela Mahfooz Durrani said efforts are underway but acknowledged deep-rooted challenges as the department runs over 800 family welfare centres, 35 reproductive health service centers and 43 mobile units across the province. “We are working in cultural sensitivity to promote family planning and reproductive health,” she said, adding that peace and sustained investment remain critical.
For women like Gul Rukh, however, political promises remain distant realities. “I don’t want my daughters to live the life I lived,” she said.
