In Kurram district, patriarchy and poor healthcare leave women like Gul Rukh struggling to survive
Gul Rukh Bibi, 35, still remembers the silence that followed the birth of her eighth child: no congratulations, no whispered prayers, no relatives arriving with sweets. Just the quiet certainty that his life was about to change.
Her husband had warned her months before that having another daughter would cost her her marriage. “When the midwife said it was a girl, I closed my eyes,” Gul Rukh recalled, sitting on a woven charpoy inside her mud house in the newly merged Kurram district of Khyber Pakhtunkhwa.
“Here the woman is blamed for what she gives birth to, even though it is not in her hands,” she told me.
Within weeks of the birth, Gul Rukh’s fears were realized, she said, when her husband took a second wife and withdrew financial support for her medications and postnatal care. Weak from repeated pregnancies and complicated births, she was forced to recover alone while raising eight daughters in a district where access to reproductive health care remains very limited.
Read: How a mother’s stress can decide when her baby arrives
An endemic problem
Health workers say their 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 moved slowly, but for women like Gul Rukh, access to maternal and reproductive healthcare has improved little, according to Shahid Hussain, a resident of Kurram district.
He further added that Kurram and other merged districts have limited health facilities for women and due to the security situation, curfews are sometimes imposed in tribal areas and women have to give birth at home without facilities. Health visitors and midwives are few and far between in tribal regions, he added.
Lack of education, especially for women and girls, prevents them from making informed decisions about their reproductive health and contraceptive use, she said.
Dr Ali Mohammad Mir, senior program director of the Population Council, said there was a shortage of trained female staff, contraceptive supplies, postnatal services and functional maternal health facilities in the merged districts.
Demographic data underscores the magnitude of the challenge. According to the 2023 population census, KP’s population has exceeded 40.8 million, 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.
The population of Bajaur district now stands at over 1.28 million, while North Waziristan has crossed 693,000. The 2023 census record notes that local health infrastructure was never designed to support these numbers.
The crisis is compounded by broader demographic pressures, as Pakistan is now the fifth most populous country in the world, 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, lack of qualified midwives and delay in emergency care. In the merged districts, the fertility rate is 4.8, compared to 4.0 for KP overall, while contraceptive prevalence remains low at 21.8%.
Health worker Aisha Khan from Mohmand district explained how frontline health workers see daily struggles that often prove fatal. “Most women give birth at home because there is no doctor, no midwife, no functioning delivery room nearby,” she said. “By the time complications arise and families decide to move, it is often too late.”
According to national estimates, around nine million pregnancies occur in Pakistan every year: five million wanted and four million unwanted. Of these, 1.4 million result in unwanted births, while 2.2 million end in induced abortions, Dr. Mir added.
She said decision-making power remains overwhelmingly biased against women, as only about 10% of Pakistani women can independently make decisions about their own healthcare, while decisions about family size and contraception 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 situation, adding that the government should expand the budget and emergency planning for population control.
Educational gaps further accentuate these vulnerabilities, according to Qamar Naseem, an activist for girls’ education. He cited the Global Gender Gap Index 2024, which ranks Pakistan 139th among 146 countries in educational attainment. “Pakistan has more than 26.2 million out-of-school children, the second highest number globally,” he said. “KP alone represents 4.9 million, and almost 60% of them are girls.”
Health professionals say social pressure on boys is a silent driver of repeat pregnancies. A gynecologist at Bajaur District Central Hospital, Dr Abdul Basit, said many women arrive severely anemic after multiple, closely spaced pregnancies. “Families pressure women to keep trying to have a child,” she said. “These mothers face increased risks of complications and even death, but very few husbands or family members support them.”
UNFPA KP provincial coordinator 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 centers or for workers to provide services,” she said.
KP Population Welfare Department Secretary Dr Aneela Mahfooz Durrani said efforts are being made but acknowledged deep-rooted challenges as the department operates more than 800 Family Welfare Centres, 35 Reproductive Health Service Centers and 43 mobile units across the province. “We are working within cultural sensitivities to promote family planning and reproductive health,” he said, adding that peace and sustained investment remain critical.
However, for women like Gul Rukh, political promises remain distant realities. “I don’t want my daughters to live the life I lived,” she said.
