Invisible and silent, the women in Balochistan are absent from the accounts that come out from the violence-ridden province.

The voices that do come out are almost always wails.

Women remain the worst sufferers of the prevailing unrest in Pakistan's least developed but resource-rich province. They live under the constant shadow of poverty, unemployment, illiteracy and growing radicalisation. Basic health facilities, under the present circumstances, rank a distant last.

According to Pakistan Health Demographic Survey (PHDS), Balochistan stands first in terms of Maternal Mortality Rate (MMR) as compared to other provinces of the country. Long distances, poor communication systems and lack of basic health facilities compound the problems of women. A large number of women lose the battle for life during pregnancy. “Out of 100,000 women, 785 die in Balochistan as compared to 272 in rest of the country,” the survey revealed. The situation is dire, health experts warn.

Except Quetta, the provincial capital of militancy-hit Balochistan, gynecologists are rare in remote areas of the province. Most of the pregnant women are treated by traditional, unskilled birth attendants. “Growing militarisation forced skilled birth attendants to flee from rural parts of the province,” Dr. Rukhsana Kasi, a well-known gynecologist tells Dawn.

Kasi terms the worsening law and order situation in the province as one of the underlying reasons behind increasing ratio of maternal mortality rate.

Most of the women are treated by unskilled and traditional birth attendants in poor the neighbourhoods of Quetta and the far-flung areas of the province, Kasi says. A dozen female patients accompanied by male members of their families waiting outside her clinic for check up.

The female patients outside refuse to share details of the problems they encounter with regards to their health conditions owing to tribal customs. However, Arshad Bugti, the Secretary Health Government of Balochistan says that besides militancy, poor transportation and lack of accommodation for doctors are important factors contributing to the increasing MMR rate. He says gynecologists or skilled birth attendants yearn to practice only in Quetta, the provincial capital of Balochistan, rather than the remote parts.

“We are concerned about increasing MMR ratio and trying to reduce it,” Bugti says, adding that currently the services of 7200 Lady Health Workers were regularised in order to ensure provision of basic health facilities and reduce the MMR rate. However, ground realities negate his claims and most of the LHWs do not perform their duties in remote areas.

Balochistan covers half of Pakistan in terms of area but its population is only five per cent of the entire country. Successive governments have failed to address the health issues across the province. Despite allocation of substantial amounts, medicines and other equipment is not available in the government-run hospitals of the province. Women are faced with a host of diseases as skilled birth attendants' numbers only amount to 30 per cent in the province, according the PHDS survey.

High blood pressure, anemia, bleeding before and after delivery remains the common problems of pregnant women, Kasi explains.

“No access to trained birth attendants or gynecologists imperils the lives of thousands of women,” she says.

During pregnancy, multiple vaccinations are required. But in Balochistan out of a total of 627 union councils there are no trained officials to administer these medicines in a whopping 247 union councils, an officer of the health department, who declined to be named, tells Dawn while quoting the official data. Most of the union councils are located in the least developed, militancy-hit remote districts of Balochistan, the officer informs.

During Pakistan Peoples Party’s (PPP) government in Balochistan, doctors were being kidnapped and subjected to targeted killings. The growing fear prompted doctors and professors to leave the province. Dr. Haqdad Tareen, a senior member of Pakistan Medical Association (Balochistan Chapter) says that 29 doctors and professors have left the province owing to security threats during last five years. Impunity remains the contributing factor behind the increase in kidnapping of doctors and people belonging to different walks of life in broad day light. Besides male, Tareen says, female doctors have also left different areas of the province owing to looming security threats.

A report released by Medicines Sans Frontiers (MSF) backs these claims and it too cites poverty, poor literacy rate, political instability and conflict as the main reasons behind increasing maternal mortality rate in the province. Apart from this, MSF says that the province is also prone to natural disasters such as floods and earthquakes. Many people live in remote areas and women have no access to clinics for medical consultations. On average, women in the province give birth to six to eight children and they have their first baby as early as 16. Most of the women are underweight and when they become pregnant their health worsens.

Nadeem Shahid, a health advocacy expert, says that the number of community mid-wives and lady health workers must be doubled to decrease the MMR in the province. He also points out that the lady health workers are simply not serving the troubled parts of the province.

“They are either treated by unskilled, aged-women or referred to any district headquarter,” Shahid says. Women are always referred to district head quarters hospital or Quetta city when a serious complication develops during pregnancy.

“Some of the women breathe their last on the way to Quetta.”

All of these complications mean that most of the women deliver at home attended by non-trained relatives or neighbours. These unskilled birth attendants often use a medication for uterus contractions available locally at a low price to speed up the delivery.

Dr Kasi says that wrongly administering this drug can lead to serious complications for both the mother and new born baby. “In worst cases, it leads to death.”