Gulatun is due to give birth in two months time, but the baby’s placenta is blocking her uterus, meaning she will need a caesarean section.
 
“I became worried about my baby when I started bleeding for a few days," said Gulatun. "Someone in the camp told me I should come to this hospital. I really hope my baby will be safe."
 
Galatun’s home today is a makeshift shelter in an open space on the outskirts of Dera Murad Jamali in Pakistan’s Balochistan province. She is one of the millions of people who have been displaced by the devastating floods that have destroyed homes and livelihoods in massive swathes of the country.
 
In the bed next to Gulatun in the Mother and Child Hospital in Dera Murad Jamali, Haseena is pregnant for the ninth time. Only four of the infants have survived, and now, in the last month of her pregnancy, she has a prolapsed uterus.

Haseena is praying for her unborn baby’s survival: “I hope my husband will allow me to have a caesarean section and my baby will be fine,” she said.
 
Haseena and Gulatun are among the hundreds of women facing complicated deliveries who have been admitted to the inpatient department of the hospital since Médecins Sans Frontières (MSF) started offering free emergency obstetric services in March, 2010. Services offered include non-surgical deliveries, caesarean sections (C-sections), neonatal, antenatal and postnatal care.
 
"Before the floods, for example, in June, we dealt with 13 complicated cases and performed four C-sections," MSF obstetrician Dr Linnea Ekdahl explained at the start of her morning round in the hospital. "Now after the floods, in the month of September, we have seen 79 women facing complicated deliveries and our team has performed ten c-sections."

Even before the floods, there was already a critical lack of maternal healthcare for expectant mothers living in Pakistan’s southern rural areas. Usually, women give birth at home in unhygienic conditions with the help of a private midwife (dai). Consequently infants are exposed to higher chances of deadly infections, and the floods have only worsened the situation. At the same time, the lack of knowledge and access to proper medical care during pregnancy means that thousands of women are at much higher risk of miscarriage and even dying during childbirth.

“I felt pain in my body and had fever during the last five months of my pregnancy but I thought it was a normal part of being pregnant, so I never went to a doctor," said Jamila who had just given birth to a baby boy.

It turns out Jamila’s body pains and fever were symptoms of cerebral malaria during her pregnancy and she is now finally receiving proper care and treatment in the hospital. “I have been so worried about Jamila," said Dr Ekdahl. "At first I thought she would not survive and that the baby would not make it. All of this could have been avoided if she had received proper antenatal, care and clear information about what to look out for."

But there is another worry for Dr Ekdahl. In Pakistan there is excessive use of a drug called oxytocin during delivery. Oxytocin is a naturally occurring hormone that is released into bloodstream during labour. If given in the correct dose and at the correct time, synthetic oxytocin can assist when natural labour is delayed. However giving of oxytocin unnecessarily, or at the wrong time and in the wrong dose can cause mothers to super-contract which not only harms the baby but can cause the uterus to rupture, often leading to maternal or infant deaths.

“People in Pakistan, unfortunately, believe that a good delivery has to be short and, as such, practitioners often give large of amounts of oxytocin – sometimes eight times as much as allowed in order to have the quicker deliveries which then leads to more complicated and dangerous births. This is the biggest problem we face here and we are deeply concerned,” said Dr Ekdahl.

“We are even more worried about cases where the person assisting the delivery already knows the situation has become critical but refuses to send the mothers to the hospital so that they can get still get the poor mothers to pay them the birthing fee."

Once the babies from mothers facing all these complications in birth have been born in the MSF-run maternity ward, they are transferred to an around-the-clock nursery next to the inpatient department. Most of the babies admitted here are treated for prematurity, birth asphyxia, tetanus, or jaundice. The nursery also admits infants who are delivered in other location but need intensive post delivery care.

Dr Ekdahl smiles when she relates how two days after being admitted, Haseena gave birth to a healthy baby boy after her husband agreed to the Cesarian section, while Jamila is recovering from her bout of malaria while her baby daughter is doing well.

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care and natural disasters in KPK, FATA, Balochistan, Sindh, Punjab, and Kashmir.
 
Since the start of the maternity and neonatal programme in Dera Murad Jamali in March 2010, MSF has conducted 339 deliveries, 244 of which were complicated, 41 of which were done through Cesarian sections. The majority of these women would have died without the MSF service. MSF has also admitted 247 newborns to the nursery.