Pregnancy without protection: Pakistan’s struggle with population growth and maternal health

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 is not in her hands,” she told me.

Within weeks of the birth, Gul Rukh’s fears materialised, she said, as her husband took a second wife and withdrew financial support for her medicines and postnatal care. Weak from repeated pregnancies and complicated deliveries, she was left to recover alone while raising eight daughters in a district where access to reproductive healthcare remains severely limited.

Read: How a mother’s stress can decide when her baby arrives

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 moved slowly, but for women like Gul Rukh, access to maternal and reproductive healthcare has seen little improvement, according to Shahid Hussain, a resident of Kurram district.

He further added that Kurram and other merged districts have limited health centres for women, and that, because of the security situation, sometimes curfews are imposed in tribal areas, and women have to give birth at home without any facilities. Lady 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 the use of contraceptives, he said.

Dr Ali Mohammad Mir, Senior Director of Programs at the Population Council, said that there were shortages of trained female staff, contraceptive supplies, 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, growing at an annual rate of 2.38%. A significant share 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 has crossed 693,000. 2023's census record notes that local health infrastructure was never designed to support these figures.

The crisis is compounded by broader 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 ratio 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 skilled birth attendants, and delayed emergency care. In the merged districts, the fertility rate stands at 4.8, compared to 4.0 for KP overall, while contraceptive prevalence remains low at 21.8%.

Lady health worker Aisha Khan in the Mohmand district explained how frontline health workers see daily struggles that often turn fatal. “Most women deliver at home because there is no female doctor, no midwife, no functioning labour room nearby,” she said. “By the time complications arise, and families decide to move, it is often too late.”

According to national estimates, Pakistan sees around nine million pregnancies each year: five million wanted and four million unintended. Of these, 1.4 million result in unwanted births, while 2.2 million end in induced abortions, Dr Mir added.

He said that the decision-making power remains overwhelmingly skewed against women, as only about 10% of Pakistani women can independently make decisions regarding their own healthcare, while choices about family size and contraception are largely controlled by men.

Dr Mir said that because of this imbalance, our population is severely affected, which in turn has adverse effects on climate change and financial situations, adding that the government should extend the budget and emergency planning for population control.

Education 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 139th out of 146 countries in educational attainment. “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 nearly 60% of them are girls.”

Health professionals say social pressure for male children is a silent driver of repeated pregnancies. A gynaecologist at Bajaur District Headquarters Hospital Dr Abdul Basit said many women arrive severely anaemic after multiple, closely spaced pregnancies. “Families pressure women to keep trying for a boy,” he said. “These mothers face higher risks of complications and even death, yet very few husbands or relatives stand by them.”

Provincial coordinator for UNFPA in KP Mah Jabeen Qazi noted that limited government resources, donor hesitancy due to security concerns, and past attacks on health workers have constrained outreach. “Curfews, mobility restrictions, and fear make it difficult for women to reach health facilities or for workers to deliver services,” she said.

KP Secretary of the Population Welfare Department Dr Aneela Mahfooz Durrani said that efforts are underway but acknowledged deep-rooted challenges, as the department operates over 800 Family Welfare Centres, 35 Reproductive Health Service Centres, and 43 mobile units across the province. “We are working within cultural sensitivities to promote family planning and reproductive health,” she said, adding that peace and sustained investment remain critical.

For women like Gul Rukh, however, policy promises remain distant realities. “I don’t want my daughters to live the life I lived,” she said.