Ikramullah’s Story

Photos and story by Khaula Jamil for MSF Pakistan

It was the year 2009 and young, carefree, Ikramullah, was playing football with his friends in Munda, Lower Dir, when he saw large trucks coming down the road. A leader amongst his friends and curious by nature, he walked up to where the trucks parked to find out what was going on. 

“A man named Shahid introduced himself to me and said he was from Islamabad. I did not know what MSF was so he explained that they have arrived to provide relief goods to the internally displaced people in our area.” 

A budding humanitarian himself, Ikramullah had been volunteering with a local organization ever since the conflict had displaced hundreds of people in his district. 

“They (MSF people) did not have any place to stay and asked for my help so I introduced them to some people I knew and arranged accommodation. After I did that, Shahid asked me to join the MSF team and distribute goods. I said I would be happy to volunteer my time and did not want any money but he insisted on paying me – he said that is not how MSF did things. This was strange and new for me but I appreciated it and was given the role of supervising the distributions.”

It was not as simple as it seemed to Ikramullah at the time when he agreed to this role. Over the next few days, he learnt how MSF did things – the protocols and rules that needed to be followed. 

“ I learnt they (MSF) had their own way of working and they assured us that everyone who is in need will get the relief goods once they have assessed the situation. I had never seen this kind of approach before but I really appreciated it.

Ikramullah, Head Watchman at MSF in Timergara, KPK, Pakistan

Ikramullah observed how MSF carried out the assessment of which IDP families were needy and how the employees managed to win the local jirga’s trust – without which no one is allowed to work in the community. Quite used to seeing organizations come and go after a few days, he assumed that MSF would soon be on their way and hosted a lunch for them at his house to thank them for their work in his hometown. 

“It was at the lunch that they told me they were going to stay for a few months.” 

And so, his journey with MSF continued. The same year, Ikramullah went with MSF to visit a large IDP camp in Samarbagh, Lower Dir, where families did not have food, shelter or toilets. He helped gather over 160 laborers for MSF and started construction of the bathrooms the very next day. MSF also opened outpatient services (OPD) for the IDPs along with providing drinking water and shelter for over 600 families. 

“To me, the most commendable part was that they MSF always followed their own rules and regulations instead of being influenced by anyone.  After finishing emergency work in this camp, we took over another camp in the same Tehsil which was situated 6 kms away from Timergara in the mountains where I handled the emergency chlorination of water.” 

Jalozai Camp for Internally Displaced Persons (Nowshera, KPK, Pakistan) April 2016

“I remember, just when things had started to get better in Bajaur and Medan, MSF had taken over a camp in Mundir where over 1800 families had been living inside shops in the market. The local authorities had issues with the location of the camp and asked us to remove it within 24 hours.. Within a month we arranged for a new camp to be functional in another area of Lower Dir called ‘Walai’. We got as much labour and help as we could because children and families couldn’t bear the cold weather conditions for too long.” 

In 2009, 52 people, including Ikramullah, were stationed at the DHQ, Timergara, including 3 people from the department of health. It was then that he was officially offered a contract which he accepted and was given the responsibility of supervising 30 watchmen and laborers at the hospital. At the time MSF only managed a part of the Emergency Department but eventually took it over entirely.  

District Headquarter Hospital, Timergara, KPK, Pakistan

“Once we found out more about MSF and their mission, we spread the word about it in our local community. I have never seen an organization that believes in working this hard for the betterment of people. I am not praising MSF because I am an employee- I have nothing to gain from false praises. I say this because I have seen it from the inside for over 12 years and can vouch for the purity of their intentions.”

According to Ikramullah, 99% of the people in Timergara District as well as neighboring districts are satisfied and happy with treatment provided by MSF. He claims this level of satisfaction is achieved because MSF is works on their own terms and very fairly.

“I learnt many things at MSF, how to be fair is one of them and I will carry these learnings in whatever I do for the rest of my life.”

MSF’s Head Watchman, Ikramullah, with his team outside the MCH in Timergara, KPK, Pakistan

“Médecins Sans Frontières has provided an emergency medical assistance programme in Timergara District Headquarter Hospital since October 2010. This assistance includes support to the Maternal and Child Health (MCH) department,, in the form of human resources, provision of medical and logistical supplies, as well as rehabilitation of the emergency operating theatre, recovery room and acute post-operative wards and full support to sterilization, hygiene and waste management. The hospital is meant to cater to the inhabitants of Lower Dir (where Timergara is located), but patients also come from neighboring districts, with the majority coming from Lower Dir, followed by Upper Dir and others within KPK as well as the Federally Administered Tribal Areas (FATA). All services are provided free of charge.

ASIYA’S STORY

Photos and Story by Khaula Jamil for MSF Pakistan

Somewhere in a remote village of Bajaur district (a former Federally Administered Tribal Area in Pakistan that borders Afghanistan) 27-year-old, Asiya, is waiting to give birth in her home on a cold December night. 

She has a cup of hot tea and starts feeling the contractions. Since this is her sixth pregnancy, she is gripped with anxiety. With only one child alive, she lost all others to early neonatal deaths and still births. She hopes this one will make it so that he six-year-old son will finally have a sibling. 

Something goes horribly wrong when the baby starts to come out but instead of the head or the feet, out comes a small hand! Panicked and frightened, her husband (a religious leader at a local mosque) rushed Asiya to the nearest medical center which was a two hour drive away. 

When they reached the clinic, the doctor recognized that the baby was in a transverse position with a prolapsed hand and that this was beyond the clinic’s capabilities to handle. The couple was referred to MSF’s mother and child health unit in Timergara. 

Timergara, KPK, Pakistan

Asiya recalls the six hour painful journey to Timergara with her baby’s arm sticking out of her; 

“I was 100 percent convinced my baby is dead that I am going to die also! I left everything up to God because I knew it was out of my control! I was so afraid that they were going to cut me up!” 

Dr. Shumaila, the gynecologist who was on duty that night, said that she took a quick but calculated decision when Asiya arrived at the MCH at 7:00 am; “When I saw the patient, I did a quick assessment of the situation. The nurses had already started preparing for a C-section but I felt confident that I could deliver the baby normally. I took the patient’s consent and went in for an internal podalic version; a procedure in which I put my hand inside the vagina, grab the legs – rotate and then pull the baby out in a breech position. Thank God it went smoothly. The baby cried loudly so all was well!” 

Since she joined MSF in Timergara, this is the third time Dr. Shumaila has delivered a baby in a transverse position with a prolapsed limb. 

Gynecologist, Dr. Shumaila, with a new born baby at the MCH managed by MSF at the DHQ Hospital in Timergara, KPK, Pakistan on 10th December 2020.

“This kind of situation usually arises when the women have not gone for proper pre-natal checkups to a hospital. Usually they go to a ‘dai’ (untrained midwife) at the time of delivery and when the ‘dai’ tries to induce a baby who is in a transverse position, the limb comes out first. Luckily, Asiya’s husband did not overthink and came to us directly or else we could have lost the baby.” 

According to Dr. Shumaila, if they had waited for a c-section, by the time Asiya would be given anesthesia, the chances are the baby would have lost her heartbeat. 

“Asiya was very cooperative. I could tell she had all but given up on the chances of her baby surviving so when I told her the baby was okay and that she needed to trust me I could see her get hopeful again.” 

A few hours after delivering a healthy baby girl, Asiya could not be happier. 

“I was certain I was going to die but the doctor was amazing and she delivered my baby normally! I can’t believe I didn’t need to have an operation. I’m the happiest woman in the world right now!” 

MSF Gynecologist, Dr. Shumaila, delivered a baby that arrived with a prolapsed hand after a 7 hour car journey at the DHQ Hospital in Timergara, KPK, Pakistan on 10th December 2020.

After difficult births, all new born babies are sent to the DHQ Hospital’s New Born Unit for a full assessment by the pediatric doctors and specialists. Dr. Waqar Alam, the District Orthopedic Surgeon from MOH, checked Asiya’s baby and ordered an ultra sound of the arm. 

“From what I can tell, there is clear trauma to the hand but there is no dislocation or fracture. We will know more after an ultra sound but are hopeful the baby will make a full recovery.” 

(Patient’s name changed upon her request) 

A baby is soothed by her aunt shortly after being born. MSF Gynecologist, Dr. Shumaila, delivered this baby girl who arrived in a transverse position with a prolapsed arm after a 7 hour car journey at the DHQ Hospital in Timergara, KPK, Pakistan on 10th December 2020.

“Médecins Sans Frontières has provided an emergency medical assistance programme in Timergara District Headquarter Hospital since October 2010. This assistance includes support to the Maternal and Child Health (MCH) department, in the form of human resources, provision of medical and logistical supplies, as well as rehabilitation of the emergency operating theatre, recovery room and acute post-operative wards and full support to sterilization, hygiene and waste management. The hospital is meant to cater to the inhabitants of Lower Dir (where Timurgara is located), but patients also come from neighbouring districts, with the majority coming from Lower Dir, followed by Upper Dir and others within KPK as well as the Federally Administered Tribal Areas (FATA). All services are provided free of charge. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778630/

“Antenatal care in Pakistan is far from satisfactory. The reason being that majority of the population live in rural areas, with a high illiteracy rate, restricted health care facilities with an underlying synergistic background of anemia, malnutrition, infection and unregulated fertility. Consequently, a large majority of patients reach hospital too late with features of obstructed labour with grave consequences. Poor patient compliance to the advice given due to lack of understanding and education with a tendency to rely more on advice given by traditional birth attendants. Good intrapartum care can easily diagnose the condition. Prevalence of obstructed labour, an obstetrical disaster, is influenced by availability, quality and acceptance of maternity services in a community. The long term solution lies in prophylaxis i.e., provision of adequate antepartum and intrapartum care which could avert the preventable nature of obstructed labour.” 

(https://jpma.org.pk/article-details/4658

Zaiba’s Story

(Photos and story by Khaula Jamil for MSF Pakistan)

After two years of marriage, 26-year-old Zaiba, finally conceived a baby. Hailing from a small remote village in Bajaur District, Pakistan, she grew up in abject poverty with her three brothers and four sisters. Life was never easy for Zaiba. At home, she had two brothers with mental illnesses and was eventually married off to an unemployed sick young man from a neighboring village. Uneducated herself, Zaiba is dependent on her father-in-law to provide for her and her husband while she stays at home and helps her mother-in-law with household chores.

26 year old, Zaiba, a mishandled patient from Bajaur District is being treated at the MCH managed by MSF at the DHQ Hospital in Timergara, KP, Pakistan on 8th December 2020

 On the night of 10th December, the end of her pregnancy term, Zaiba started feeling a nagging pain in her back. She sought medical help from a private clinic for which she had to travel four hours by road to the nearest city. 

“The doctor gave me 3 injections and two tablets and told me I would be fine in a few hours. I did not get better! I went to a Lady Health Visitor at another place and she gave me two drips and told me to keep walking in order to deliver the baby.” 

26 year old, Zaiba, a mishandled patient from Bajaur District is being treated at the MCH managed by MSF at the DHQ Hospital in Timergara, KP, Pakistan on 8th December 2020

It was several hours before the traditional birth attendant (TBA) told her she needs to go to the MSF facility in Timergara (a six hour drive away from the clinic) because her situation was beyond their abilities to care for.

What Zaiba did not know was that she had been terribly mishandled by both the TBA and the LHV. After gathering the patient’s history, Esther, MSF’s midwife manager at the maternity unit in Timergara, shared her assessment of what happened; 

“Zaiba received a very high dose of Oxytocin and Misoprostol tablets which induced premature labor. When she arrived at MSF, the baby’s heart beat was faint and the patient had developed complications.” 

MSF Midwife Assistant manager, Shabana, checks the pulse of a a mishandled patient who delivered a baby at the MCH managed by MSF at the DHQ Hospital in Timergara, KP, Pakistan on 9th December 2020

Oxytocin is a medication used to begin or improve contractions during labour. If used incorrectly  can lead to the uterus rupturing and neonatal death. In Khyber Pakhtunkhwa, exposure to unregulated treatment with labour-inducing medication is common. Despite carrying high risk for mother and child, the traditional birth clinics tend to use this drug without much caution. 

“The baby was in severe distress and the patient was bleeding. Luckily, we delivered the baby and he is alive (for now) but his oxygen levels are low and he needs to be observed closely over the next 48 hours,” continued Esther. 

Zaiba’s baby will be in the neonatal care till he stabilizes. His birth weight was 4kg – too big for a normal delivery for a woman as petite as Zaiba, therefore delivered through an emergency c-section. She will also be receiving counselling in regards to birth control and spacing since she needs to allow her body to heal from this trauma.

A new born baby, who was delivered after his mother, Zaiba, arrived at the hospital due to a mishandled pregnancy, fights for his life in the NBU facility at the DHQ Hospital in Timergara, KP, Pakistan on 8th December 2020.

Birth trauma aside, Zaiba’s abdomen is full of blood post-delivery. She will remain admitted at MSF in the post-op ward for several days till her urine is clear. A very worried mother-in-law is by her side with not just her daughter-in-law’s condition to take care but also the finances it cost them to get her here. 

“My husband is the only earning member of the family and he works in another city. We paid the LHV Rs 1,300/- and it cost us Rs.5000/- ($40/-) just to get here after driving almost 7 hours. I don’t know how we will pay this amount but my husband will have to arrange it somehow,” she says. 

She regrets not bringing Zaiba to MSF directly when she did not get better after the first three injections she received. However, thinking they could save the expense of travel, they decided to keep on waiting – till the situation got out of hand.

After her near death experience, Zaiba is finally gaining her strength back – enough to feel angry about what she was put through by the Lady Health Visitor and TBA before she came to MSF; “If I could, I would go back and strangle them for what they did to me! They kept saying push and walk till I collapsed due to exhaustion.”

MSF Midwife Asstistant manager, Shabana, helps a mishandled patient walk with the help of a nurse and the patient’s attendant. 26 year old, Zaiba, delivered a baby at the MCH managed by MSF at the DHQ Hospital in Timergara, KP, Pakistan.

Over the next two days, Zaiba started walking and eating. With her stitches healing slowly, her mother-in-law and the MSF midwives help her with her movements. What she has not been told yet, however, is that after two days of fighting for his life, her baby did not survive. 


“Médecins Sans Frontières has provided an emergency medical assistance programme in Timergara District Headquarter Hospital since October 2010. This assistance includes support to the Maternal and Child Health (MCH) department,, in the form of human resources, provision of medical and logistical supplies, as well as rehabilitation of the emergency operating theatre, recovery room and acute post-operative wards and full support to sterilization, hygiene and waste management. The hospital is meant to cater to the inhabitants of Lower Dir (where Timergara is located), but patients also come from neighboring districts, with the majority coming from Lower Dir, followed by Upper Dir and others within KPK as well as the Federally Administered Tribal Areas (FATA). All services are provided free of charge.

Use of labour-inducing medication by insufficiently trained cadres of healthcare workers is prevalent in a vulnerable population of Pakistan. The stakes are high, with unregulated usage of such medication resulting in severe consequences for mother and child. Tighter regulatory control measures for the use of labour-inducing medication, as well as better training and awareness among healthcare workers and the community are critical to improve this situation.” 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778630/


 ©Khaula Jamil/MSF Pakistan