“I am actually nine months pregnant and it is a little tricky for me to travel,” says midwife Fatima as she carefully makes her way down some steep stone steps to the door of her clinic.
“But I come here for the sake of my patients.”
It is thought that up to 99% of maternal deaths could be prevented if a doctor or trained midwife was present.
In Pakistan, one woman dies every 20 minutes from complications in pregnancy or childbirth, says the Centre of Excellence for Rural Development.
Fatima works with Sehat Kahani, a Pakistani organisation that trains community midwives, and connects them to female doctors via video link.
These video consultations cost from as little as Rs50 ($1.30; 96p), making basic healthcare affordable and accessible to many women in rural areas.
Today Fatima is seeing Rubina Mukhtiar, who lives in Mansehra, a town 71km (40 miles) north of Islamabad.
“I have had two stillborn boys and four miscarriages, and now I am two months pregnant,” says Rubina.
Rubina is lucky to be alive.
She describes severe headaches, swollen limbs and dizziness during a previous pregnancy. These are all classic symptoms of pre-eclampsia, a form of very high blood pressure that can kill both mother and child.
By the time she reached the hospital in Islamabad, it was too late for her twin boys.
“When they did my ultrasound they told me the babies had been dead for 15 days.
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“I wished so long for a son…but this is Allah’s will.”
This will be Rubina’s tenth pregnancy but it will be the first with regular antenatal checks with a trained midwife and doctor.
Fatima checks Rubina’s blood pressure, and then reports back to the doctor on the screen of her laptop. Everything appears normal.
“There is a lady in my neighbourhood who recommended I go and see Sehat Kehani,” says Rubina.
“Coming here I am quite hopeful that despite my previous miscarriages, this time I will give birth to a healthy boy.”
“I feel a lot of pain for them,” says Fatima after Rubina leaves the examination room.
“If you’ve had multiple miscarriages only a mother knows the pain that causes.”
Fatima adds that she wasn’t able to work in the past because she “couldn’t get permission from my family”.
“Because I only deal with women I am allowed to work here. I didn’t have permission to work with men.”
This reluctance to grant permission to women to leave the home means there are thousands of qualified female doctors and midwives missing from Pakistan’s workforce.
According to the Pakistan Medical and Dental Council, more than 70% of medical students are women, but only half will ever practice as doctors.
Sehat Kahani was founded by doctors Sara Saeed and Iffat Zafar.
“We both are medical doctors, we’ve both graduated from the best universities in Pakistan,” says Sara.
“We’ve both faced the trouble of coming back into the workforce after marriage, or having children, so we relate to those missing doctors who are not working today.”
They set up DoctHers in 2014, which allowed them to practice from home using video links. This also helped address the shortage of affordable healthcare in much of Pakistan.
In 2017 Sara and Iffat decided to concentrate on primary care for women, and set up Sehat Kahani – which means “health story” in Urdu.
“We realised that there are multiple people who do not even reach the clinics,” says Sara.
“Either their health is not that important to their family, or they never get the permission to come out of the house.”
“So we came up with the idea of a midwife or lady health worker [carrying] a tablet [computer], and a bag. She travels door to door to deliver consultations at home to patients who can’t make it to the clinic.”
Tayyaba Anjum Ali, is one of Fatima’s patients. She has four children including a newborn son.
“When I was pregnant the first time I was in a lot of pain, but for this pregnancy it’s been much easier,” says Tayyaba.
“If I’m not able to leave the house because my children are alone, then I can call the midwife to come to my home and do any tests.”
Fatima examines both mother and baby, and then shows Tayyaba a short video about breast-feeding on her tablet.
“I work in a town where women do not consider it important to go to a doctor,” says Fatima. “I work for an organisation that provides awareness to these women, along with good doctors.”