Reproductive health crisis amidst a natural disaster in Pakistan: A call to action

Abstract

In 2022, Pakistan and the South Asian region experienced unprecedented natural disasters. The country was devastated by severe floods caused by unusually high monsoon rains and river overflows. The Pakistani government reported that at least 80 districts nationwide were impacted, leading to the loss of one million homes, over 1000 fatalities, and 1600 injuries. The floods left no one unaffected, but vulnerable groups, such as pregnant women and adolescent girls, suffered the most. The United Nations Population Fund estimates that at least 650,000 pregnant women were trapped following the flood crisis, while 73,000 women required urgent obstetric treatment due to impending deliveries. The United Nations Population Fund responded by distributing 7411 newborn baby kits, 8311 menstruation kits, and 6412 clean delivery kits on an emergency basis. In response to the crisis, global leaders convened at the 76th World Health Assembly in Geneva, committing to enhancing healthcare resilience. These commitments present a critical opportunity for Pakistan to strengthen its reproductive healthcare system, improve disaster preparedness, and integrate climate adaptation policies into its health sector. Furthermore, in October 2022, Pakistan announced its National Adaptation Plan to address climate change and mitigate the impact of future disasters. Given the devastating effects of the floods on maternal and reproductive health, immediate and sustained action is required to fortify Pakistan’s healthcare infrastructure, enhance emergency response measures, and ensure reproductive health services are accessible to all affected communities.

Plain language summary

Background:

In 2022, Pakistan was faced with unusually heavy rains across the country that led to river overflows, triggering a catastrophic flood that caused widespread devastation. More than 80 districts were affected, resulting in the loss of more than 1000 lives, 1600 injuries, and damage to one million homes, and at least 33 million people were impacted by the disaster.

Interventions:

The collaborative efforts of the Rahnuma-Family Planning Association of Pakistan and the United Nations Population Fund promptly took action by disseminating 7411 newborn baby kits, 8311 menstruation kits, and 6412 clean delivery kits on an emergency basis. In addition, global leaders have convened for the 76th World Health Assembly in Geneva. In that assembly delegates committed to ensuring that by 2023, an additional one billion people would have improved protection against health emergencies, and another billion would experience enhanced health and well-being. In October 2022, Pakistan announced its plans to develop a National Adaptation Plan aimed at addressing climate change.

Recommendations:

• Governments in Pakistan should develop comprehensive disaster preparedness policies tailored to the country’s unique climate risks. Investment in transparent risk communication strengthened health facility infrastructure, and emergency reproductive healthcare services should be prioritized. Communities in Pakistan must actively engage in disaster response planning, utilizing local knowledge to ensure that healthcare and reproductive services remain accessible during crises. Additionally, professional societies should focus on Pakistan-specific research to address climate-related health impacts, develop regionally appropriate healthcare guidelines, and promote educational resources for disaster preparedness.

• Communities are encouraged to create disaster management plans that utilize local knowledge and resources, educate members about climate risks, and build strong support networks.

• Professional societies should conduct research on climate change’s health impacts, develop guidelines for healthcare professionals, and promote educational resources to improve preparedness.

Highlights

1. For South Asia, especially Pakistan, the middle of 2022 started off on an ominous note. Due to the country experiencing higher-than-normal monsoon rain and the ensuing river overflow, a flood—a natural cataclysm—followed its course and wreaked havoc across the entire nation, shattering it to pieces.

2. Over 1000 people have died, 1600 people have been injured, and one million homes have been affected, according to the Pakistani government, which claims that at least 80 districts throughout the country have been affected.

3. At least 33 million people are reportedly dealing with the effects of the natural disaster, according to further reports from Pakistan’s National Disaster Management Authority 2. As it will take time to formally quantify the complete damage, these statistics are only estimates and might only be the tip of the iceberg.

4. While no one was spared in the flood devastation, vulnerable populations, such as girls and pregnant women, experienced the worst. The United Nations Population Fund estimates that at least 73,000 women require urgent obstetric treatment since their deliveries are scheduled for the next month, and at least 6.5 lakh pregnant women are still stranded as a result of the flood situation.

In 2022, the second half began on a daunting note for the South Asian region, particularly Pakistan. With higher than usual monsoon rain throughout the country, and subsequent river overflow, an inevitable natural cataclysm, flood, followed the course, devastating the whole country and putting it to ruin. According to the Government of Pakistan at the time, at least 80 districts across the nation suffered, with a loss of over 1000 human lives, 1600 injured, and one million houses impacted. ¹ Further reports from the National Disaster Management Authority (NDMA), Pakistan, declared that at least 33 million people were facing the repercussions of the natural disaster. ²

While the flood wreckage spared no one, vulnerable groups, including girls and pregnant women, encountered the worst. According to the United Nations Population Fund (UNFPA), at least 73,000 women needed urgent obstetric care with their deliveries due in the next month, while at least 6.5 lakh pregnant women were left stranded after the flood crisis. The situation has been further aggravated by the destruction of more than 1000 health facilities around the provinces of Sindh and Baluchistan. ³ The already subpar maternal care for these women would suffer more from the lack of adequate shelter and food crops destroyed over acres. Moreover, these women’s access to urgent medical facilities was further harmed by the damage to roadways. Notably, not just obstetric care was affected by the disaster’s effects. According to several estimates, the floods have left at least 1.6 million women of reproductive age aground. ³

In Pakistan, challenges with maternal mortality, newborn survival, and reproductive health have a long history. Pakistan was ranked the third-worst country in terms of maternal mortality in the previous decade. ⁴ A recent study found that the maternal death rate was 319/100,000 live births, which is not significantly better than prior estimates. ⁵ Pakistan continues to rank among the poorest countries in the world for maternal mortality when compared to other low-resource environments and economies. ⁵ The causes are multifactorial ranging from multiple births, low socio-economic status, unavailability of resources and contraception, lack of healthcare facilities, and low investment. Similarly, menstruation, another area of reproductive health, has not progressed either. In Pakistan, the subject of menstruation is still taboo and rarely mentioned in public. Many people across the nation still view sanitary pads as a luxury rather than a necessity, which may directly impact donations made to raise money and provide kits to more than a million flood-affected women. Hence, a catastrophe like this was undoubtedly expected to cause massive damage to an already deprived nation, and as the statistics indicate, it has already done so.

Regarding the health system and the government’s preparedness for such a natural phenomenon, the NDMA issued a pre-monsoon warning on June 15, 2022. This alert prompted the initiation of disaster preparedness activities. By June, flood cells were established in all districts and became operational around the clock following the warning. In Sindh, there were delays in risk monitoring and early warnings. Initially, tents were distributed to the affected population, although their effectiveness was limited, and subsequently, 14 tent cities were set up. In Baluchistan and Khyber Pakhtunkhwa (KP), early warnings from the NDMA/Provincial Disaster Management Authority were received, leading to a coordinated response with the help of partners. ⁶

In reaction to the floods, the National Flood Response and Coordination Centre was established at the national level, comprising representatives from federal and provincial governments and the armed forces, to improve coordination and support flood relief efforts during rescue, relief, and rehabilitation/reconstruction activities. However, all provinces were unprepared for a disaster of such magnitude. Each year, disaster management authorities at the national, provincial, and district levels prepare contingency plans for monsoon floods, but they were unable to adequately respond to this disaster’s extent. ⁶

In addition, it is important to acknowledge the efforts of the Rahnuma-Family Planning Association of Pakistan, which is an initiative that undertook efforts to build community capacity to prepare for and respond to sexual and reproductive health (SRH) risks in selected disaster-prone areas of Pakistan. This initiative aimed to connect communities with existing disaster risk management structures at the national, regional, and district levels. The initiative began with a national-level training of trainers, which was subsequently extended to six union councils (UCs) across three districts in KP, Punjab, and Sindh provinces. Participants created action plans for their respective UCs to address gaps in implementing the Minimum Initial Service Package for SRH, the international standard for SRH care in emergency settings. Over the course of 1.5 years, communities worked on executing their action plans to enhance their capacity to meet SRH needs during emergencies. ⁷

However, with a catastrophe of such magnitude, the lack of adequate preparedness led to several issues, including challenges with data reporting from flood-affected areas, misdiagnosis of emergency illnesses, and difficulties in registering pregnant women. Timely and accurate data reporting is essential for assessing the on-ground situation and systematically formulating necessary policies. A 2020 report by UNDRR highlighted the critical role of data reporting in disaster management. ⁸ To enhance decision-making and response, it is recommended that data collection and analysis be integrated into disaster management systems. ⁹

Following the calamity, assistance and support have flooded in from around the globe, including the United Nations Central Emergency Response Fund. ¹⁰ However, most of the aid was focused on addressing affected people’s basic necessities, such as food, makeshift shelters, and medications. Although UNFPA has taken prompt action by disseminating 7411 newborn baby kits, 8311 menstruation kits, and 6412 clean delivery kits on an emergency basis, there was still a need for more, considering the large number of stranded women. ³ Hence, it was essential to divide aid strategically along with these demands. In addition, global leaders have convened for the 76th World Health Assembly in Geneva, where delegates committed to ensuring that by 2023, an additional one billion people would have improved protection against health emergencies, and another billion would experience enhanced health and well-being, ¹¹ and furthermore, in October 2022, Pakistan announced its plans to develop a National Adaptation Plan aimed at addressing climate change. ¹² A crucial aspect of this initiative is the establishment of robust, climate-resilient maternal health services to safeguard pregnant women from future climate disasters.

To mitigate the consequences of climate change and natural disasters, governments should develop comprehensive disaster preparedness policies that address the unique needs of various communities, invest in transparent risk communication, enhance health facility infrastructure for resilience, and enforce regulations to limit carbon emissions. Communities are encouraged to create disaster management plans that utilize local knowledge and resources, educate members about climate risks, and build strong support networks. Professional societies should conduct research on climate change’s health impacts, develop guidelines for healthcare professionals, and promote educational resources to improve preparedness. Physicians must familiarize themselves with climate-related health risks, educate patients, advocate for emissions regulations, and utilize telemedicine to maintain care during disruptions. Lastly, women should recognize their disproportionate vulnerability to climate disasters, advocate for policies addressing their specific needs, and educate themselves and their families on disaster preparedness. Moreover, it is imperative to raise awareness of the correct disposal techniques of sanitary goods to stop any further environmental degradation.

Thereby, it is our call for all authorities to act vigilantly to work on the already neglected reproductive health area. If the obstetric conditions are not well-addressed, they can have severe consequences on infant and maternal health, along with lifelong disorders. Likewise, poor menstrual hygiene can cause various illnesses, including pelvic inflammatory disease, urinary tract infections, and even sepsis. The flood-affected communities are already at risk of contracting several ailments, and inappropriate handling of reproductive concerns may aggravate the matter, with repercussions that could persist for years to come. Essential measures include training medical staff in disaster management and enhancing community resilience to cope with disasters. In addition, investing in training and deploying healthcare professionals to disaster-affected areas is crucial to ensure adequate healthcare for affected populations.