The perils of motherhood near Kashmir’s strife-torn borders

Adeeba Begum was seven months pregnant in June 2020, when she woke up to the news that a woman in a village 20 km away from hers had died from heavy shelling. Begum whimpered and shivered for hours in her home, worried that she and her unborn child would meet the same fate.

Like the woman who had died, Begum lived in an “LoC village”, an informal term that refers to villages in Jammu and Kashmir that lie close to the Line of Control, the volatile de facto border between India and Pakistan.

While Begum lived in Hathlanga, the other woman’s village was Batgran. They were part of a string of LoC villages in Baramulla district that included Thajal, Tillawari and others, all of which had experienced intense shelling over the years.

Begum had only weeks to go before she delivered her baby, and she was terrified of the risk to its life if any harm came to her.

She decided that she had to leave the village as soon as possible, and make her way to a safer place. “I couldn’t have waited for shelling to kill me, my unborn child and my husband,” she said. “So we decided to move out.”

A week later, she and her husband Umer Lone, a daily wage labourer, made the journey out of the village, travelling first by bus, and then by a local taxi to Baramulla town, where they would have easier access to the Government Medical College hospital, the official district hospital. “It was a tough journey we made, with the fear of shelling, my scared wife and the 50 km distance,” explained Lone.

Two-and-half months later, Begum gave birth to a healthy girl. The couple stayed in Baramulla town for an additional month, to avoid the risk of violence in Hathlanga, as well as to gather medicines and supplies that were not easily available back home.

Residents of LoC villages like Hathlanga have long lived in the shadow of conflict. Hathlanga is located in Uri, the last sector on the Indian side of the Indo-Pakistan border. It has a population of more than 75,000, according to the last census, conducted in 2011. The sector has 41 villages, of which around a dozen, like Hathlanga, lie next to the Line of Control.

Though the two countries declared a ceasefire in 2003, the region has suffered from regular bursts of cross-border violence over the years. In perhaps the most shocking instance of violence, in September 2016, four militants stormed an army camp in Uri, killing 17 Indian soldiers. Otherwise, too, cross-border tensions and violence simmered through the years, spiking in 2020, which saw 5,133 ceasefire violations, up from 2,140 in 2018 and 3,479 in 2019.

Then, on February 25, 2021, villages along the LoC received news that India and Pakistan had agreed to strictly adhere to the ceasefire agreement along the LoC in Jammu and Kashmir and other states. Since then, there has been a marked reduction in instances of cross-border violence in the region.

But the violence has not subsided completely. On December 22, 2021, a 20-year-old girl lost her leg to a landmine blast in Hathlanga. Ghulam Mohammed Bhat, a resident of Sahoora, an LoC village, who lost his leg to a mine blast 37 years ago, said he understood the girl’s trauma. “All of us are a casualty of the conflict,” he said. “We live with this sense of pain within us, it is a part of us.”

Ayub Lone, a resident of Garkote village in Uri, echoed this sentiment. “Our wounds have stayed cut open for long now,” he said.

Some believe the current phase is merely one of temporary calm. “We never know when the ceasefire will be violated, and also our right to live in peace,” said Asadullah Lone, 88, a resident of Uri town.

While the general population suffers as a result of this conflict, expectant mothers feel a particularly acute terror because of their vulnerable health, their need for regular care through the pregnancy and, closer to delivery, the fear that they will not be able to readily access medical help.

In the last week of November, Farkhanda Aziz, a five-month pregnant resident of Uri town, explained that she had been asking her husband and other family members to buy medicines every time they left the house, and then storing them. “I just can’t take the risk of lacking medicines at the last moment,” she said. “Whoever goes out into the town’s market, or even to Srinagar, I keep asking them to bring me back medicines and health supplements. I want to avoid panic during labour.”

Though she lives less than a kilometre from the Uri sub-district hospital, she remains anxious because of the continued presence of army trucks and other military vehicles in the area. “I just pray to Allah that the ceasefire stays put,” she said. “I want to deliver my child in peace.”

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The problems of pregnant women in these villages are compounded by the poor state of health infrastructure in the region.

Dr Bashir Ahmad Chalkoo, who until March was deputy director of Jammu and Kashmir’s Directorate of Health Services, noted that in Uri, this infrastructure had been adversely affected by its proximity to the volatile border.

“Living in the conflict zone has impacted development over the last 30 years,” he said. “I have been observing that it takes years to complete construction work at hospitals. Then, within that time, there is cost escalation.”

He added that the fact that there was “no timeframe of completion is also problematic”.

The need for better infrastructure and personnel was particularly acute because of the conflict in the region, he noted. “In border areas, due to shelling, casualties occur,” he said. “They need to strengthen hospitals and equipment both.”

The health centres that do exist are poorly equipped, as a result of which locals pick up skills in managing their own health problems. “Our life in this LoC village has taught us desperate survival skills,” said Ghulam Hassan, a resident of Kamalkote, an LoC village, whose home was reduced to rubble by shelling in June 2020. “I can pluck out pellets, shards of glass, nurse bleeding wounds. But importantly, we have learnt to survive this pain.”

The most remote villages in the region have only “sub-centres”, also known as health and wellness sub-centres and are typically health facilities with basic staff, such as accredited social health activists, or ASHAs, and female multipurpose health workers. These workers are not doctors, and only help with simple ailments such as fevers, and simple procedures, such as for first aid.

For pregnant women, they administer antenatal care tests, which include blood pressure checks, urine tests for albumin and sugar and blood tests to check for anaemia. While these tests can help ensure that a woman’s pregnancy is proceeding normally, for deliveries, the woman must travel to the nearest primary health centre, or PHC. These centres usually have the necessary facilities, such as a delivery table, and a general practitioner who can oversee the procedure, as well as nurses to assist – a few even have gynaecologists as part of their staff.

However, Sayeeda Akhtar, a female multipurpose health worker who has been working in the field of women’s health for 30 years, explained that some PHCs, such as the one in Bijhama village, don’t have facilities for deliveries and can only refer patients to other centres. Further, she added, even the centres that do have facilities for deliveries do not typically have staff on hand beyond daytime working hours.

Data from PHC Boniyar paints a worrying picture. According to the data, which Parvez Ahmad, Block Monitoring and Evaluation Officer at PHC Boniyar shared with Scroll.in, in the year 2020-’21, the centre saw 465 successful deliveries, and 11 deaths of newborns. This indicates an infant mortality rate of 24 for every 1,000 live births, significantly higher than the figure of 17 recorded for Jammu and Kashmir as a whole in 2020, the last year for which data is available. Akhtar noted that PHCs cannot usually handle any complications in deliveries, and in such cases, refer patients to the nearest sub-district hospital, such as the one at Uri. These centres have equipment such as ultrasound machines to diagnose such complications, and can perform Caesarean surgeries where needed.

But here too, Chalkoo noted, facilities at these centres were often inadequate. “We don’t have ICUs, cardiac units, newborn care units, in sub-district hospitals,” he said.

There was also a shortfall of personnel at these centres. Referring to the sub-district hospital, Uri, he explained that the centre had “the post of only one consulting gynaecologist, they cannot work round the clock.” He added that it only had one anaesthesiologist, who was essential for Caesarean surgeries, and that it needed more.

Thus, for a pregnant woman from a village like Hathlanga to ensure that she can receive all the treatment she needs, even in case of any complications in her pregnancy, and to ensure reliable postnatal care, she has to travel 50 km to the district hospital in Baramulla.

Nadia Pathan is among those who made this journey. She is a resident of Mayan, a picturesque village around 30 km from Uri town, with a population of 1,100 people, and one sub-centre. It is cut off from Uri and its hospital for several weeks every year because of snowfall.

The sub-centre in Mayan remains open between 10 am and 4 pm. It only has the capacity to treat patients with minor ailments, such as fevers and stomach upsets, and has one bed to admit a patient. It does not have equipment such as an ultrasound machine and delivery tables – Pathan and other women, therefore, typically travel to Boniyar or even Baramulla for their deliveries.

“My daughter-in-law delivered her first born recently at a hospital in Baramulla,” said Akhtar Nisa, Pathan’s mother-in-law. “All throughout her pregnancy, I kept reminding her of the journey she would have to undertake. She remained patient, even in pain.”

Ghulam Qader Sheikh from Dudran, a village around 55 km from Uri town, recounted the tragedy that befell his family because the village, like Mayan, is isolated by snowfall for several weeks every year.

“Our village is hidden away in dense mountain cover,” he said. “My own sister lost her child in her womb because of zero connectivity during snow.”

Those who initially seek facilities closer to them are often referred onward multiple times. Such was the case with 35-year-old Parveena Ather, who was pregnant with her fourth child in November. Her husband, Mohammed Iqbal, recounted how, because of a paucity of facilities and equipment, the sub-centre in Mayan referred his wife to the primary health centre in Bijhama, which referred her to the primary health centre in Boniyar, which in turn referred her to Government Medical College, Baramulla. “For all her deliveries, I was worried about whether we’d make it in time to the other hospitals,” said Iqbal.

“We mainly act as a referral unit,” said the female multipurpose health worker Sayeeda Akhtar, who has been working at the sub-centre in Mayan for three years. “Once we chart out when a delivery is due, the mother can be sent to Bijhama or Boniyar.”

Holding out a list of patients’ names with due dates, she explained that women whose estimated delivery date is approaching are informed one week in advance that “they should shift to well-connected areas where maternal healthcare is more accessible.”

But even if a woman reaches a better equipped centre, there is no guarantee that she will receive care there. In 2018, for the delivery of her third child, Ather had been referred to Baramulla, where Iqbal had taken her for two previous deliveries, but she was sent back because the hospital was full and she wasn’t due to deliver immediately. The process was frustrating, Iqbal said, “when the pregnant woman is asked to travel back and forth, in her delicate medical condition.”

Ather noted that she had to “prepare myself mentally, that I will be forwarded from one place to another”. She added, “That is when I wish that Mayan had a centre which is equipped to deliver babies.”

Experts echoed locals’ worries about the risks of transporting pregnant women from sub-centres and primary health centres in the late stages of their pregnancy. “The last-minute panic of getting an ambulance to the PHC and rushing the patient to another hospital is often critically time consuming and risky for the mother and the child,” Dr Sheikh Farooq, former block medical officer, Uri, and a social activist. “So, if these PHCs are strengthened, critical time can be saved.”

In Thajal, another village near the LoC, residents explained that they often help each other lift pregnant women so that they can travel out of the village. Ghulam Ahsan, a resident of Thajal, said, “When there’s knee-deep snow, we make the pregnant woman sit on a table, and four men lift that table so that she can escape the village in time.”

Some villages also have to contend with severe restrictions put in place by the army. Silikote, 10 km from Uri town, a village of just 27 homes, is encircled in barbed wire, and has one gate to allow movement into and out of the village – but to leave and return, residents need prior permission from the army.

“Silikote feels like a different world altogether, it is where Kashmir ends,” said a resident of the village, who is a mother of two. “We have no health infrastructure here. During both my pregnancies, essentials like maternity sanitary napkins were a necessity, sitting 10 km away in Uri town. How does one deal with such emergencies? I had to ask a relative to give her napkins to me.”

These difficulties are exacerbated by the fact that the village does not even have a sub-centre, and has just one ASHA worker to attend to residents’ health needs. A resident of Silikote said on condition of anonymity, “We don’t even have the facility to get a paracetamol tablet in case we fall ill. This is just like other villages sitting on the LoC, we are away from the world. We rush to the one sub-district hospital in Uri or hospitals in Baramulla.”

Some residents of Silikote also explained that they barely earned between Rs 200 and Rs 300 a day as porters or working as labourers on farms – on this salary, procuring medicines and nutritious food for pregnant women in such far-off villages was an almost insurmountable challenge.

Prior to the 2021 ceasefire, Silikote had suffered from frequent shelling, and had seen several incidents through 2019 and 2020 in which civilian lives were lost and homes were destroyed. Though the village hasn’t been hit by shelling since the ceasefire, the memories continue to haunt its residents – and expectant mothers are reluctant to take any risks. In November, Hubza S, who is expecting to deliver in February said that in her mind, she was already in the Uri sub-district hospital. “I know when the time comes, I will just have to leave,” she said. “I have already made a list of essentials I will take along.”

Given the inaccessibility and the precarious geopolitics of the region, expectant mothers rely significantly on the assistance of Accredited Social Health Activists, also known as ASHAs, community health workers who are found across the country, who assist those with poor access to healthcare. Unlike even ground-level health staff at sub-centres, part of the ASHAs’ role is to go from home to home to check on the health and nutrition of different families, including of pregnant women. They are among the approximately 13,000 female healthcare workers in Jammu and Kashmir. Apart from maternal healthcare, they help locals in tasks such as immunisation, and also assist with nutrition and sanitation.

Afsheen, an ASHA from Uri town, recounted that 2020 was a particularly trying time for health workers like her. “In 2020, the worst year we saw in terms of shelling, many pregnant women were reeling under depression, many were moving to Srinagar, which is a 100 km away, to flee as far as possible,” she said. “During that time, even I was in two minds, whether to meet the women I assist or stay at home. Then eventually, I would only venture out on calmer days.”

Twenty-two-year-old Mehrunnisa, who asked to be identified by a single name, works as an ASHA at the health and wellness sub-centre in Lachipora. Three times a week, she walks three kilometres from her home in the village of Gawas to Lachipora for work.

When asked what motivated her to become an ASHA, she responded “Khidmat-e-Khalq” or the wish to serve god’s creation. “Every time that I have assisted a pregnant lady in my three years’ tenure as an ASHA, she has become my sister,” she said.

For Rs 2,000 a month, Mehrunnisa creates a log of pregnant women, reminds them of their ANC check-ups, follows up on their healthcare, and advises them about when to shift towards a lower altitude village before Lachipora is cut off from the rest of the region because of snow. She also assists them, and the general population, in the treatment of minor ailments and injuries.

“On my way from Gawas to Lachipora, I know the pregnancy map, who is due when, who needs to be shifted soon, who has a frail heart and needs my motivation more,” she said. “Before they finally reach the delivery table, their heart, body and mind are deeply dependent on ASHAs.”

But she rued the lack of facilities in the area, and noted that there was a limit to which health and wellness sub-centres could help. “I wish HWSCs [health and wellness sub-centres] were equipped with facilities to undertake deliveries, that would make the pain of so many mothers easy.”

When Scroll.in spoke to Mehrunissa in November, there were 13 pregnant women in Lachipora, all of whom were relying on her assistance through their pregnancies. “Even if I take a course in midwifery, still we will need equipment here,” she said.

Other ASHAs, too, spoke despairingly of the lack of adequate facilities. A former ASHA from Baramulla, who asked to remain anonymous, told Scroll.in about a case where a woman from the village of Kasi, in Boniyar tehsil, died after delivering her child at PHC Boniyar. “The PHC could not determine whether the mother was doing well post-delivery or not, passing time took a toll on her and she passed away at the PHC,” she said. “This is how the lack of facilities takes lives.”

Women’s struggles are even more pronounced in villages like Dudran, which have fewer facilities than Mayan and Lachipora. The village was connected by road only in 2012, and even today residents barely get any cellular network. “It is very troublesome for pregnant women to be anticipating travel and the stress that comes with it,” said Shafiqa Sultan, 22, an ASHA in Dudran. “But we try to pacify them with our words, that’s all we have here. For regular patients, all I can do is ask them to go to PHC Boniyar. And for pregnant patients, I strive to have them shifted as early as possible, because there is a risk of two lives together, not just one.”

Sultan’s own family carries traumatic memories of struggling with childbirth because of the remoteness of the region. “In 2013, my mother was due for delivery,” said Ghulam Mustafa Sheikh, Sultan’s brother, who trained as a dentist. “It was snowing in February and we took her on our shoulders downhill to be admitted to PHC Boniyar. On our way down, her girl child began to hang out of her. We couldn’t do anything to save the child. She died battling the freezing weather.”

In early 2022, when Sheikh’s wife, Kulsuma Begum, who is 24, became pregnant, he took every possible measure to ensure a smooth delivery. “I used to take her to GMC Baramulla for ultrasounds, keep stock of her medicines and supplements ready,” said Sheikh.

When Begum went into labour on November 7, Sheikh took her directly to Government Medical College, Baramulla. “I was just focused that my wife should have everything available to her on time, even if it meant travelling to GMC Baramulla, which is 40 km from here,” Sheikh said.

Residents of LoC villages claimed that their struggles with healthcare had become more difficult to address since August 2019, when Jammu and Kashmir was divided into two Union territories, and the special privileges accorded to it under Article 370 of the Indian constitution were revoked. Since then, residents of these regions have had no elected assembly members to turn to for help with their problems. Meanwhile, members of elected local bodies, such as block development councils and district development councils have protested that their work is being stymied by a lack of funds and administrative responsibilities.

Shah Musadiq, a local from Dudran, who turned 18 in 2019, said, “The year I got the right to vote, all leaders were jailed. I wanted to vote for someone who would make this village liveable.”

Musadiq added that if ballot boxes could be brought in for voting for the district development council elections in November 2020, “Why not medicines and medical equipment?”

As Ghulam Mohammed Lone, a panchayat member in Lachipora, noted, “Being leader-less pushes us further away from the periphery of Kashmir, even politically now.”

Tariq Hameed Karra, a Congress leader and former Lok Sabha member of parliament from Srinagar, noted that the structure and functioning of health institutions in the region had been established by previous governments, while Article 370 was still in force. He argued that while the Central government, under the Bharatiya Janata Party, had “demonised Article 370 as an impediment in the way of development” and boasted that there would be a “development boom” after it was revoked, residents were “yet to see any of that happening”. He added, “Everything is the same, no changes in equipment, infrastructure or gap in access to healthcare.”

Residents of all the villages Scroll.in visited – Dudran, Mayan and Lachipora – echoed this complaint. They noted that though during the Covid-19 pandemic, their vaccinations were provided, there seemed to be no upgrades in the sub-centres and primary health centres nearby. “My fellow villagers and I are grateful that we were vaccinated but there is no significant improvement in our village,” Abaan Malik, a resident of Mayan, said. “God forbid if anyone breaks their leg here, they will have to travel all the way to Boniyar for a simple X-ray. To think of pregnant women going through the ordeal of travel in pain is unimaginable.”

The closer villages were to the border, “the farther we are from development in any phase of life,” said Ghulam Qader Shaikh, the resident of Dudran whose sister lost her baby,. “Our sisters have lost their children, sometimes in their wombs and sometimes in their laps”. He added, “Aren’t our lives important? Aren’t children being born here precious?”