In November, Attaur Rehman's 34-year-old sister, who was a mother of six, went into labour. In an effort to get her immediate medical attention, her husband rushed her to a basic health unit where a lady health visitor (LHV) was assigned the case.

Recounting his sister’s ordeal, Rehman explains that the inexperienced practitioner administered an injection to his sister which caused her condition to deteriorate rapidly.

“She remained in ‘shock’ for nearly three hours before we were told to take her to a hospital,” he recounts. “She died at a hospital in Battagram.”

Rehman holds the inexperienced LHV responsible for the death of his sister. “She died because of the LHV who was clearly not authorised to run a maternity centre."

Even though Rehman wanted to take action against the woman in question, he chose to remain silent out of the fear that his sister's grave would be desecrated and her body exhumed to conduct an inquiry.

"From what I hear, my sister was the sixth woman who died at the hands of this woman."

This is just one of the troubling incidents that have occurred due to a prevalence of unregistered clinics and unqualified medics in Shangla district in Khyber Pakhtunkhwa. Doctors working in government hospitals have attributed the rise in emergency cesarean sections (C-sections) in the district to such facilities.

According to unofficial records, approximately 1,000 C-sections were carried out in private clinics across the district so far in 2019.

On the other hand, the records for Alpuri District Headquarter Hospital, a government facility, show that only 68 such procedures were performed during the current year.

Speaking to Dawn, Dr Noon Saha, a senior gynaecologist at Shangla District Headquarter Hospital, says the main reason behind a rise in the number of such procedures is an increase in unregistered clinics, where midwives are taking over delivery procedures.

"Complications during birth only accounted for two per cent of the cases I performed this year. The rest, were cases that were referred to me after being mishandled by unregistered clinics and inexperienced midwives," she says.

"In majority of the cases, the midwives injected the patient with oxytocin prematurely, causing their condition to deteriorate rapidly," she explains.

Oxytocin is a hormone that causes contractions in the uterus and can be used to induce labour.

Dr Najma, a female medical officer at Tehsil Headquarter Hospital, Puran, reveals that she typically opts for performing natural births in majority of the cases she oversees.

"However, women living in remote areas are prone to visiting private, unregistered clinics. By the time they are referred to us, their condition is so precarious that they are in no state to have a natural birth and have to be referred to bigger hospitals which are better equipped to perform emergency C-sections."

She alleged that these unregistered clinics have an "under-the-table" deal with major private hospitals in Swat and are paid between Rs3,000 and Rs5,00 for referring a patient for a C-section.

"Most of the clinics in Puran tehsil are unregistered and are carrying out medical procedures without proper training and experience." This is leading to botched delivery procedures and an overall increase in the number of C-sections, she explains.

Maria Sajjad, a doctor working at a private clinic in Alpuri, says that a lack of education, zero antenatal healthcare and untrained midwives, LHVs are major factors contributing towards a rapid increase in the number of C-sections.

"The cost for conducting a C-section is higher than that of a natural birth. One procedure costs between Rs25,000 and Rs30,000 while the other costs between Rs2,000 and Rs5,000."

Last resort

Dr Javid Iqbal, a senior surgeon at Tehsil Headquarter Hospital, Bisham, maintains that 75pc of the 400 C-sections he performed this year were emergency procedures.

“The cases were referred to me after inexperienced nurses ruptured the uterus or the bladder. In such a scenario, there is no choice but to perform a C-section to save the life of the patient.

"In at least 25pc of such cases, the child's life cannot be saved."

Such was the case of Shaheen, who was rushed to Bisham Medican Complex after spending a day writhing in pain on an operating table at an unregistered clinic.

"Her condition was so critical that the doctor on duty advised her husband that conducting a C-section was the best course of action," says a official working at the facility, who wished to remain anonymous.

"The patient's bladder and uterus had ruptured which lead us to believe that she had been administered a large amount of oxytocin.

"Typically, a woman can be in labour for 12 hours. However, sometimes midwives inject patients with the hormone to speed along the process which can have devastating complications," he added.

In Shaheen's case, doctors were able to save her life but not that of her child.

Alarming number of unregistered clinics

A survey by the district health office conducted by officials from the Extended Programme on Immunisation (EPI) reveals there are at least 1,203 unregistered clinics across the district; around 250 of these are unofficial maternity centres.

"LHVs and midwives are the ones primarily involved in medical malpractice," says EPI District Coordinator Dr Wajid Ali. "They run their own clinics and even have signboards outside the premises claiming they are certified doctors," he adds.

"Even though inquiries are initiated against them, these women have enough influence to approach higher authorities and have their transfers, as well as inquiries against them, cancelled."

KP Information Minister Shaukat Ali Yousafzai says that this practice is not specific to Shangla.

"Medical malpractice is also cropping up in other districts of KP province, such as Battagram, Toghar, Kohistan, and Kolai Palas Kohistan."

He maintains that he has submitted a complaint to the authorities concerned in this connection and plans to take the issue up with the chief minister of the province.

"I have demanded a complete audit of all unregistered, private clinics in all the districts. However, the healthcare commission has failed to take action against these quacks and has even accepted bribes to have these facilities registered," he says.

Saeedur Rehman, a senior official, at the KP healthcare commission says that raids are being conducted against unregistered clinics in the province.

"There are only 133 registered hospitals in Shangla district. As per the rules and regulations of the commission, LHVs and midwives are not authorised to run private clinics," he maintains.

"The issue has been brought to our notice and effective measures are being taken to tackle them."