WOMEN’S access to healthcare in Pakistan is shaped not only by poverty, but also by the intersection of documentation, marginalisation and gender. After more than a decade of work in one of Karachi’s largest informal settlements, it has become evident how the absence of identity documents interacts with restrictive social norms and institutional power imbalances to systematically exclude women from public services. Insights from a community-based maternity home reveal that women’s avoidance of healthcare is less about awareness and more about fear, administrative exclusion, and the everyday costs — financial, social, and emotional — of navigating systems that were not designed with them in mind.

Women consistently report feeling safer and more willing to seek care when maternity services are located within their own communities. Proxi­mity reduces travel costs, but more importantly, it limits exposure to spaces where women anticipate scrutiny and judgement. Despite this, reliance on traditional birth attendants, or dais, and home bir­ths remains widespread. These choices are oft­en dismissed as backward or uninformed. In reality, they reflect rational decision-making in an envir­o­nment where institutional healthcare is frequen­tly experienced as punitive rather than protective.

Documentation, fear and gender keep women from accessing healthcare in Pakistan.

Home births are not chosen because women are unaware of the risks. Families are acutely conscious of the dangers of maternal and infant mortality, unhygienic practices, and delivery-related complications. What weighs more heavily, however, is the fear of mistreatment within formal health facilities. Women describe being spoken to harshly, questioned about their morality or marital status, and made to feel unwelcome. For many, the prospect of humiliation — particularly in male-dominated, overcrowded public hospitals — is a stronger deterrent than the clinical risks of delivering at home.

This fear is reinforced by the real costs of accessing Pakistan’s public healthcare system, even where services are officially free. Travel, repeated visits due to referrals, diagnostic tests, and the time spent away from household or income-generating work can make a single hospital visit a significant burden for low-income families. The cum­ulative impact of transport, lost wages and logistical challenges often makes seeking institutional care a difficult and sometimes untenable choice.

Documentation acts as a further and decisive barrier. While policy may not always mandate identity documents for maternity care, in practice CNICs, marriage certificates and other paperwork are routinely demanded. Front-line discretion determines access and undocumented women are frequently delayed, discouraged, or turned away. For women without CNICs — many of whom belong to historically marginalised or stateless communities — health facilities become sites of anxiety rather than care.

These administrative barriers are deeply gendered. Women are more likely than men to lack documentation, and more dependent on male relatives to obtain or present it. When documents are missing, women bear the burden of explanation and negotiation. In maternity settings, this vulnerability is heightened. The fear is not only of being refused care, but of being reported, questioned, or publicly shamed. Stories of such encounters circulate quickly within communities, reinforcing collective avoidance of formal healthcare.

For stateless and undocumented populations, the consequences are particularly severe. Statelessness does not simply limit mobility or access to education; it directly amplifies maternal risk. A woman without legal identity is less likely to seek antenatal care, more likely to delay seeking help during complications, and more vulnerable to being excluded at critical moments. In these cases, the link between legal identity and survival in childbirth is stark but largely unacknowledged in policy discussions.

Private healthcare, often presented as an alternative, offers little relief. Costs are prohibitive, and there is growing concern about the routine medicalisation of childbirth. Families report being pushed toward caesarean sections even when normal delivery is medically viable. Decisions are poorly explained, consent is often perfunctory, and costs escalate rapidly. For women who already feel powerless within healthcare settings, such experiences deepen mistrust and reinforce the perception that institutional care prioritises profit or control over patient well-being.

At the core of these experiences lies the question of dignity. Women from low-income and undocumented backgrounds repeatedly describe being treated as burdens rather than patients. Communication is minimal, empathy scarce, and accountability weak. These interactions mirror broader social hierarchies, where class, gender, and legal status intersect to shape who is deemed deserving of care.

The persistence of home births and reliance on dais should therefore be understood as a symptom of systemic failure. Pakistan’s health system rem­ains heavily oriented towards tertiary care, while primary and community-based services — those most accessible to women — remain under-res­o­u­rced and undervalued. Weak referral systems, in­­a­­dequate oversight of front-line behaviour, and the exclusion of undocumented populations from planning processes allow these patterns to persist.

Reframing the issue is essential. Women do not avoid healthcare because they are careless or res­istant to modern medicine. They avoid it because the system exposes them to indignity, financial strain, and administrative risk. Awareness campaigns alone cannot address this. What is required is health system design that recognises documentation as a barrier, addresses gendered power dynamics, and treats dignity as integral to care.

Until healthcare can be accessed without fear, without hidden costs, and without proof of legal belonging, avoidance will remain a rational response. The true measure of a health system is not the sophistication of its hospitals, but whether women — regardless of status — feel safe enough to seek care when it matters most.

The writer is a lawyer and founder-CEO of Imkaan Welfare Organisation.

Published in Dawn, January 9th, 2026