“I was just 17 when I got married and I almost immediately became pregnant,” says 24-year-old Rukhsar Abdul Wasiq, who is the mother of a six-year-old daughter and an 18-month-old son. Her first delivery, by Caesarean section, is something she remembers with fear. “I was terrified throughout my pregnancy,” she says. “When the doctor mentioned a C-section, I thought I would die.”

Training at the midwifery school at the Sindh Government Qatar Hospital with 27 others, she now exudes confidence. Five months into the two-year diploma, she says her understanding of childbirth has transformed. She, like most of her classmates, is from Orangi Town in northwest Karachi, a settlement where the hospital is based, but the facility also serves the nearby neighbourhoods of Baldia, SITE and Manghopir.

“A mother doesn’t have to die to bring a new life into the world,” she says. “Pregnancy and childbirth don’t have to be traumatic.” Her confidence reflects the vital role midwives can play in transforming maternal care in Pakistan.

However, in many parts of the country, this role is still fulfilled by unregistered dais, or traditional birth attendants, who have no formal training when it comes to delivering babies. The reality is that systemic gaps in Pakistan’s healthcare systems and a lack of public awareness help sustain a parallel, largely unregulated system of childbirth care.

Behind Pakistan’s high maternal and infant mortality rates lies a fractured system, in which trained midwives are sidelined while unregulated practices continue unchecked. As trained midwives struggle to replace traditional dais, their profession is undermined by weak healthcare structures, undefined career paths and a lack of trust in their work

A THRIVING, UNSAFE BIRTH TRADE

In Karachi’s shadows, an unchecked network of untrained, unregistered dais continues to deliver babies — right under the noses of health authorities. With no official data, anecdotal evidence points to a vast, hidden market of unsafe deliveries.

Dr Azra Ahsan, an obstetrician and secretary-general of the Association for Mothers and Newborns, says, “Many dais overstep their scope — some even attempt C-sections and keep patients until it’s too late. Without clear referral pathways — knowing when and where to send patients — cases are often critical by the time they are put in a car and referred elsewhere.”

Dr Fatima Jehangir has run a primary care clinic supported by the Ziauddin University Hospital in Gulshan-i-Sikandarabad (an informal neighbourhood next to Clifton) for the past 15 years. She has observed dais in the area using ultrasound machines: “They double as sonologists and issue reports — I’ve seen these myself,” she says. “I can’t even read what they scribble on printed forms they pass as reports. And nearly every patient is diagnosed as having some infection or another.” Dr Jehangir sees the consequences of such medical neglect daily — such as children with cerebral palsy, which is often linked to birth asphyxia.

Neha Mankani, a midwife with 16 years’ experience, has seen similar cases at Baba Island, where she runs a maternity boat clinic. She explains, “It stems from unsafe birth practices — prolonged obstructed labour and misuse of oxytocin [a hormone that stimulates uterine contractions during childbirth].”

Over the past five years, her work has expanded across coastal communities around Karachi, reaching a population of 60,000. She describes a system rife with “dispensers acting as surgeons, midwives performing C-sections, and one where there was almost no pharmacological control, and no oversight of the dais.”

Neha recalls harrowing cases of pregnant women harmed by quacks in the city’s shadows. “I often receive women after they’ve already suffered at a maternity clinic run by a charity in Keamari,” she says. “One case still haunts me — a C-section patient who arrived with maggots in her stitches.”

More recently, she saw a woman from a coastal community who delivered a 25-week foetus at the hands of a dai after being told that the baby wasn’t growing and the amniotic fluid had dried up. “But the ultrasound report she brought from the dai showed a perfectly healthy baby,” points out Mankani. The dai probably misdiagnosed and put the woman in early labour.

Little wonder the country presents dismally high maternal and infant mortality rates. The maternal mortality ratio stands at 186 deaths per 100,000 live births, according to the 2019 Maternal Mortality Survey, while infant mortality is 56 per 1,000 live births. Neonatal and post-neonatal mortality rates are 42 and 14 per 1,000 respectively.

Against this backdrop, Mankani says, it is unlikely Pakistan will meet its Sustainable Development Goal of reducing maternal mortality to fewer than 70 deaths per 100,000 live births by 2030. Still, this fails to sap her enthusiasm. Mankani says, “I love being part of the messiness of human life, sharing in people’s emotional journeys, their celebrations and their losses.”

According to Mankani, “We can provide up to 90 percent of sexual, reproductive, maternal, new-born and adolescent healthcare.” Echoing the words of the World Health Organisation, she says that midwives trained on international standards can prevent over 80 percent of maternal and new-born deaths, “if fully integrated” into the healthcare systems.

Such training and integration would also reduce the need for and dependence on dais. Which is why it is also crucial that the masses understand the difference between a dai and a midwife.

BREAKING THE ‘DAI’ LABEL AND SYSTEMIC FAILURES

Mankani’s sense of care is echoed in the midwifery classroom, where trainees are learning that technical skill alone is not enough.

“Undoubtedly, the training to deliver the baby safely is the most important thing,” says 35-year-old Mariam Bint Abdul Mutalib, who has been studying with Rukhsar. But Mariam also points out that the past five months have taught her an important lesson in empathy. For her, midwifery is as much about words as it is about skill, saying, “How you speak to a woman, the language you use to make yourself understood and how safe you make her feel, that’s half the battle.”

As a mother of three, Mariam says she can recall being in labour, frightened and in pain, only to be shouted at by a birth attendant: “Kyun cheekh rahi ho? Zor lagao [Why are you screaming? Push harder],” Mariam recalls her saying. “That’s what I remember most about my own deliveries. I hated it.” She is determined to change that. “No woman should have to go through such indignity, especially when she’s also at her most vulnerable,” she adds.

These experiences point to a deeper problem — the perception of midwives in Pakistan.

Dr Rafat Jan, president of the Midwifery Association of Pakistan (MAP), says part of the issue lies in how midwives are labelled, stating, “A midwife, by definition, is a skilled professional… but, in our context… she is lumped under one title — dai.”

Still, the problem goes beyond labels, points out Mankani, into how the healthcare system itself functions. “Our country is hugely medicalised,” she says. “The healthcare system is overly reliant on medical specialists, and there is a significant lack of collaboration between doctors and midwives, which hinders professional trust.”

Against this backdrop, improving teamwork and training becomes critical. Calling skilled, empowered midwives the “spine” of safe deliveries, Dr Ahsan admits teamwork is essential, but training must go beyond ticking boxes of ‘conducted’, ‘assisted’, or ‘observed’ deliveries. She points out, “Safe, high-quality care depends on solid education, hands-on skills and continuous mentorship.”

Yet, despite such intent, Pakistan’s formal midwifery workforce remains constrained. According to the Pakistan Nursing and Midwifery Council’s (PNMC) website, there are 20,347 midwives, 14,547 community midwives (CMWs, who provide care in the out-of-hospital setting), 119,027 nurses, 29,378 lady health visitors, 3,621 certified nursing assistants and 4,097 family welfare workers registered with the PNMC.

The United Nations Population Fund’s (UNFPA) State of Asia’s Midwifery 2024 Report, which covered 21 countries, placed Pakistan among just five facing a severe shortfall of midwives — alongside Lao PDR, Mongolia, Papua New Guinea and Timor-Leste. Even if training continues at current rates and all graduates are employed — a challenge in itself — the report warns, Pakistan will still face shortages through 2030.

The gap is widening fast. Based on actual need, Pakistan was short of 3,100 midwives in 2021. By 2024, that deficit had surged to 81,900 — the highest among the countries flagged in the report. However, it should be noted that some of the increase since 2021 is due to a change in classification, as most of Pakistan’s midwives used to be classed as ‘professional’, but now most are ‘associate professional.’ Associate professionals are assumed to have a narrower range of competencies.

Furthermore, according to Mankani, “Girls entering midwifery training often struggle due to weak foundational education that limits critical thinking and decision-making. They face poor collaborations — obstetricians are reluctant to trust them and hospitals often refuse their referrals, even in emergencies — making it difficult for midwives to establish a reliable safety net for births.”

But even if Pakistan leapfrogs and invests in training a huge brigade of midwives, until the systemic barriers are not removed, there will not be much impact, especially on averting maternal and neonatal deaths.

A MISSED OPPORTUNITY

According to MAP’s Dr Jan, one issue is that there is no clear strategy to deploy trained midwives, leaving “a huge vacuum between education and employment.” This gap persists despite 114 nursing institutes nationwide offering midwifery and lady health visitor (LHV) training. Yet, many graduates struggle to translate training into livelihoods.

“Most want to start practice closer to home but lack funds, which is why several give up,” she says. Habiba Junaid, a student and mother of three, says, “It would be best to find clients in my own neighbourhood.”

Of the more than two dozen students at Qatar Hospital’s midwifery school, 23-year-old Maria Mithal is the only one from outside Karachi — and the only girl from her village in Dadu to continue her education. Her village relies on two dais, and she hopes to become the first trained midwife there. “We have no birthing centres. I want to open one,” she says. But beyond cost barriers, she fears a lack of trust: “Because I’m unmarried, people don’t think I can deliver babies.”

For most, ambition runs into a dead end. “Without a career pathway, they are doomed,” says Mankani, who sees this loss of trained midwives as a missed opportunity. “Neither the public sector nor private healthcare facilities have jobs for them, and there is little acceptability in the community.”

In Sindh, the government-run healthcare initiative PPHI is working to make a difference. Of the 2,166 midwife posts and 360 LHV positions, 1,871 and 326, respectively, have been filled, says Shafaq Fahad, head of communications at PPHI Sindh.

Still, according to Mankani, progress will remain limited until delivery is truly based on a midwife-led model. There are a handful of facilities, such as the maternity units run by the Aga Khan University in Sindh and Gilgit-Baltistan, the Lady Dufferin Hospital (the 128-year-old hospital is perhaps the oldest formal maternity facility in Karachi), the Koohi Goth hospitals in Landhi and Gadap, and the Al Farabi Hospital, which do follow this model.

While all these are well-established, old institutions, a midwife-led unit at the Indus Hospital and Health Network’s Al-Ghazi Campus in Bhong in Rahim Yar Khan is worth mentioning. In 2018, it employed six fresh out-of-school midwives from its midwifery school to run the maternity unit.

“At first, no one came,” recalled supervisor Ayesha Muqaddas, who was among the freshly trained midwives. But, within a year, word spread, and the facility gained acceptance. Ayesha says, “While quality of service remains paramount, patients say they are drawn to the respectful, gentle care they receive.”

In addition, fresh graduates from the Al-Ghazi School of Midwifery are much sought after at both private and public facilities in and around Rahim Yar Khan. According to Ayesha, “Starting salaries for new midwives are around 35,000 rupees per month, on par with the public sector, but the latter have added incentives — they get 500 rupees per referred delivery. With shorter hours, from 8am to 2pm, many take on a second job, earning up to 80,000 rupees per month.”

For those working at PPHI facilities in Sindh, pay varies according to shift timings. But, on average, a midwife or a community midwife earns a minimum of Rs45,000 per month, says Shafaq, adding, “Some are also eligible for hard-area allowance.”

Without clear career pathways and retention, many midwives may emigrate. Dr Mariyam Sarfraz, dean of the School of Nursing and Midwifery at the Islamabad-based Health Services Academy (HSA), says, “Most applicants to the four-year midwifery programme say they plan to work in the Middle East, where demand is high.” Finding little to no employment here, a lot of nurses as well as nurse-midwives are leaving for Europe to serve the elderly, reveals Dr Sarfraz.

A 2025 report by the Pakistan Business Council and AKU’s School of Nursing and Midwifery highlights a severe nurse shortage — 5.2 per 10,000 people — worsened by migration, especially of qualified faculty. But the shortage of midwives is not just a Pakistan problem. Globally, too, midwives are in short supply. Estimates vary widely — from just over 700,000 to nearly one million — largely because of the difficulty in counting nurse-midwives, whose roles often overlap and blur workforce data.

Pakistan faces the same dilemma, according to Dr Sarfraz: “We cannot separate the tasks considered to be a midwife’s carried out by all the three cadres — the LHVs, the female welfare workers [FWW] and the CMWs — who not only deliver but provide antenatal and postnatal care. And then there are nurses who work as nurse-midwives.”

But beyond role definitions, working conditions are what is driving a growing exodus.

Gloria Noble Khan, principal of the Institute of Nursing and Allied Health Sciences at the SHED Foundation hospital in Karachi, says, “With earnings between 30,000 to 40,000 rupees per month, it’s more lucrative for these health providers to go abroad.” Working in the private sector is worse, where “low salaries, long hours, no transport, no leave, minimal health benefits and forced overtime are common.”

That is why, says Dr Sarfraz, a minimum standardised wage should be defined for the different healthcare cadres. “It will protect them from exploitation by the private sector,” she says. Many do not want to go to rural and underdeveloped areas. So, to retain them there, the salary and other perks should be good.”

BUILDING A SYSTEM THAT WORKS

As things stand, Pakistan continues to operate with a fragmented system in which trained midwives exist alongside an unregulated network of dais. This duality perpetuates preventable harm, delays critical care and undermines the very professionals capable of improving outcomes.

However, expanding midwifery training programmes, while necessary, is not sufficient. Newly trained midwives will continue to face the same barriers as those before them if investments aren’t made in employment pathways, fair wages, institutional trust and community acceptance. Many will leave the profession altogether, or the country itself, if the issues persist, further deepening an already critical shortage.

What is required is a decisive shift towards a midwife-led model that is fully integrated into the healthcare system. This would entail deploying midwives where they are most needed, while simultaneously also building referral networks, fostering collaborations with doctors and redefining public perceptions of care.

Without such reforms, Pakistan risks continuing on its current trajectory, where maternal health targets remain unmet and safe childbirth remains an uneven privilege rather than a guaranteed right.

This article is part of a Globesight initiative on Mother and Child Health.

The writer is an independent journalist based in Karachi. X: @zofeen28

Published in Dawn, EOS, May 3rd, 2026