Sughra Ramzan knew something was wrong when strange pains began ripping through her stomach for the second time. The pregnant mother feared her baby was in trouble _ but there was nothing she could do.
It was dark, and she was stranded with no way to reach a doctor from her village, still floating in thigh-high murky water from last month's massive floods. She desperately needed a boat to ferry her through even deeper water to reach the road, but nothing was available until morning.
All she could do was wait and pray.
"I felt there was something very wrong," she said softly. "I was scared about what would happen."
Like Ramzan, tens of thousands of expectant moms were marooned by floods that have swallowed an area of Pakistan larger than Florida. Some 18 million people have been affected, 70 percent of them women and children, in the country's worst natural disaster.
The World Health Organization estimates a half million Pakistani women hit by the floods will give birth over the next six months, and about 32,000 of them will experience complications. Many were malnourished and anemic before the disaster due to a lack of protein and iron in their diets. Now, with so many going hungry and facing diseases ranging from severe diarrhea to malaria, they and their newborns are among the most vulnerable.
"It is getting worse day by day. They are suffering extremely, extremely miserable conditions," said Zahifa Khan, who runs the 14-person Pakistan Human Development Foundation, an organization in the central city of Multan that's helping pregnant women and babies left homeless by the floods. "They have no camps, and they are sitting under open sky."
Even before the floods, giving birth in Pakistan was risky and difficult. About 80 percent of women deliver at home, often in filthy conditions on the dirt floors of their traditional mud houses. And six out of 10 expectant mothers do not have a skilled birth attendant.
Complications mean death rates in childbirth are high, at 276 per 100,000 compared to 11 per 100,000 in the U.S. And that number was already double in Pakistan's poorest rural areas, where flooding has washed away what little people had and cut off access to roads. One in 20 Pakistani babies do not make it through their first month, and doctors fear rates among those affected by the floods will soar much higher.
Some women are getting food and medical care in camps run by aid groups or the government. But many pregnant women, such as those living along the road on the outskirts of hard-hit Multan, are forced to sleep on burlap rice sacks spread across gritty sand under tents propped up by bamboo poles.
The sun and 100-degree (38-Celsius) temperatures turn the flimsy canvas shelters into pressure cookers that attract snakes and scorpions. Thousands of flies swarm the sweat-soaked women, most of whom have not bathed in a month because there is no water, toilet or privacy to escape men's eyes in this conservative Muslim country. They are surviving on a daily handful of boiled rice and grains.
If they are lucky, a mobile health unit will provide checkups and transport to the hospital when it's time for their babies to come. But some have been forced to deliver in tents on their own, using dirty water without even a towel or blanket to clean and wrap their newborns.
For others, it's even worse.
"I'm sleeping on a bed on the roadside," said Shama Mai, 18, who's due to deliver any day, with a stomach so swollen it's stretching her dirty threadbare shirt into a tight-fitting tunic. She has six young daughters at her side and not even a sheet to shield them from the elements. They were forced to flee the surging water at night with only the clothes they were wearing and still cannot return to their flood-ravaged village.
"There is no safe place that I can go. We are dying of hunger," she cried. "There is no water, no food. We are waiting for help from God or the government."
Like many poor women from Pakistan's agricultural heartland, Ramzan learned early about birthing babies. At 25, she had successfully delivered six children. She was eight months pregnant with her seventh when the Indus River exploded, as it thundered down the country following extreme monsoon rains in late July, killing more than 1,700 people.
It was night when the announcement was broadcast through speakers that the water had almost reached her village. She and her husband scurried to save their family by holing up on the second floor of their house. Water gushed and rose downstairs, but they remained dry and, unlike many other neighbors' foundations that were swept away, their house stood firm.
Ramzan thought the worst was over. She could keep living in her home and there was still food for her family. God had spared her.
But about two weeks ago, something felt wrong. Pain started pulsing through her womb. She knew it wasn't yet time for the baby to come, so she slogged through snake-infested waters on foot and by boat to eventually reach a doctor. She was given an ultrasound, some medicine and advice to come back in five days.
She felt better after returning to her village. So she stayed at home instead of again trying to make the 40-kilometer (25-mile) journey on foot, boat and bus for the checkup.
Then the pains came again. This time worse and at night.
One of the biggest problems with births throughout Pakistan is a delayed call for help. Women and girls often as young as 12 try to deliver at home and only seek a doctor once they realize the situation is life-threatening.
The floods destroyed roads and bridges, forcing people into areas with strangers and unfamiliar transport routes. Many have no mobile phones or cash to arrange an emergency trip to the hospital, leaving pregnant women on their own.
"We've doubled our number of C-sections, we've doubled our number of complicated deliveries. Women are coming having started delivery essentially in the open," said Hilary Bower, medical coordinator for the aid group Doctors Without Borders, which provides emergency care to pregnant women in rugged flood-hit Baluchistan province. "Often we can save the mother and the baby, but sometimes we can't. These are the ones that are making it to us."
Newborns, a quarter of whom were born with low birth weight prior to the floods, also are at great risk of infection. Many are being given milk formula instead of breast milk because women have no privacy to nurse or they simply feel too weak. Some moms believe they are too unclean to breast-feed, instead giving babies milk substitutes mixed with contaminated water that causes diarrhea, the number two killer of children worldwide.
"I don't think there will be enough care for them," said Dr. Ahmed Shadoul, head of maternal and child health at the WHO in Pakistan. "This is a grave situation, and those affected are the poorest people and those who are also living in remote areas which are not accessible."
When morning finally came, Ramzan was weak and exhausted, but she hoped there was still time.
Her husband, brother and sister-in-law all feared she would not survive the long journey. They took turns helping to lead and carry her through 4 kilometers (2 1/2 miles) of muddy water littered with decaying animal carcasses. She then boarded a boat and took six buses before finally reaching the hospital.
By the time the doctor arrived, Ramzan already knew the outcome.
"I came too late. It should have been a C-section. The baby died three days ago," she said, still cradling her watermelon belly as the tears came. "It was a very long trip. If the flood had not come, the baby would be OK."
Still in pain, she laid back on the bed and stared at the ceiling _ waiting for the doctor to return and remove the latest flood victim lost inside her.