Zainab Kulsoom, a 27-year-old resident of Lotar village in Kohistan, Khyber Pakhtunkhwa is in the ninth month of her sixth delivery, embracing the challenges of motherhood with five children. Residing in a shared home with her husband’s fourteen brothers, Kulsoom, along with two co-wives and a total of 16 children, occupies a single room. Despite being in the final days of her pregnancy, she tends to household chores, preparing meals, herding animals and grazing, illustrating the challenges she faces in the dawn of each day. Kulsoom has given birth to two children at home without consulting a medical practitioner, while three others were born with the assistance of a local midwife. Kulsoom, in an interview with the Daily Times, shared the scene of January 13, 2023, where she was working on a steep hill cutting grass for animals when she started feeling intense pain from labor and became unconscious, falling into a ravine. Thankfully, someone from the village quickly helped her. They took her to the local health center where she received fluids to help her feel better. “This labour pain was distinct from my previous deliveries, expressing a fear of imminent death. In urgency, my mother-in-law directed my husband’s brothers to take me to a nearby midwife. Recognizing the complexity of the situation, the midwife advised a referral to a larger hospital. I was then transported in a 4×4 local jeep to a nearby BHU, where a female medical technician provided initial treatment and arranged my transfer to a more advanced hospital”.she asserted. She expressed the immense difficulty she faced due to the dilapidated state of the unpaved road, describing the travel as a nightmare. While adding to the severity, the jeep experienced brake failure and plunged into a ravine. Trapped and unconscious, she was rescued by villagers and transported to Mansehra where, a surgical operation was conducted, leading to the birth of her baby who unfortunately did not survive. She regrets losing her baby boy in the last delivery, while her earlier births were girls, who are not considered heirs. Worried about her husband’s dislike for surgical procedures like cesarean sections, she this time hesitates to go to a big hospital. She fears surgery might affect her chances of having more children and fulfilling her husband’s family’s desire for male heirs, a concern echoed by her mother-in-law. She bears severe pain but keeps it from her husband, feeling it inappropriate to share with him. Instead, she confides in her mother-in-law. Hoping for a miracle, she prays for a home birth without surgery, desiring a natural delivery. While speaking to Daily Times, a female member of the Population Welfare Department on condition of anonymity, stated factors contributing to population growth, citing a male-dominated society where women are considered commodities. While answering to a question she said, inflation doesn’t bother them much because their children, lacking education and luxuries, only need food. This belief leads to more offspring, seen as both a religious and cultural duty. While discussing the marginalized status of women she said she is working in the population department while her husband stays idle, her earnings support the family. When she asks for his help, she is dismissed, highlighting the limited say women often have at home. When reached to the population department, the district population officer Kohistan, Muhammad Suleman affirmed the government’s endeavours to create awareness and curb the high birth rate. However, the challenge remained due to deep-rooted beliefs and widespread illiteracy. “Despite the establishment of awareness centers, their impact remains minimal, despite extensive efforts to enlighten the public.” he said. While addressing a question regarding threats, he said the community is reluctant to confront authorities due to fear of repercussions. However, they view contraceptive measures as un-Islamic and unethical, influenced by uneducated clergy exploiting religious sentiments for personal gain. He criticized their opportunism, highlighting their acceptance of incentives from the department while disregarding broader community welfare. The latest data from the Pakistan Bureau of Statistics reveals that in 2023, the population of Upper Kohistan District reached 422,947, accommodated within 71,543 households, with an average household size of 5.91. Haroon Tanoli, a civil society activist who worked in Kohistan, stated that although the government allocates a big amount to the Population Welfare Department for education in Kohistan, the department lacks proper planning. Despite functioning centers, the entire staff resides in Abbottabad with their families, drawing salaries from there. This situation, coupled with a lack of healthcare facilities and other amenities further aggravating the existing problems. He highlighted early marriages issue in the area, with girls aged 14 or 15 getting married, leading to a high number of children by the age of 35. He noted a low divorce ratio and in the case of a male’s death, his wife is expected to remarry his younger brother immediately, as women cannot live without remarrying. He emphasized the dismal health conditions in the area, pointing out that basic health units are established on inaccessible hilltops with no appointed staff. In Kolai Palas district, although there is a large Tehsil Headquarter hospital building in Pattan, it is understaffed and lacks resources. Of the appointed 150 medical and paramedical staff, only three, including a medical superintendent running a private clinic, remain, as the rest left and transferred to more convenient areas. According to him, the medical superintendent of THQ Pattan opposes having doctors there to protect his private clinic’s interests. He mentioned a shortage of emergency medical facilities in the area. Tanoli doubts the accuracy of the 2023 census, claiming that the reported average family size in the three Kohistan districts doesn’t reflect reality. He insists the true average is much higher, with families having 12 to 15 children. Waqas alleges that the Population and Health Departments, failing in their duties, have submitted false reports to higher authorities merely going through formalities. During a visit to a basic health unit in Shalkan Abad, wher a consultant gynecologist, serves under the MNCH program. Speaking to this correspondent, Dr Mehwish Rajpoot shares, patients visiting them in emergency required life-saving fluids and a blood transfusion before embarking on the six-hour journey to Manshera or Abbottabad for critical care. Despite transportation challenges there is the critical need for emergency healthcare facilities in the region, acknowledging the risks faced by mothers and infants due to delayed care. She stressed the need to establish an emergency healthcare center in the area and also urged immediate action to provide emergency care services facilities so they can save the women lives in the hilly region. Responding to queries, Dr Faisal Khanzada, Additional Director General Health Services Hazara, admitted the shortage of health facilities in Kohistan due to numerous factors. He assured that the health department, in collaboration with INGOs is actively working to safeguard maternal and child health through MNCH programs in KP.