Inside the gynaecology clinic of Karachi’s largest public hospital, the air felt several degrees hotter. It was only 9.30am on a Friday in late February, and the windowless waiting room was already packed with women jostling for a place to sit, calling nurses for help, and scuffling for an ultrasound.
Asiya, 21, was pregnant with her third child. The baby was due in May, when the mercury often crosses 38C, and humidity soars past 70%, making the heat unbearable. As temperatures rose in the room, Asiya felt nauseated and dizzy.
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This story is part of Dialogue Earth’s work on the Community Adaptations to City Heat (CATCH) project, in partnership with Boston University. The project is funded by Wellcome. All Dialogue Earth content is editorially independent.
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“The heat exhausts me,” she said. “My body feels like lead, I’m barely able to stomach food. I am afraid that my child might be born sick.”
Asiya lives in Lyari, one of Karachi’s most densely populated neighbourhoods, with narrow alleys and little to no green space. Inside her home, ventilation is poor and cooling scant. Intense summer heat in her neighbourhood is compounded by power outages that last up to 12 hours a day, shutting down fans and other appliances that might provide relief.
“During my last pregnancy two years ago, I took showers thrice a day to cool down because I could feel my baby kicking in distress,” she told Dialogue Earth. Evenings in Karachi are often pleasant, with temperatures dipping to a palatable 25C, bolstered by a sea breeze. But this is no help as Asiya dresses modestly, veils and when she ventures outside, wears an abaya – a loose but heavy cloak, often made of polyester. “My husband won’t let me stand near the window either.”
Heat, inequalities and pregnancy
Home to over 20 million people, Pakistan’s largest city, Karachi, is projected to become substantially hotter in the years to come – an additional 2 to 7C on top of global warming projections. In 2024, temperatures climbed above 40C, which, combined with high humidity, created conditions at the very limits of human tolerance.
City temperatures are driven higher than surrounding rural locations due to the urban heat island effect. This fuels health problems including heatstroke, respiratory and cardiovascular problems, mental health issues, and even deaths.
Karachi is an exemplar of many overlapping problems of urban heat and pregnancy. It has high levels of humidity and very little tree cover and green spaces. Over half of the city’s population lives in densely packed informal settlements. High fertility rates and low contraceptive use among women are compounded by often poor antenatal care.
Cities are often warmer than the countryside that surrounds them due to a combination of factors: there are typically fewer trees to provide shade and cooling; a greater number of concrete and brick buildings, which can absorb heat; and more energy use, which produces waste heat. The result is known as the urban heat island effect.
Emerging evidence suggests that extreme heat is associated with an increased risk of complications that may result in adverse outcomes for both mother and baby. These include preterm births, low birth weights and stillbirths. These risks are higher for women in low- and middle-income countries without the means to mitigate high temperatures, such as purchasing relatively inexpensive fans or air conditioners.
Rubina Hussain, a gynaecologist associated with Ziauddin University in Karachi, told Dialogue Earth that the impact of heat on pregnant women and newborns is disproportionate. “They are far more likely to develop dehydration-related complications, UTIs, even pyelonephritis,” a serious kidney infection.
And Karachi is a city rife with inequalities. The rich have access to generators and solar power, meaning they have air conditioning that can keep running through the power cuts that trouble Asiya’s neighbourhood. The poor contend with no power for 22 hours some summer days due to load shedding from increased demand.
The less well-off also face a serious lack of reliable healthcare. A 2020 provincial ombudsman report noted that Karachi has not seen a new public hospital since 1974, and that the quality of services available in such hospitals has led the public to have “no confidence” in them.
Pregnancy adds another vulnerability on top.
Savera, 19, gave birth to her first child in July last year. On a hot afternoon two weeks later, she felt his body heating up. There was no electricity inside her 400 sq ft, poorly ventilated apartment. Savera tried fanning him, and then, in a desperate attempt to cool him down, swaddled the baby in a damp towel.
“I was scolded by the doctor later because that could have caused pneumonia,” she told Dialogue Earth. “I didn’t know what else to do.”
Grassroots organisations step in
While there is growing evidence that climate change and rising levels of heat have a negative impact on pregnancies, Neha Mankani, a midwife who runs a nonprofit called Mama Baby Fund, says reality on the ground feels much worse than many studies suggest.
At her clinic on Baba Island – a 0.15 sq km settlement just off the coast of Karachi that is among the most densely populated islands in the world – Mankani has been witnessing second trimester pregnancy losses at an alarming rate. Cases of hypertension, respiratory illnesses and neurological issues are also rising among babies. Mankani says nearly every second child on the island is born with some of these problems.
Mankani’s clinic is the only provider of maternal, newborn and gynaecological care for women on the island, which is situated within a perfect storm. Residents battle high levels of heat, with “feels like” temperatures rising to 48C on some summer days. They have no access to running water, very little electricity and very little tree cover.
Rising sea levels mean floods often plague Baba Island. Waterborne and skin diseases run rampant. Women are at particular risk: they face disproportionate levels of heat exposure, being typically responsible for cooking, which they do over open flames in small rooms with no fans or proper ventilation.
For these women, Mankani’s clinic has turned into a reprieve – a place where they can seek shelter under a fan with their children, and get access to clean water.
Since 2022, Mankani has been distributing Summer Care Packages to women on the island. Among other items, these contain cotton clothes and cloth diapers for breathability, washcloths that can be dampened and applied to skin, spray bottles for misting, rehydration salts and a plastic hand fan.
Organisations like Mama Baby Fund fill a vacuum left by a lack of official support, but such efforts are not enough. An Amnesty International assessment of Pakistan’s healthcare system published this year warned it was failing to meet the needs of its population, particularly young children and older adults. It noted how relatives of dozens of people interviewed who had been victims of heatwaves and floods could have been saved with timely medical treatment or preventative measures. As climate disasters intensify, that gap between need and provision is likely to widen.
Last month, Mankani was part of a panel on women and children’s health amid climate change in Karachi.
Towards the end, a member of the audience got up and commended the women of Baba Island for their resilience against a myriad of systemic inequalities and climate change. Mankani interjected.
“Why do we expect resilience from vulnerable communities?” she asked the people seated in front of her. “Why don’t we question the circumstances that have compelled them to be resilient? Resilience is not a badge of honour.”
The room fell silent.
In part two of this article: Pregnancy and heat in Pakistan: Researchers seek to fill dangerous knowledge gaps
