It is mid-afternoon on a Wednesday and Toyoba Begum, 37, is sitting upright at the end of her hospital bed, the second in a row of eight. Dressed in a beige tunic and canary yellow trousers, a belly recovery belt clasped around her stomach, she watches her two-day-old daughter sleeping under a fleece blanket.
She says she feels a great sense of relief that her fourth baby arrived safely into the world. That was not the case three years ago when Begum laboured for six days. Her third baby was eventually delivered by caesarean section but did not survive.
Looking down at her hands, Begum says she blames herself. “All the time, I would tell myself that maybe it was because I slept like this, that’s why the baby died,” she says. The exact reason will probably never be known.
Begum was born here in a refugee camp at Cox’s Bazar in Bangladesh to parents from neighbouring Myanmar. In the site, made up of 33 overcrowded camps, deaths of newborns and mothers are not uncommon. While recent data is sparse, Unicef reported 84 maternal deaths in 2023 – 295 for every 100,000 births.
In some areas of the camps, which house about one million Rohingya refugees, maternal mortality is 44% higher than elsewhere in Bangladesh.
While there are efficient and well run maternal health centres in the camps, not everyone opts to use them, while the expertise to manage complications can be found only in a few specialist centres.
This time around, Begum was able to reach Friendship hospital, a 24-hour referral centre for emergency obstetric and neonatal care, the only such facility inside the camps. As she went into labour, Begum was diagnosed with hypertension and pre-eclampsia at a smaller clinic and referred immediately to Friendship. Since then, she has been resting in the general women’s ward where eight fans circulate the clammy air and multiple other women lie with their babies. With only six cots available and up to 12 women giving birth here each day, sharing the bed is the best option.
Most women will take the dusty roads back to their one-roomed homes within 24 hours of giving birth. But none remain safe, according to Begum, who says child trafficking and stealing are among the perils of camp life in Cox’s Bazar.
“Somebody might just pick the baby up and go and sell it in another camp,” Begum says. “After delivery and after raising the child, when somebody kidnaps or takes them away, then it is very painful.”
In the absence of opportunities to work or study, and with no possibility of returning to Myanmar, many gangs have sprung up whose criminal activities include kidnapping, as well as rape and murder, arson and forced marriages.
Many of the Rohingya arrived in the camp in 2017, after the Myanmar military government’s persecution of the ethnic minority group. With no way of integrating into Bangladesh, Begum’s family, like others, are stuck in a no man’s land.
Kindness Ngoh is an international midwife mentor working with the UN Population Fund (UNFPA), which funds the Friendship hospital and trains about 500 Bangladeshi midwives to work across the camps.
She explains that when women go into labour at night it can be impossible for them to leave home – violence after dark means the camps are not safe. “Because of that, the women are not able to access the health facilities on time,” says Ngoh.
Midwife Sumana Akter, 24, on a quick break from attending to three women in Friendship’s labour ward, says she opted to work here instead of a private facility because “in this Rohingya or humanitarian context there is always a need for midwives”.
On a shift that will probably see the four on-duty midwives deliver a dozen babies, Akter has already prepped a patient for a C-section, supported a labouring mother, and treated another three for complications.
Dressed in the pink uniform and matching headscarf of the hospital’s maternity staff, Akter says it is Rohingya tradition for a woman to labour at home. “I will ask them ‘why didn’t you come earlier? Your condition is so critical.’ She will say that my husband didn’t agree.”
The journey to a clinic can also be long – often up to a 30-minute drive depending on their camp location – and dependent on access to a vehicle. When they get to a facility, perhaps a basic primary health centre (PHC), it could be that their case requires a referral – and yet more time is lost, says Ngoh.
Today, Kalpana Rani, a midwife coordinator for UNFPA, is on duty at the PHC in Cox’s Bazar refugee camp No 4, about a 20-minute drive from Friendship. It serves a population of almost 9,000 with about 50 babies delivered each month. In November, three women died – two from pre-eclampsia and one from postpartum haemorrhage, says Rani.
A worn wooden birthing seat sits against the window, and a thick rope, marked by the hands that have held it before, hangs above a narrow bed. It is traditional to use a rope in a home birth and having one here helps make women feel more comfortable, she says.
Rani trains other midwives and supports them in convincing communities of the benefits of maternal medical care. “They counsel the mother and build up trust,” she says. Her work means she only sees her husband, a long bus ride away in Dhaka, for an hour a week.
It is small units such as this, tucked away at the back of a larger clinic, where cats roam the concrete floors and the heat seems to hover in the corridors, that refer patients with suspected complications to Friendship.
A few nights previously, on her Sunday night shift at Friendship, in a room with only three beds, Akter had six patients in labour, six needing C-sections and five women waiting for blood transfusions. “It was not a nice feeling because everybody came in active labour, so it’s not that you can prioritise this over this. It’s unfortunate that they have to wait,” she says.
Today it is quieter, and she is able to spend more time with patients such as Begum. Akter places a stethoscope to the as yet unnamed newborn’s heart and checks in with Begum on her post-delivery pain. The mother will be heading home later today, with a difficult future ahead, but with a healthy daughter.
