It is 10am and the queue of women at Khwaza Khela health clinic in Pakistan's Swat Valley is already more than 200 strong. A few years ago in this ultra-conservative region it would have been unthinkable for these women to be here at all. The fact that many have come to seek family planning advice is more remarkable still.
The medical relief charity Merlin, which The Independent on Sunday has chosen for this year's appeal, is supporting the government clinic so that it is able to deliver quality healthcare to the 50,000 people who rely on it.
Pakistan has suffered a succession of man-made and natural disasters over the past decade. The Kashmir earthquake in 2005 was followed swiftly by a bloody conflict with the Taliban in the north. The refugee crisis triggered by the fighting was then exacerbated by catastrophic floods in 2010, which killed an estimated 1,700 people and left 1.9 million homes destroyed or damaged. During these terrible years, the charity has been there ensuring that people can still get medical help. Now that the worst has passed, Merlin is staying until the clinics can run effectively on their own.
For women such as Nusrat, 25, who is waiting at the centre dressed in a black full-face veil, the opportunity to see nurses and doctors is still a novelty. The mother of three said: "Women here face great difficulty. When we get sick we are told by mothers-in-law and families: 'You will be fine. All you need to do is take paracetamol for the pain.' This is their solution to everything because they would prefer we didn't go out unless we need to and because we are used to living a tough life."
Now basic services are needed that were lacking even before the country's recent troubles. Family planning clinics in Swat were limited or non-existent before medical aid workers arrived. Condoms and oral contraceptives could be found, but that assumed that a woman's husband and mother-in-law – the two main household authorities for wives – gave permission to seek them in the first place. In an attempt to change these attitudes, the charity has recruited teams of local health promoters, who travel around the region persuading family leaders to allow women to seek treatment.
Nusrat is one of a growing number of women in the area now using contraception thanks to their intervention. "My pregnancies are always tough," she said. "I don't enjoy being pregnant as I have a very bad back and abdominal pain. I do not want any more children. I came to the clinic to talk to the women here about family planning. I have total peace of mind now that I am taking the contraceptive injection."
Naheed Begum, 27, is one of Khwaza Khela clinic's health promoters. She said: "At first many mothers-in-law believed NGOs didn't want women to have children and women were warned to be careful of us. Thankfully, this no longer the case.
"This is a cultural change and an important one. Women have more of a chance of delivering their baby safely in hospital than they do at home with untrained traditional birthing attendants. It will take years for our work to make a lasting difference on people's lives, but already we can see the changes and the benefits."
Contraception is still taboo for many couples, however. Only one in five people in Swat currently use birth control, and Merlin plans to increase the use of modern family planning methods by 40 per cent through the 19 clinics in which it operates.
Here, preventing pregnancy is not a lifestyle choice but a means of ensuring a mother's survival. In rural Pakistan, it is possible for a woman to give birth to a large family without ever seeing a doctor. Each year, 770,000 of the five million women who become pregnant in Pakistan experience complications. Many are pregnant with their next child within six months of giving birth, and anaemia, high blood pressure and weight loss are serious problems.
The medical officer at the clinic, Dr Sana Tajamal, 28, sees more than 150 patients a day. She has managed to win the respect and trust of people despite being a rarity for the area: a single professional woman.
"Women come and discuss their contraceptive needs with us. Before they were too shy or felt ashamed to be open about these issues, but now that they know Merlin is here to help them, they are open and willing to talk about what they need. I have heard women tell me they feel relief that we are here. They feel that they are respected and they will be treated well; rich or poor, they will be treated with respect. Some women come in secret for contraceptive advice as their husbands and mothers-in-law won't allow them to take contraceptives. Women often travel from distant villages in upper Swat."
Dr Tajamal says the need for birth control is urgent. "In this part of Pakistan, women have on average eight children, and in some cases girls get married as young as 14. As you can imagine, they start having babies early and spend many years pregnant. It has a major impact on their bodies and on their health. The women say they are fed up, exhausted with being pregnant and having children. To be frank, women have little control over their lives."
In 2009, when more than a million people were forced to flee Taliban-occupied Swat, Merlin went to Jalozai camp in Peshawar, where some 130,000 refugees were sheltering from the conflict. Later that year, when it looked as if the camps were about to empty, it was the first organisation to return to Swat to kick-start forgotten clinics in the region in anticipation of returning refugees.
After the fighting and floods, Swat remained cut off from the rest of the country, with no medical supplies getting through and more than half its doctors and nurses still absent. Before these clinics were brought back to life, people had to travel hundreds of miles to Islamabad to get decent healthcare. Now the charity runs 19 clinics in Swat and 13 to the south in Buner district.
The earthquake, war and floods may have passed, but Dr Asmat Khan, the charity's health director for Pakistan, says Merlin will not leave until Swat can provide excellent healthcare without its help. "We work closely with the Ministry of Health because our aim is not to build a parallel system but to grow within that system and replace people and resources that have been lost. That way we strengthen the system and leave a legacy that lasts."
How your donation can help to change lives
The Independent on Sunday Christmas Appeal is for the international health charity Merlin, whose medical experts are saving lives in some of the toughest places on earth. Treating people injured during the conflict in Libya, training midwives in Afghanistan, and feeding malnourished children in Kenya, Merlin takes countries from emergency to recovery. A specialist in emergency medical response, Merlin delivers aid in 16 countries, rebuilding health systems that have been devastated by conflict or natural disaster. Just £10 can feed 45 children with life-saving PlumyNut in Kenya; £25 can buy a surgical kit to treat casualties in Libya; £75 can treat one HIV patient for a year in South Sudan.
To make a donation visit: www.merlin.org.uk/independent-on-sunday-appeal or call 0800 035 6035 (24 hour, seven days a week - donation line).