Motherhood on the Front Lines of the Climate Crisis

Release date November 23. Listen on Apple Podcasts, Spotify, and YouTube.

Key Takeaways

• Climate change is already a maternal health crisis. Extreme heat, floods, and rising sea levels are affecting pregnancy, birth, newborn health, and recovery today, not in some distant future.

• Disasters don't put pregnancy on hold. During Pakistan's 2022 floods, roads washed out, health facilities flooded, and providers were displaced along with everyone else. Mankani says maternal and newborn health has to be built into emergency preparedness from the start, not added once a crisis hits.

• Simple solutions are rarely simple. Making an ambulance boat work on Baba Island meant rethinking where it was docked, how it fit alongside the local boat-taxi system, and whether women could reach it at all.

• Heat solutions have to fit people's real lives. Advice like soaking your feet doesn't work where water is scarce. Solar-powered fans, postpartum heat kits, and a solar-powered clinic that doubles as a cooling space are making a difference for women on the island.

• Midwives are part of the climate solution. Embedded in their communities and with women throughout pregnancy and the newborn period, they can see and respond to climate risks that conventional adaptation plans overlook.

"It's Very Much Here"

Mankani works every day on Baba Island, a small, highly climate-affected fishing community off the coast of Karachi, Pakistan. There, she says, climate change "is not some abstract future risk for pregnant women. It's really changing the conditions in which pregnancy, birth, and recovery are happening."

She asked listeners to picture what that means. Imagine being pregnant in 40°C heat, in a home without reliable electricity, steady access to water, or a fan, and trying to recover from childbirth in those conditions. In an emergency, reaching a hospital means taking a boat to the city and paying for private care, in a fishing community whose livelihoods climate change has already disrupted.

One moment made the connection unmistakable for her. Visiting a pregnant client at home, Mankani looked out the window and saw a neighbor across the way holding up a baby born through her program. Between the two houses, the water was so high that a woman walking toward her would have been waist-deep, wading through seawater and trash in a place with no solid waste management. In her clinic, she began seeing that around 80 percent of pregnant women also came in with skin infections linked to rising water coming into their homes.

"This is a problem that is literally staring me in the face," she said.

No Pause Button

Dr. Ngô, who wrote about the 2022 Pakistan floods in the BMJ, noted that more than 33 million people were affected, including hundreds of thousands of pregnant women needing care. Mankani's response began with a phone call. A man on a donor visit had found a young woman having a pregnancy loss. The nearest facility, once ten minutes away, was now a twenty-minute boat ride, and he couldn't find anywhere to take her.

Over three months, Mankani and one other midwife covered about 23 sites and reached roughly 15,000 people, providing antenatal care, family planning, births, and other reproductive health services. "For pregnant women, there was no pause button," she said.

One woman she met in a displacement camp in Sindh has stayed with her. Pregnant with twins and sick with malaria, she had a way to reach a referral facility, but she declined to go. "I've lost my home. I have a three-year-old," she told Mankani. With her community scattered, she had no one to leave her child with, and no idea who would be waiting for her at the facility.

For Mankani, the story shows the gap between structural solutions and lived reality. A pregnant woman with malaria needs treatment, but what does that mean when she has lost everything that keeps her safe?

The biggest lesson from the floods, she said, is that "emergency preparedness cannot begin when a disaster hits. It's too late at that point." Midwives told her they couldn't work because their own facilities had drowned. Planning has to account for how women will reach care, where they will give birth, and how midwives will keep working. Otherwise, she said, it will always be response, never readiness.

A Simple Idea, Hard to Build

The ambulance boat on Baba Island sounded straightforward in theory. In practice, Mankani said, it taught her how much has to go right between offering a service and people actually using it.

"The assumption we always have is that if people don't have access to a service and you give it to them, they will use it," she said. At first, the boat was docked at a jetty where men gathered, so women couldn't walk to it. It also ran up against the island's boat-taxi system, where passengers pay and wait for the boat to fill before heading to the city, and some felt the ambulance was taking away business.

Working through those challenges took time, but the boat has transformed how quickly island women can reach emergency care in the city.

Pregnant in the Heat

Mankani first felt the toll of extreme heat while providing care in a makeshift tent in Dadu, in rural Sindh, during the floods. She felt close to passing out each time she stood to see a patient, and her portable ultrasound overheated every few minutes. If healthcare providers were struggling, she thought, imagine what women were facing.

Today she is seeing much of what the emerging research describes: higher rates of pregnancy-induced hypertension in women she would otherwise consider low-risk, more second-trimester losses after heat waves, breastfeeding difficulties, and newborns who overheat quickly. She is careful not to attribute every case to heat in a community facing so many compounding pressures. But when a loss or preterm birth doesn't make sense, she asks about living conditions, and women often describe weeks without electricity in the peak of summer. Heat also brings secondary harms, from lost sleep and depression to increases in domestic violence.

Solutions, she said, have to fit the context. Common advice such as soaking your feet after heat exposure isn't appropriate where water is scarce. Instead, the Mama Baby Fund distributes solar-powered fans during pregnancy, which women described as one of the most helpful interventions in a recent study. Even then, cultural dynamics matter. "If you give a pregnant woman a fan, will she be the one using it in the house?" Mankani asked. Or will it go to her mother-in-law?

The organization also provides postpartum heat kits with breathable baby clothing, mist spray bottles, cooling soap, and rehydration salts. Its solar-powered clinic doubles as a cooling space where women can come, no questions asked. Next, the team plans to heat-adapt the clinic itself and learn what that means for women and children in the community.

Dr. Ngô noted that climate investment still flows heavily to modeling aggregate data that doesn't reflect conditions at the village level, and called for more research into community-driven solutions like these.

Midwives as a Climate Solution

Midwives can provide up to 90 percent of essential sexual, reproductive, maternal, newborn, and adolescent health services, Dr. Ngô noted, yet the world faces a shortage of nearly 900,000, with some of the largest gaps in South Asia and sub-Saharan Africa.

Mankani said the midwifery model of care, rooted in being "with women," gives midwives a distinct understanding of people's lives. Unlike many other providers, they stay with women through pregnancy and the newborn period. A midwife knows when a woman can't afford transport, when her home has become unbearably hot, or when flooding keeps her from an appointment, and she will bring care to her doorstep.

That, Mankani argued, makes midwives a strong case for investment. "You invest in a midwife, you enable her to do her job better," she said, and she becomes part of making the health system around her climate-resilient.

Bridging Two Worlds

Despite progress, the climate and health communities still work largely in silos. Only about 2 percent of climate adaptation funding goes to protecting health, Dr. Ngô noted, and maternal and newborn health must compete for an even smaller share.

The question is no longer whether midwives have a role in climate action, Mankani said, but why policy and financing haven't caught up. Heat adaptation plans rarely look beyond lost income or heat stroke to what is happening to pregnant women. Small organizations like hers do the practical work adaptation requires, but often lack the capacity to navigate climate financing.

She also challenged what counts as adaptation. A climate-resilient health facility, reliable power, clean water, and safe transport to emergency care are all climate adaptation, she said, even if they aren't usually labeled that way.

From a Columbia Classroom to the Front Lines

Mankani, a Columbia Mailman PopFam alum, traces her path to midwifery to a systems-thinking course on maternal mortality taught by Professor Helen de Pinho. Students broke public health problems into the many causes that contribute to them. Studying obstetric fistula, she realized that while she couldn't solve every factor, there were a few she could address.

That idea, that "there is always something in your capacity that you can do," changed how she saw her own impact and led her to become a midwife. Her advice for students and young people builds on it. Climate change now touches nearly everything in health, and rather than being overwhelmed by its scale, they should find the part of it within their own field that needs new solutions. "Everyone has a solution to offer," she said.

What Leaders Need to Hear

Reflecting on COP31, Mankani hopes leaders will integrate maternal health into climate financing and adaptation, and listen to the right people: women, midwives, families, and those whose experience of climate change is shaped by disability, livelihood, housing, or age.

She closed with three things she hopes listeners remember. Climate change is already a maternal health crisis. Midwives must be part of climate action, because climate-resilient health systems can't be built without the people providing essential care. And climate resilience must begin with people's everyday needs: a solar-powered clinic, safe transport to a hospital, clean water, affordable care, and the freedom to make decisions about one's own body.

PopTalks is a podcast from Dr. Thoại Ngô and Columbia's Department of Population and Family Health. New episodes release every two weeks.

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