A pregnant woman carries a load of wood Monday in Muzaffargarh district, Punjab province, Pakistan. Thousands of expectant mothers in Pakistan were stranded during the floods with no way to reach a hospital or contact anyone.

Muzaffargarh, Pakistan ? Sughra Ramzan knew something was wrong when strange pains began ripping through her stomach for the second time. The pregnant mother feared her baby was in trouble — but there was nothing she could do.

It was dark, and she was stranded with no way to reach a doctor from her village, still floating in thigh-high murky water from last month’s massive floods. She desperately needed a boat to ferry her through even deeper water to reach the road, but nothing was available until morning.

All she could do was wait and pray.

“I felt there was something very wrong,” she said softly. “I was scared about what would happen.”

Like Ramzan, tens of thousands of expectant moms were marooned by floods that have swallowed an area of Pakistan larger than Florida. Some 18 million people have been affected, 70 percent of them women and children, in the country’s worst natural disaster.

The World Health Organization estimates a half million Pakistani women hit by the floods will give birth over the next six months, and about 32,000 of them will experience complications. Many were malnourished and anemic before the disaster due to a lack of protein and iron in their diets. Now, with so many going hungry and facing diseases ranging from severe diarrhea to malaria, they and their newborns are among the most vulnerable.

“It is getting worse day by day. They are suffering extremely, extremely miserable conditions,” said Zahifa Khan, who runs the 14-person Pakistan Human Development Foundation, an organization in the central city of Multan that’s helping pregnant women and babies left homeless by the floods. “They have no camps, and they are sitting under open sky.”

Even before the floods, giving birth in Pakistan was risky and difficult. About 80 percent of women deliver at home, often in filthy conditions on the dirt floors of their traditional mud houses. And six out of 10 expectant mothers do not have a skilled birth attendant.

‘Waiting for help’

Complications mean death rates in childbirth are high, at 276 per 100,000 compared to 11 per 100,000 in the U.S. And that number was already double in Pakistan’s poorest rural areas, where flooding has washed away what little people had and cut off access to roads. One in 20 Pakistani babies do not make it through their first month, and doctors fear rates among those affected by the floods will soar much higher.

Some women are getting food and medical care in camps run by aid groups or the government. But many pregnant women, such as those living along the road on the outskirts of hard-hit Multan, are forced to sleep on burlap rice sacks spread across gritty sand under tents propped up by bamboo poles.

The sun and 100-degree temperatures turn the flimsy canvas shelters into pressure cookers that attract snakes and scorpions. Thousands of flies swarm the sweat-soaked women, most of whom have not bathed in a month because there is no water, toilet or privacy to escape men’s eyes in this conservative Muslim country. They are surviving on a daily handful of boiled rice and grains.

If they are lucky, a mobile health unit will provide checkups and transport to the hospital when it’s time for their babies to come. But some have been forced to deliver in tents on their own, using dirty water without even a towel or blanket to clean and wrap their newborns.

For others, it’s even worse.

“I’m sleeping on a bed on the roadside,” said Shama Mai, 18, who’s due to deliver any day, with a stomach so swollen it’s stretching her dirty threadbare shirt into a tight-fitting tunic. She has six young daughters at her side and not even a sheet to shield them from the elements. They were forced to flee the surging water at night with only the clothes they were wearing and still cannot return to their flood-ravaged village.

“There is no safe place that I can go. We are dying of hunger,” she cried. “There is no water, no food. We are waiting for help from God or the government.”