SITTWE, Myanmar (AP) — When the kicking stopped, Zura Begum suspected something was wrong with the twins she was supposed to deliver that month. When the pain started shooting through her body, all doubt was erased.
She needed help, but had nowhere to turn. She was trapped with thousands of other Muslim Rohingya in a squalid, dusty camp in western Myanmar's Rakhine state. The foreign aid workers she had relied on early in her pregnancy were gone — forced out by a distrustful government and extremist Buddhist mobs. Getting help outside the camps, in hospitals run by the Buddhist Rakhine majority, requires special permission that is harder than ever to obtain.
And there is one more obstacle: The fear that has grown over two years in which ethnic violence in Rakhine, mostly by Buddhist mobs against Rohingya, has left up to 280 people dead and forced another 140,000 from their homes. Rohingya worry Buddhist doctors and nurses will hurt or even kill them, though aid workers, now just beginning to return to Rakhine, say there is nothing to suggest that the rumors are true.
All those factors weigh on Rohingya who need medical attention — especially pregnant women like Begum. Her family said that instead of getting the treatment she and her twins needed, the 20-year-old lay at the camp in a "long house" — a shelter of bamboo and corrugated metal where multiple families live. Her mother stroked her hand and placed packs of ice on her huge belly between screams.
Myanmar, a predominantly Buddhist nation of 60 million, has been gripped by ethnic and religious violence — mostly in Rakhine — since it began its bumpy transition to democracy three years ago.
Though many Rohingya here are from families that arrived generations ago, the government considers them all illegal migrants from Bangladesh and has denied them citizenship. Many of those displaced by recent violence live under apartheid-like conditions on the outskirts of Sittwe, the capital of Rakhine.
There are reports almost daily about deaths, many of them pregnant women experiencing complications that could have been prevented, according to aid workers and Rohingya in the camps. Before Doctors Without Borders was kicked out of Rakhine, pregnant women made up a quarter of the group's emergency referrals.
The government expelled the group in February. It had angered officials by hiring some Rohingya staff, and by saying it had treated victims of an attack on a village in northern Rakhine state early this year. The United Nations has said more than 40 people may have been killed in that attack, but the government says the only death was that of a policeman.
Weeks later, more than 700 other foreign aid workers were forced to flee after their guest houses, offices and warehouses were attacked by Buddhist mobs.
The government insisted it could fill the gap, though the health care system across the country is still rebuilding after years of neglect. The former military government spent around $1 per person on medical care annually before it was replaced in 2011.
The state deployed dozens of its own doctors into Muslim camps, but some initially refused to go, saying they felt unsafe. Now they show up several times a week, but only for a few hours.
Long lines form with hundreds of patients, each getting only a few minutes of attention. Some suffer from respiratory infections and diarrhea, the two biggest child-killers worldwide. And experts fear cholera or other waterborne outbreaks will flare when the sprawling camps, now blanketed by choking clouds of dust, turn to mud when the rainy season starts.
The government also promised to let aid workers from Save the Children, Oxfam and other humanitarian groups return to Sittwe within days, but few staff have returned so far.
Most are working out of hotel rooms with cardboard boxes turned into makeshift filing cabinets. While a few started visiting camps this week with supplies, they say the must operate under greater restrictions than they had before.
They point to the Emergency Coordination Center as one of the most worrying signs. Comprised of state and central government officials, as well as representatives from the United Nations, nonprofits and members of the local Buddhist Rakhine community, its role initially was to be an information-sharing mechanism.
But last week, one of most influential members, Than Tun, told aid workers their terms of engagement had changed. Now aid groups' activities must be approved by the center, and must give Buddhists and Rohingya equal amounts of aid.
"They have to create a situation that both communities can accept," Than Tun said in an interview. "If they keep working the old way, I'm sure there will be more conflict in our state."
It is clear to aid workers that Rohingya in Rakhine state require much more aid than Buddhists, who can get help at government clinics and hospitals with none of the obstacles Rohingya face.
Begum married Mohamad Rafis two years ago, just as their world was being turned upside down by hatred. They entered the camp after Buddhist mobs destroyed their village.
Like most men in the camps, unable to leave without paying hefty bribes, Rafis was not working.
But Begum managed to hold onto hope. Though many of her friends already had several children by the age of 20, the twins in her bulging belly would be her first and she was thrilled.
She was also getting the prenatal care she needed — until Doctors Without Borders was forced out in February. As her due date neared, something went wrong with her pregnancy, and when the pain came it was obvious that she needed a doctor.
On April 13, Begum's family took her to a small hospital in Dapaing village, but the doctor wasn't there. He told the nurses by phone that she should go to Sittwe General Hospital.
Like others in the camp, Begum had heard rumors that several Rohingya admitted into the hospital did not make it out alive. Foreign aid workers have not seen evidence of Buddhist doctors treating Rohingya improperly.
A more certain risk was not getting medical help. If a hospital cannot be reached for a cesarean section, the risk of death for moms and babies is greatly increased.
Begum went home. Her husband and parents took turns holding her hand, rubbing her stomach with ice, trying to console her.
"She was screaming, 'I'm dying! This is so painful! The pain comes from the belly! Help me!'" said Abdul Melik," a friend of Begum's family who stayed with them through much of her ordeal. "She screamed so loudly that about 10 long houses could hear her."
When the International Red Cross, which has managed to maintain a tiny presence in Sittwe, learned about Begum's case, the group was able to convince her that Sittwe General was the only option she had.
She went to the Sittwe hospital three days after she had gone to the one in Dapaing. One baby was believed to have died several days before the other, and sepsis may have set in by the time she was admitted. But after her surgery, Begum appeared to be in stable condition. She spent a week in recovery and was supposed to be released April 25.
Begum's aunt Mastaba Khatu, who stayed with her in the hospital, said that hours before her niece was due to go home, a doctor led her to another room, saying he just needed to give her one final injection.
Twenty minutes later, pain started surging again through Begum's stomach. And moments later, she was dead.
Tin Aung, an obstetrics doctor at the hospital, would not comment about Begum's case but said Rohingya and Buddhist Rakhine patients are all treated the same.
"We have so many patients here. ... Whether we can help them depends somewhat on what condition they were in when they arrived," he said. "We do the best we can."
Word about Begum's death spread quickly among Rohingya, adding to the rumors and fear that deterred her from seeking help in Sittwe.
On Tuesday, another Rohingya woman died in childbirth, 27-year-old Alima Khatu. She, too, went to the Dapaing hospital, but her husband initially refused to have her transferred to the hospital in Sittwe because he was concerned about her wife's safety.
Begum's father, Abdul Lamin, is simply struggling to understand. "When I was told that she died in the hospital, I felt like the whole world was broken and my heart too," the 50-year-old said, sobbing.
"I keep hearing people say, 'She was killed. She was killed,'" he said. "But I didn't see anything with my own eyes. I don't want to blame anyone. I just want my daughter."
Associated Press writer Robin McDowell contributed to this report from Yangon.