Maternal morbidity is depriving the country of a prosperous future. And nobody seems to be bothered by it

THE thin jute curtain was about to fall as a bunch of half-naked kids clung to it. It was getting dark outside and yet, nobody called them inside. Pale and feeble, the bodies of these children were missing the touch of their mother’s lap.

“Our men do not have any entertainment outlets,” Rafia noted tongue-in-cheek. “They are frustrated by lack of interaction, and of course, we are not supposed to oppose attempts by men to approach physically.” Rafia, holding a two-month-old baby girl of her sister-in-law, who died recently during delivery at Jinnah Post-Graduate Hospital, Karachi, seemed to have a point there.

Forty-year-old Rafia herself is a mother of 10 children. And managing all of them is quite a task. She lives in a one-room house in one of the shantytowns of the country. It’s a typical case where hunger, poverty and little choices to survive, have become the fate of the women living in Third-World countries. A large number of urban and rural under-privileged Pakistani women suffer from multiple factors of mortality; they are undernourished, illiterate and forced into early childhood marriages.

There are approximately 32 million women in the reproductive age group (15-49 years). Majority of them belong to poor families. An estimated four to five million births occur annually with eight to nine babies born every minute. The maternal death rate per 100,000 live births is 300 to 600. That means that in Pakistan, one woman dies every 20 minutes, or one in 38. Compare this to one in 230 in Sri Lanka, one in 5100 in the United Kingdom and one in 6000 in Sweden and you’ll get a clear picture of where we stand. The causes of such a high count are delay in medical aid, anaemia, blood pressure, infections, ruptures in uterus, sepsis, unskilled attendant, absence of emergencies in rural areas and unavailability of equipments, financial constraints, etc.

According to reports, about 25 per cent of all babies born are of low birth weight i.e. less than 2.5kg. Every year, 400,000 — 500,000 babies are either born dead or die within the first week of birth. Discrimination against girl child from birth, preference for a male child, inadequate breast-feeding, early marriages, high fertility rates, poor birthing methods, poor ante and postnatal services are the problems that women face in this region. Some 13 million under-5 children die each year in the developing countries. And seven million of these pre-natal deaths are not only due to problems during pregnancy and labour, but due to poor health status of the mother. Our gynaecology departments in different government and private hospitals take the cases very casually, as they say bearing a baby is a natural process and it can take place anywhere anytime.

“My mother had never used contraceptives or visited any family planning clinic. She always said that it is God’s wish. So, how can I be thankless,” said 20-year-old Sajida, who somehow did not want to admit it, but seemed all too worried about her nine sisters and four brothers. Her mother expired during the birth of her 14th baby. The father of those kids works as a labourer from early morning till late evening, to feed his huge family. A large percentage of such men depends on alcoholic liquids, charas and other contrabands to escape the harsh realities of life.

Most of the families living in slums comprise of five to six children, who never have access to education, proper health facilities and nutrition. A rural girl-child is perennially neglected and overworked. She bears children, prepares food, searches for fodder, collects fuel and shares the burden of working in the fields. The socio-cultural practices force the families to have births at home. In many cases, from the medical point of view most of the deaths are preventable, if only these people manage to reach the hospital in time. All this would have been possible if effective maternity services existed in all large population centres and had a link with a tertiary care service.

Pakistan is now the 5th most populated country in the world, with an estimated population of 140 million. Pakistan is a male-dominated society. Our females are living under some of the worst conditions, nearly as bad as in Sudan, where according to reports, the nastiest living conditions prevail. These conditions are the result of more than two decades of war and traditional inequality prevalent due to callous power structure.

“We are poised on the threshold of the 21st century. Modern knowledge concerning genetics, immunology and endocrinology, is available to most of the developing and the Third-World countries. But in this age of high technology, majority of our population is deprived of the basic needs”, this was stated by Prof. Dr Sadiqua Jafery, who is the president and also the founder member of the National Committee on Maternal Health.

This committee was formed during the era of ex-Prime Minister, Benazir Bhutto. It also works as an extended arm of the federal government. The committee has prepared a manual on Emergency Obstetric Care, and Unicef funds the project. World Health Organization (Who) is working with authorities in China, Myammar, Mongolia, Vietnam, Laos and the Philippines to implement the use of contraceptives to curb HIV/Aids.

Most of our people, whether urban or rural, do not have a proper knowledge of these safe techniques, that are necessary to avoid complications and risks. Though the media campaign was launched years ago by the National Health Ministry to somehow arrest the alarming population growth, lack of education and illogical approach of the traditionally superstitious natives has been the cause of the failure of the drive.

Induced abortions are common in our society, one that many doctors, midwives, skilled and unskilled nurses do undertake such risks of life. Less than 30 per cent married women use contraceptives and just 54 per cent of the pregnant women are fully immunized against tetanus. Some 95 per cent of births take place at home that are attended by untrained and illiterate traditional birth attendants.

Recently in China, the population policies that encourage rural couples to limit themselves to two children have increased the female fetus abortions, as they do not want a female child. Which means that in the coming 20 years of so, there will be a situation where millions of young Chinese men will be unable to marry because of lack of women!

The government has signed CEDAW and CRC, and is committed to “Health for All” and “Education for All”. Yet we are nowhere near the targets that should have been achieved. President Musharraf has announced a training programme for the midwives, called a National Community Midwives Program (NCMP). Still, the demographic pointers do not display a very encouraging picture. The less-privileged of the society feel that the government, at any cost, must help them get economic assistance, health care, education and protection.

The practice of purdah, or seclusion makes it difficult for women to access services outside home and it is difficult for female health workers to travel alone or in the company of men in certain areas of the country. The change in concepts and attitudes is required, and that can only come through education of the entire society, both men and women.

According to the doctors of government hospitals, patients who live near the hospitals do not reach in time. This is, of course, due to the combination of social and economic factors. Accountability for saving women’s lives must be strengthened through institutionalization. Professional and support personnel must uphold women’s right to pride and self-worth. Mobilization and community-based development projects are needed to help poor survive the difficult conditions and gain resources and opportunities. Orientation and training of all birth attendants; development of a strong system of referral to our hospital, and information, education and communication (IEC) programmes are badly needed. A countrywide drive should be launched to avoid high number of teen pregnancies, and at the same time, deficiencies should be removed in order to provide effective support to health system and access to Emergency Obstetric.