Fatal conception: Stilled life

For millions of Pakistani women the birth of a new baby is not a moment of joy
Published September 14, 2014

Stilled life

Married at a young age, most of Shumaila’s pregnancies ended in stillbirths. Until one claimed her life

By Noman Ansari

Had you seen her from a distance, perhaps you would have mistaken her for a hunching teenager. Up close however, you would have realised that this frail and barely 5 feet tall woman was in her mid-20s. From her stunted physique, your focus would have shifted to her weathered face, which carried the weariness of a woman twice her age and contrasted strangely with her youthful and defiant eyes.

Unfortunately, the following story of Shumaila* isn’t an unusual one. As is often the case of young women born into a family of few means, she was married off at a young age to a man incapable of supporting a family. Under pressure from her husband and in-laws, Shumaila became pregnant often, yet only had one living child by the time she reached her mid-20s. This young boy was Shumaila’s life, and accompanied her to Karachi where she worked several jobs as a maid in order to support herself and her husband.

The world had been cruel to Shumaila and as a result she lashed out often with her barely contained frustration. Sadly, life was about to grow harsher. Less than a year ago, this young woman became pregnant once again, and recently was about to give birth to her second child; a baby girl.

The dai in her village warned Shumaila’s in-laws that the pregnancy was heading towards complications, and that she should be immediately taken to a hospital. Unable to afford the expenses of a professional delivery, her family convinced the dai to handle the birth. She agreed, but tellingly only did so after having Shumaila’s family sign a disclaimer.

Three days after giving birth to her second child Shumaila passed away; it came as a shock to those who had known her.

 Women rushing to collect  a token number for the antenatal clinic
Women rushing to collect a token number for the antenatal clinic

Alarmingly, Shumaila is one of many Pakistani women who die due to complications in pregnancy and childbirth. As Dr Noshin Tariq, a gynaecologist with tons of experience at a maternity hospital explains, women such as Shumaila lack nutrition, knowledge, and access to basic health care,

“Hospitals in rural areas are overburdened, poorly managed and lack resources, resulting in disturbingly high infant and maternal mortality rates. The typical issues that these women suffer from are postpartum haemorrhages and anaemia, as well as other complications and deficiencies. Some women also lack knowledge about healthcare, for example they may not know that they need iron supplements even after giving birth.”

Dr Noshin claims the government needs to take a greater initiative in rural areas through an awareness programme that is planned well.

 Courtesy: World Health Organisation
Courtesy: World Health Organisation

As of 2012, it was estimated that Pakistan had the highest maternal mortality rate in South Asia and one of the highest in the world. Meanwhile, statistics available from Unicef using data gathered from 2010, state that the lifetime risk of maternal death in Pakistan is one out of 110.

Dr Noshin says that aside from providing better health care the best way to combat this problem is education,

“These women simply lack knowledge as to their special needs during pregnancy. There is nothing unhealthy about a woman giving birth to several children, and women of better economic means don’t suffer from the same issues. There is no harm in it. Problems occur when women don’t have access to proper facilities and nourishment; frequent multiple pregnancies take a toll on their bodies as they lack a lot of support and are facing abuse through being overworked. As they grow older they lack other kinds of support and have to look after a lot of children alone.”

A department head at her hospital, Erum Riaz-Ghazi is currently pursuing her PhD from the Institute of Clinical Psychology at the University of Karachi, and has also been associated with the NGO called Health Education & Literacy Programme (HELP), where she recently consulted Dr Amara from HELP to lend some psychological insight into the maternal mortality issue.

“Hospitals in rural areas are overburdened, poorly managed and lack resources, resulting in disturbingly high infant and maternal mortality rates. The typical issues that these women suffer from are postpartum haemorrhages and anaemia, as well as other complications and deficiencies.’’

Erum believes that men pressurise their wives into pregnancy largely due to insecurity, “The way one can prove their manhood is through child-bearing once they get married. It is imperative that one starts reproducing otherwise the whole clan makes it their business to pointedly ask why the new bahu (daughter-in-law) has not conceived, making sympathetic clucking noises and casting suspicious glances at the man. This can prove to be traumatic for the newly married couple.

 Women walking to a health centre in Dera Murad Jamali
Women walking to a health centre in Dera Murad Jamali

The woman bears the onus of responsibility for not only conceiving, but also ensuring that a male is produced notwithstanding the fact that it is the husband’s chromosomal uniqueness which determines the gender of the child. Women in our culture are taught to be submissive. I still remember hearing my elders discussing at the time of the IrishtaI setting ‘make sure there is an age gap and that the girl is younger, too old and she will be (heaven forbid) independent and will do as she pleases; and you know men never age it is the woman who ages faster’.

According to Erum, in-laws resort to all sorts of tactics to push their daughter-in-law into pregnancy. These tactics range from psychological such as guilt manipulation and threats of second marriages, to acts of physical violence. It is difficult for young women to resist this pressure due to a lack of empowerment and an inability to separate themselves as an individual from the family dynamic. The women who do rebel tend to use contraceptives in secrecy. Reportedly, Shumaila’s own family had been insisting that she leave her husband, but, for reasons best known to her, she did not in spite of her hardships.

Dr Noshin adds,

“Women are unable to resist the pressure of their husbands because they have nowhere to go. Due to the stigma associated with divorce, women are encouraged to stay with their husbands [who may not have their best interest at heart], rather than go back to their own families.”

Here, Erum elaborates more on the family dynamic,

“The Pakistani culture is very collectivistic and family oriented, here the group is more important than the individual. Societies which are collectivistic such as India, Bangladesh and Pakistan put a lot of value on the family paradigm. Which means the family comes first, and the value system of the family and society is of paramount importance. Where the people hold an interdependent view of the self as part of a larger network which includes one’s family, friends, neighbours, co-workers and others to whom one may be socially connected. The values and beliefs thus become set in stone, and need to be adhered to maintain equilibrium and a status quo. Independent thinking, rebellion and trying to realise one’s dreams becomes of secondary importance.”

Dr Noshin does feel that mindsets can be changed. She gives the example of a poor family that has been under her own family’s employment for generations. Although they were initially resistant to the idea of family planning, with time they have come to accept the wisdom of planned pregnancies. Dr Noshin claims the government needs to take a greater initiative in rural areas through an awareness programme that is planned well, “We have to not only educate women but their husbands as well. But you can’t expect things to change overnight. In Pakistan, politicians aren’t willing to change, so then how can we expect these rural people so set in their ways to change their thinking so quickly?”

Erum agrees that the best way to tackle the problem is through education, “The key figures in their communities, the religious scholars, need to explain the importance of having small families and of birth control. Part of the responsibility falls on their shoulders of educating the masses, and this can be done easily, when the whole city congregates in various mosques for their Friday prayers. This is an ideal platform to teach basic human rights and how to have healthier and happier families.”

name has been changed due to privacy concerns.

Channeling tradition

The traditional birth attendant, or ‘dai’ is an indispensible reality for millions of pregnant Pakistani women. What we need to do is to tap and hone their skills

By Dr.Naveed

The recently published recommendations in Lancet Every Newborn series strongly advocate ensuring the quality of care at birth. This is the time when most deaths occur and when most lives can be saved as well as long-term disabilities averted, through higher coverage of effective interventions.

However, since many decades the situation in Pakistan remains dismal. The statistics from Pakistan Demographic and Health Survey indicate that Neonatal Mortality in Pakistan is still high as out of every 1,000 live births 55 newborns die within a month of birth. Among other factors, a point of deep concern is that more than 48pc deliveries are being conducted by traditional birth attendants (TBAs).

According to the Global and National Newborn Health Indicators database (May 2014), Pakistan ranks on top for Still Birth Rate/First day Mortality Rate among South Asian countries. Despite a huge population, many key health indicators are far better in India than in Pakistan.

 Pakistan Demographic and Health Survey
Pakistan Demographic and Health Survey

The traditional birth attendant, or ‘dai’ is an indispensible reality for millions of pregnant Pakistani women. What we need to do is to tap and hone their skills.

In our country, a number of programmes and projects are being implemented to improve the overall situation of maternal, neonatal and child care. Two major programmes — the Lady Health Worker Programme (LHWP) and the National Maternal Newborn & Child Health Program (NMNCH) — claim to cover the 65pc of the population.

Community midwives (CMW) working under NMNCH programme are trained to conduct deliveries at community level but unfortunately due to multiple reasons, the programme has not been expanded yet to the level that was expected at the time of its conception.

An important task of the CMWs was to establish linkages with all the health work force working at community level but functional integration cannot yet be witnessed in the field.

Although TBAs are still considered controversial by a number of internal organisations, they probably share a significant burden of more than 47pc of deliveries being conducted by unskilled birth attendants in the rural areas.

Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality.

Since TBAs are from the rural setting, their bonding and relationship building with the rural community runs across generations.

Talk to a mother-in-law at the community level, it is not surprising to find that the TBA conducting the delivery of her daughter-in-law was actually trained by her own mother (TBA). This kind of relationship building is a key factor in convincing and attracting the families of rural areas to consult TBAs in case of emergencies .

The probability of conducting unskilled deliveries by TBAs is higher in areas which are not covered by frontline health workers.

The main reasons due to which Pakistan is not on track for achieving the UN Millennium Development Goals (MDGs) 4 & 5 are practicing multiple strategies, redesigning them repeatedly, implementing both independently and in integration resulting in a failure to achieve results as desired.

This is because the policies implemented till now have mostly been projects created and driven without considering local factors that come into play.

There is a dire need to revisit our policies and strategies and accept ground realities.

We have several evidences in South Asia and in Pakistan that the TBAs have been trained on Safe Motherhood patterns resulting in the betterment of maternal and newborn health indicators but unfortunately those models were not taken up by the government or scaled up due to the absence of any policy guidance for TBAs in our health strategy.

The rate of maternal and neonatal mortality can be lowered specially in the rural settings by improving the capacity building of TBAs through several interventions like antenatal care and identifications of danger signs during pregnancy, management of normal delivery process; detection of obstetrical complications and timely referral to the nearest health care facility and the establishment of linkages with first level health care facilities like equipping them with safe delivery kits to ensure safe motherhood.

Similarly, TBAs can be trained on simple interventions in order to decrease the infant mortality rate as well as immediate care of the newborn, promotion of early and exclusive breastfeeding, cord care, the detection of danger signs (preterm pneumonia/infection, asphyxia) and early referral of newborns to the first level health care facilities, etc. Studies have proved that the level of accessibility and acceptability of TBAs are much higher in our rural settings since they belong to the same vicinities.

The State of World Midwifery Report 2014 launched two months ago, has also endorsed the importance of TBAs and urged that “TBAs will continue to be part of service delivery models in the coming years, including in those countries where there are severe deficits in the number of professional health workers. In communities where community health workers and TBAs hold a respected position, they can influence women’s use of midwifery care and can provide basic health information about healthy pregnancy, safe birth options, newborn care, nutrition, breastfeeding support, family planning and HIV prevention. Formal and informal links between the traditional birth services in a community and professional health services can facilitate not only the effective use of available resources as well as access to quality. Such links can also open a career pathway for community workers to enter professional midwifery cadre through appropriate education programs.

The government needs to acknowledge the important role of TBAs as a ground reality in Pakistan. Without doing that, long-term planning may be impossible.

Natal neglect in Balochistan

By Igor G.Barbero

A woman dies while giving birth almost every hour in Pakistan, and many more never even reach that point, dying due to complications during pregnancy. The vast majority of these women are not being assisted by skilled health workers. This reality is even more worrisome in the province of Balochistan than in the rest of the country. Difficulties accessing healthcare facilities, a mixture of traditional customs and lack of awareness make the biggest but least populated Pakistani province a place where basic maternal health issues can develop into something very complex and often fatal.

Last year, 785 pregnant women out of 100,000 lost their lives in Balochistan. This rate is almost three times higher than the average in the whole of Pakistan. The reasons behind these appalling numbers are many: The province has some of the lowest national developmental indicators, a third of women marry before reaching the age of 15 and two thirds of women here are illiterate. Only three out of 10 pregnant women deliver their babies with skilled attendants present and less than a half of these mothers visit a health professional before their delivery. There has been little improvement in the last few decades.

The medical humanitarian organisation Doctors without Borders/Médecins Sans Frontières (MSF) runs maternal and paediatric healthcare programmes in four locations in Baluchistan (Quetta, Kuchlak, Chaman and Dera Murad Jamali), in cooperation with the local and provincial authorities. Some of the services offered are ante- and postnatal consultations, deliveries, referrals to specialised hospitals for any emergency or complicated deliveries, newborn care and resuscitation, breastfeeding promotion and nutritional support.

Cultural differences across Balochistan don’t radically change the picture. MSF supported more than 8,000 deliveries in 2013, and provided just under 20,000 antenatal consultations. The majority of these free consultations were with pregnant women who were visiting an MSF clinic for the first time. In most cases, they did not return for a second visit and a significant number of patients did not give birth at the facility. Moreover, just a third of the women who delivered at such a clinic returned for a postnatal consultation. Patients and their families often prefer to have quick deliveries with the aid of drugs, usually administered by unskilled professionals. Once the baby is born they believe the job is done. But it is not.

Doctor Cecilio Tan has been coordinating MSF’s medical projects in Balochistan province since early 2013. He explains some of the factors behind the high maternal mortality rates in the province and why maternal healthcare programmes should be a priority in Pakistan.

What is the state of the healthcare system in Balochistan?

In the cities there are tertiary hospitals (specialised) funded by the government, and private hospitals and clinics are mushrooming. These private establishments are expensive and are unaffordable for the average person living in the province. In the rural areas there may only be basic healthcare units, where patients are lucky if there is a nurse or a paramedic. A doctor or the necessary equipment may not be available

Why is the maternal mortality rate so high in this province?

Common factors are poverty and a poor literacy rate. There is also conflict and political instability in the province and the area is prone to natural disasters such as floods and earthquakes. Many people live in remote areas and women cannot access clinics for medical consultations. Moreover, the women’s nutritional health is worse than the men’s. On average, women in the province give birth to six to eight children and they very often have their first baby at the age of 16. Some women are underweight and when they become pregnant their health worsens.

What is the profile of the people who visit the healthcare facilities supported by MSF?

We assist populations from areas inhabited by different ethnic groups, as well as Afghans who cross the border seeking healthcare. Some of our patients are Afghan refugees, who settled in the area up to 20 years ago and so have essentially become part of the local community. We also see nomads, who spend the summer in Quetta and migrate to other places in winter. They are poor people and it is often difficult for our staff to communicate with them because they speak different dialects.

What are the main issues related to maternity in Balochistan?

One of the main ones is that most — eight out of 10 — women only attend the clinic once for antenatal care. This means our ability to offer follow-up care is limited. Most of the women deliver at home attended by non-trained relatives or neighbours. These unskilled birth attendants often use a medication for uterus contractions — available locally at a low price –— to make the births happen quicker. Wrongly administering this drug can lead to serious complications for both the mother and the newborn baby. In the worst cases, it can even lead to death. During emergency obstetric situations that may require further medical or surgical intervention, referrals to specialised hospital are sometimes hampered by the unavailability of male relatives to accompany the women. In this context a female patient is not allowed to travel without a male relative to accompany her, and the men (husband or other relatives) are usually busy working to support the family. The constraints posed by this are the reason why pregnant women often come to the clinic too late, when there is already a complication. It would be advisable that they visited the clinic several times during their pregnancy and for follow-up care after the birth, but this is not usually possible. If they are not at home, there is no one to look after the children, cook, fetch the water, etc. Another challenge is that there are not enough skilled female medics and health workers in the clinics and hospitals to treat the women.

What complications can happen during the birth if a trained delivery assistant is not present?

Complications can occur whether the birth is attended by trained personnel or not, but skilled staff present can save lives. There can be severe bleeding in the woman or the blood supply to the baby can be compromised. These crucial moments can really mean the difference between life and death for the mother and the baby. Skilled staff can recognise red flags and refer the patient to hospital as soon as possible, so the chances of survival increase.

As the women want to go home as soon as possible after the birth, they often choose to attend private clinics where the delivery is speeded up by injecting drugs such as oxytocin.

This can lead to severe complications for both the baby and the mother. In the facilities where we work we treat many babies who were born in private clinics and are in critical condition after having experienced a very stressful delivery.

What are MSF’s concerns after the birth?

We are trying to promote breastfeeding and highlight its importance, as sometimes babies are not given breast milk but honey, dark tea, etc. instead. This does not have nutritional value and affects their stomach. Cultural barriers make it complicated for mothers to breastfeed their babies. Many are responsible for a large household and often they already have a number of other children to care for.

Case files

Stories of success, failures and horrors from the medical front lines

Patients names have been changed and other details have been omitted to preserve the confidentiality of the cases

The pain behind the photos

When freelance photographer Sa’adia Khan travelled to Balochistan to visit and photograph a health project, this is what she saw

By Sa'adia Khan

As we headed towards Dera Murad Jamali via Sukkur and Chaman for my visit to MSF health projects; Rehmat, the driver told me that his brother has 22 children while he has just two. He further explained that it is believed that the higher the number of children that a man has earns, the more him respect he gets from his qabeela (tribe).

At the hospital, a struggle to survive awaits the new arrivals. It is hard to watch the newborn babies in the nursery struggling to take their first breath, and as one looks at them one can’t help being reminded of one’s own children. Many of the children I photographed in Dera Murad Jamali are malnourished. After the first two children are born, the mother’s milk is not as nutritious as most mothers are malnourished.

On day two of my visit to Dera Murad Jamali, a little soul departs from this world. Shaban was healthier than the others in the ward but had a respiratory condition.

Mid-week, I visited a basic healthcare unit some 20km from Dera Murad Jamali. Some of the patients here have travelled long distances for medical care. After registration, the infants and children are weighed and their height measured. A brief consultation follows that concludes with the distribution of up to week’s supply of plumpynut, a nutritional supplement paste. Mohammad Saleem is three years old, and unable to stand or walk as he is malnourished; I am told by Amna, his eight-year-old accompanying aunt who is barely able to carry him. She told me that his mother could not leave the house as the head of the family was not able to accompany her.

 Baby has just been born and is being attended to by doctors
Baby has just been born and is being attended to by doctors

In Chaman, I met women in their final trimester and some close to going into labour. Their husbands only bring them to the facility for the delivery and they have not benefitted from any antenatal care. Many babies are born within hours of the onset of labour. In the waiting area I see women dressed in the traditional burqa, huddled together, conversing at a barely audible level.

Many of the children I photographed in Dera Murad Jamali are malnourished. After the first two children are born, the mother’s milk is not as nutritious as most mothers are malnourished.

Each nursery at the Chaman project accommodates many twins and triplets, as well as a significant number of premature babies. Once the newborns are admitted to the nursery the mothers go home and an attendant is appointed. The appointed attendant is always a relative, usually the babies’ father or grandmother, who is assisted by the staff.

I do not need to look at the photographs I took to remind myself of the people I met during my time in Balochistan. Each and every face is imprinted on my heart.

Sa’adia Khan is a freelance photographer. She visited MSF’s projects in Balochistan in March and April of this year.

Published in Dawn, Sunday Magazine, September 14th, 2014