THERE is finally some good news for Prime Minister Imran Khan and all those who care about saving every mother’s life. According to the State of World Population 2019 report released on April 29, Pakistan’ s maternal mortality rate may be down today at 178 per 100,000 — compared to 276 10 years ago, and 375 per 100,000 births in 1995. This is no small achievement and demonstrates that when policymakers and health practitioners make up their minds about a priority, change can happen in a relatively short period. What seemed immovable — women delivering in homes and not healthcare institutions — may in fact have turned around in the last decade. The default now, if women and families can afford it, is to deliver in institutions.
Today, as the world celebrates Mother’s Day, spending millions of dollars on cards, gifts, and flowers, it is worth reflecting on our values regarding women’s lives. Twenty-five years ago, Dr Sadiqua Jafarey, a leading professor of gynecology and obstetrics, conducted her seminal research on ‘mothers brought in dead’ from within a 10-kilometre radius at the Jinnah Hospital, Karachi. The study chilled many, exposing the large numbers of pregnant women dying simply because transport and money could not be arranged in time, and laying bare the truth about how cheap these mothers’ lives were held.
The National Committee on Maternal Health was founded in 1994. And in 2007, for the first time, a national maternal mortality survey was launched to assess rates of death and causes through verbal autopsies. Twenty-five years on, the considerable attention to maternal health has paid off: skilled birth attendance during delivery has almost doubled from 39 per cent to 69pc.
But does this good news mean that we as a nation have become more caring towards our mothers? Have we finally lived up to the idea that paradise lies beneath the feet of our mothers? Or is it a case of business interests coinciding with value changes at home? Notably, Balochistan, where maternal mortality is highest, has experienced the least progress: skilled birth attendance is still in the 36pc range. This is not unrelated to the less-developed private sector there.
On Mother’s Day, it is worth reflecting on our values regarding women’s lives.
Whether business or improved values have driven it, the change is positive. More money is being spent on maternal care, and there are large increases in antenatal visits and institutional deliveries. Our only hope, and worry, is that women should not be drawn into institutions only to receive poor quality of care, ie unnecessarily face infections, Caesarean sections, and other related risks. It is worth noting that in an in-depth maternal mortality study in 2014–15, the Population Council found that most maternal deaths in Punjab and KP were occurring because mothers in life-threatening health conditions were being shifted from one ill-equipped facility to another, resulting in the death of many on the way or upon arrival at the last referred hospital.
And it is also important to remember that one of the major factors in maternal deaths, apart from skilled deliveries, is the number of pregnancies and deliveries women undergo and the associated health risks. If we do not care about the millions of unwanted pregnancies in Pakistan, we will continue to see women dying or suffering from lifelong ill health brought on by complications resulting from repeated pregnancies. Unfortunately, it will not be possible after a certain point to reduce maternal mortality without bringing down fertility rates.
While lowering fertility, at least to eliminate unwanted pregnancies, seems common sense and makes policy sense too, it remains one of the hardest issues to tackle in this country. Pakistan continues to have the highest fertility rates in Asia, with women having almost one child on average in excess of their desires. The unmet need for family planning remains high, largely due to the reluctance of a health sector that is open for business to do institutional deliveries but offers a closed shop for family planning advice, information and services. Is this negligence, apathy, or a value-laden reaction against the use of contraception? The answer lies in all three reasons, but the apathy is inexcusable. We cannot expect to reduce the risk of maternal deaths without expanding access to family planning and reducing unwanted pregnancies.
There is another related question we must ask ourselves on Mother’s Day, because the answer reveals much about our values. Do we exalt only motherhood and mothers, or is there also a place in our hearts for the well-being of girls and women in other situations? To understand the urgency of this question, we need only turn to the alarming statistics emanating out of the Pakistan Demographic and Health Survey 2017-2018, which show that one out of four women experience violence in marriage, and even more worryingly, over 41pc say they think the violence was justified due to a fairly trivial set of reasons, like making an error in cooking or stepping out without the husband’s permission.
And these figures are for violence within marriage; they do not consider the violence women experience in other situations at home, or outside and at the workplace — the latter is a key factor in the low participation of women in employment. Clearly, Pakistanis need to care more for women, not just as mothers but for the value they bring in every capacity — to each home, to each family, and to society.
We must act on changing the very foundation of how we regard the rights of women and children. Every young girl married while she is a mere child, every woman who experiences an unwanted or mistimed pregnancy, every girl denied education or a chance to work outside the home due to fear of violence, and all those women and girls who face violence directly in the home and outside ought to be of as much concern as each valuable maternal life saved. Any society that does not pay attention to these aspects of human life is one deserving of pity.
The writer is country director of the Population Council in Pakistan.
Published in Dawn, May 12th, 2019