A BACKDROP to this column appeared in my last op-ed article (‘Pregnant, before the flood’) published on these pages on Oct 7.
The vulnerable need affirmative action during emergencies. Women and children are rescued first in the face of a calamity. A poor pregnant woman from a remote village in Sindh or Balochistan, with her house and everything washed away, cattle, crops and seeds gone, no foreseeable income, huddled in a camp dormitory (a tent is a privilege), worried about her three young children, one of whom is quite sick, a depressed husband and constantly worrying about food, the approaching winter and the future of her family — she is pale due to anaemia and often feels dizzy when she gets up due to low haemoglobin.
She is one of 650,000 pregnant women in the flood-hit areas and one of the 128,000 pregnant women who need immediate assistance as 42,000 of them would be giving birth in three months. These numbers are taken from an official statement by UNFPA’s executive director, Dr Natalia Kanem, issued on Sept 2. There is a simple statistical formula applied to know the probable number of pregnancies from which the probable number of deliveries can also be calculated. Usually, 15 per cent of pregnancies are high-risk, requiring special care. The National Flood Response Coordination Centre is also now providing district-specific estimated maternal health indicators. Estimated, as in Pakistan we do not have real numbers because of the lack of a digitalised real-time health information system.
With widespread waterborne diseases, skin diseases, other new and existing diseases, a “worrying upsurge in deadly cholera”, and according to WHO, being “on the verge of a public health disaster”, it is likely that the acuteness of the public health emergency situation would not prioritise the needs of the pregnant women.
Usually, 15pc of pregnancies are high-risk, requiring special care.
When last time I travelled between Sukkur and Dera Jamali with an ocean of water on both sides of the road and hordes of people in various kinds of makeshift shelters with sporadic proper tents, I was impressed by the footfall of the Alkhidmat Foundation all over the place. The sister organisation Alkhidmat Health Foundation (AHF) was present with their fixed and mobile medical camps. I wrote about the images and the impressions I gathered during that visit in my column ‘Flood notes’ published in this space on Sept 9.
On my return to Islamabad, I reached out to the chairman of the AHF, Dr Hafeez Ur Rehman (I had never met him before) and raised the issue of pregnant women in the floods and the need to establish a special programme for pregnant women in need of care in the flood-affected areas.
He immediately agreed to the idea and in three days convened a planning meeting in Peshawar where obstetric and gynaecology experts and public health practitioners met and came up with an ‘Action Plan for Taking Care of Pregnant Women & Newborns in Flood Affected Areas’. For the last few weeks, it is being implemented in full swing.
Read: How millions of women are being let down by flood relief efforts in Pakistan
The salient features of the action plan include: identification and registration of pregnant women in seven districts of Sindh and three districts of Balochistan (to begin with); determination of their stage of pregnancy and ensuring timely remaining antenatal visits in accordance with WHO recommendations; the supply of iron and folic acid; planning the births at the facility; special planning of high-risk pregnancies; arrangements with public and private hospitals in nearby cities in the case of caesarean delivery; perinatal care; provision of various kits at different stages of pregnancy and delivery.
With impressive speed, the AHF team on the ground has been able to set up this special programme nested within their general healthcare operation. Wisely, an advisory board has also been set up for fortnightly review and guidance. A few development and academic partners have joined in the effort.
Early in the discussions, an important issue was raised by Dr Sadia Malick, an accomplished and committed obstetrician and gynaecologist currently based in the UAE, and part of the advisory board of this initiative: post-partum haemorrhage (PPH) is the top reason (above 40pc) for maternal mortality in Pakistan during labour and non-availability of heat-stable carbetocin in Pakistan.
The current standard medicine used for preventing PPH is oxytocin injection and it requires strict cold chain maintenance between two degrees Celsius to 8˚C. If it is not kept refrigerated it loses its efficacy. A carbetocin injection is a great improvement on oxytocin as it does not require a cold chain and can be kept at 30˚C for three years. In Pakistan, as in many other low- and middle-income countries, the cold chain is not maintained for oxytocin, and hence the injection cannot control PPH. Carbetocin is also relatively long-acting and more effective than oxytocin. This medicine is available in more than 30 countries now but it is still not available in Pakistan as nobody has applied for market authorisation to the Drug Regulatory Authority of Pakistan. Since this issue was raised in the context of the AHF project, efforts are now being made to make available this medicine in Pakistan and hopefully soon it will be available as a donation is being worked out from the originator company in Switzerland after obtaining a no-objection certificate from Drap.
Since the beginning of this project undertaken by the AHF, 910 pregnant women had been identified and registered till day before yesterday and their pregnancies are now being taken care of and will be seen through by ensuring safe childbirths and newborn care. Eight babies have already been safely delivered. These numbers may sound small but the team involved is now committed to enlarging the scope of this work even after this emergency and turn it into a national movement for safe motherhood and childcare especially for the poor and vulnerable who cannot afford and need such care the most. Thank you, AHF!
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.
Published in Dawn, October 21st, 2022