“Mankind has reached the moon, and it’s beyond tragic that here, we are unable to transport a woman going through labour from her home to the nearest public hospital,” lamented Dr Halima Yasmeen, head of the gynaecology department at Karachi’s Jinnah Postgraduate Medical Centre (JPMC), a tertiary healthcare facility.
She was referring to the death of a woman in need of emergency obstetric care, who was stuck in a traffic jam for over four hours. “She reached us in a moribund state … we tried our best to save her but failed,” she said. It was not the first time, and will not be the last, she added quietly.
In the last 20 years, Dr Yasmeen has seen numerous such deaths at very close quarters. “One never gets used to it … it hurts every time, more so because many of these deaths could have been prevented,” she said.
Pakistan may have brought down its maternal mortality rate (MMR) significantly, from 276 deaths per 100,000 live births to 186, according to the Pakistan Demographic and Health Survey (2017-18), but it is still too high.
Pakistan has committed to bringing its MMR to less than 70 by 2030, being a signatory to the Sustainable Development Goals (SDGs) 2015–2030.
But will it be able to?
“It’s highly unlikely,” said Dr Azra Ahsan, president of the Karachi-based non-profit, Association of Mother and Newborns (AMAN). “Nothing is right!” she remarked.
Ailing healthcare system
Although 71 per cent of Pakistani women are delivering babies at healthcare facilities (HCF), mothers are dying while giving birth because of underage marriages and delays in either seeking help for an obstetric emergency or in reaching an obstetric facility.
“Women in Pakistan are caught between the devil and the deep blue sea,” said Dr Ahsan. “They are at the mercy of quacks and dais (unskilled birth attendants) and poorly trained healthcare practitioners if they remain close to home … if they travel to a hospital, poor quality of services awaits them there,” she said.
It is indeed a sad reflection of how society regards women and children.
“Incompetence of healthcare providers, unwillingness to put in their 100pc, poor quality of after care, inadequate medical supplies and the non-existent monitoring of healthcare providers,” are some of the glaring reasons why mothers die even after they reach a healthcare facility, said Dr Ahsan.
Dr Sadiqa Jafarey, president of the National Committee for Maternal and Neonatal Health (NMNCH), echoed Dr Ahsan’s assessment. “…many maternal deaths were occurring because mothers in life-threatening health conditions were being shifted from one ill-equipped facility to another, resulting in many deaths occurring on the way or upon arrival at the last referred hospital,” she wrote in her foreword of a recent in-depth analysis of the Pakistan Maternal Mortality Survey (PMMS) 2019.
In addition, the “low status of women, detrimental cultural norms and practices that restrict their mobility and access to services, lack of education and information that constrain recognition of danger signs and care, fatalism, long distance and unaffordable cost to facilities, substandard care at the facility due to lack of supplies, proper skills and training and, sometimes, provider apathy towards patients,” are some of the reasons why mothers continue to die, said Dr Iqbal Shah, research collaborator at the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, who is also one of the authors of the study.
The findings of the research, supported by the United Nations Population Fund, the World Health Organisation and the Population Council, and carried out in collaboration with Population Centre Pakistan, the NCMNH and the National Institute of Population Studies (NIPS), were released last month, having taken a deep dive into how societal and medical inequities continue to sap the life out of mothers.
The one key theme that the study found in the majority of deaths was that they occurred due to poor quality and substandard obstetric care, with one in three maternal deaths occurring due to surgical or medical “misadventures” at public hospitals, private clinics or by skilled attendants.
“Women were neglected, sent away or provided inappropriate substandard care, supplies were unavailable, and there was no accountability or transparency,” states the study.
When family planning does not figure, mothers die
Apart from deaths due to poor quality of health facilities and untrained and incompetent birth attendants, Dr Jafarey also pointed to the back-to-back pregnancies women go through that depletes them of nutrients and does not give them time to recover. Low use of contraceptives was another factor.
“A few months back, a woman came to our facility for delivery … she already had 14 kids. We tried out best to convince her to adopt a family planning method but the couple left without any,” said Dr Yasmeen.
“If we do not address millions of unwanted pregnancies that occur in Pakistan each year, we will continue to see women dying or suffering from lifelong ill health brought on by complications resulting from repeated pregnancies with short intervals in between,” Dr Jafarey wrote, adding: “It is not possible to reduce maternal mortality without bringing down fertility rates”.
On November 15, the planet will have eight billion humans. Globally, the population growth has slowed, having fallen under 1pc in 2020. In Pakistan, with a population of 225m people, it stands at 1.91pc and at least 5.2m people are added every year. Women are having at least one child more than they like.
The country’s fertility rate [the number of babies born to a woman during her reproductive cycle of ages between 15 and 49] is 3.6 births per woman according to the PDHS 2017-18. Even Saudi Arabia’s is lower at 2.34.
Furthermore, Pakistan has a contraceptive prevalence rate (CPR) — the proportion of women of reproductive age or their partners who are using a contraceptive method at a given point in time — of just 34.2pc, which is far behind other South Asian countries, although it has committed to increasing it to 60pc.
One of the main reasons for the low CPR, said Dr Iqbal Shah, is the low priority accorded to family planning by successive governments. Moreover, the devolution of healthcare to provinces further slowed the progress as different provinces allocated funding to family planning differently.
Besides, there are various other reasons such as inadequate information and counselling provided to women either during home visits by lady health workers or during contacts with healthcare facilities at antenatal care (ANC), postnatal, immunisation or other visits, lack of mass media engagement to disseminate information and generate demand for family planning, as well as the culturally low status of women — lack of education and limited or no decision-making power.
The key to saving lives
While all experts have stressed on the lack of quality care at all levels of healthcare facilities as the reason for the mother’s death, what does this translate into?
Per the study, what is required at a bare minimum is a “regulated health[care] system with trained and accredited healthcare providers who perform their duties in an ethical manner, 24/7 available childbirth care, essential equipment and supplies for providing comprehensive emergency obstetric and newborn care, referral level care by health facilities and ensuring availability of staff at all levels can significantly reduce maternal deaths and enhance the quality of care”.
“The government has set up healthcare commissions that are supposed to carry out rigorous monitoring of facilities, but this remains only on paper,” lamented Dr Yasmeen. Pilferage, looking the other way, stock of medicines finishing without being replenished, incompetence of support staff but no one keeping a tab on them and unwillingness to work are some of the problems that she wanted the commissions to look into.
Yet, of all the problems, if only the referral linkage was strengthened and transport made available, many mothers would make it out alive. “The primary care facilities are supposed to close at 1pm. But we get patients as early as 12:15pm,” said Dr Yasmeen.
According to her, secondary care seems missing from the picture altogether. Instead of the primary healthcare centres taking some pressure, they just refer all patients to tertiary care, which should only be paying attention to mothers with high-risk pregnancies.
The study recommends a system where secondary and primary healthcare centres operating in the catchment area of a particular tertiary hospital come under it. The latter can develop a rotation system where trained residents, under direct supervision of their supervisors, work in these healthcare facilities and improve maternal and neonatal care.
According to Dr Yasmeen, it is important to develop a system where individuals are assessed periodically with promotions dependent on competency, not years of service. The study also recommended providing “opportunities for refresher trainings, mentoring and handholding”, besides conducting emergency drills and appreciating well-performing units appreciated.
The Covid-19 pandemic as well as the recent floods in Pakistan laid bare the dire need for a robust healthcare system, with stringent quality checks in place. The situation has become even more dire, with over 600,000 pregnant women displaced by the floods whose access to traditional birth attendants as well as healthcare centres near their homes has been cut off.
Unless the actions recommended by the study are taken swiftly and across the board, mothers in Pakistan will continue to die due to complications arising during or after childbirth. The irony is that the fix isn’t too complicated — the recommendations listed in the study are hardly rocket science and are already part of established healthcare protocols in most countries.
The question remains: Will Pakistan’s mothers be given the priority they deserve?
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