ISLAMABAD, Sept 23: About two-third of pregnant women in Pakistan receive no prenatal care, more than 80 per cent of births occur at home, usually attended by untrained birth attendants , as the country's maternal mortality ratio (MMR) ranges between 300 and 700 per 100,000 live births, says a UN report.

Major causes of maternal mortality are similar to those in other developing countries, like postpartum haemorrhage, toxemia of pregnancy, obstructed labour and puerperal sepsis, says the Pakistan Population Assessment 2003, recently released by the United Nations Population Fund.

It says one-sixth of all pregnancies in Pakistan are complicated and that 10 per cent of pregnant women develop obstetric complications requiring medical intervention. "Unfortunately, data on the prevalence and determinants of hospital-based information suggest high prevalence of anaemia, prolapse uterus, genital fistula, rapture of the uterus and puerperal psychosis," it says.

The 15-day Dai Training Programme, which was developed and imparted in rural areas, had trained 53,000 traditional birth attendants in safe delivery care and early recognition and referral of cases with common obstetric danger signs.

Similarly, during 1992-1999, the family health project in Sindh again trained about 650 birth attendants in ten districts. The report, however, says there is no evidence that the training programmes have worked to reduce maternal mortality. The main cause of the failure was the unavailability of follow-up supervision or support system for birth attendants.

"The only alternative to traditional birth attendants is trained community midwives. In 1996-97, there were about 21,304 trained midwives (including nurses). Although most district hospitals have midwifery schools attached to them, their quality of tutors, training and, therefore, the quality of product is not of standard."

The total fertility rate for Pakistan was recorded at 6.2 in 1970-75 and 5.4 in 1986-91. The average rate for the last four years has been estimated to be 4.8. However, fertility is higher in the rural areas (5.7), in Balochistan 6.7 and among uneducated women it is 6.

Pakistan has an estimated 33 million women of reproductive age. Each year, about 5.4 million women go through pregnancy and childbirth, resulting in 4.5 million new births.

Unfortunately, the report says, there is now reliable national MMR figure available in Pakistan. Hospital-based studies over- or underestimate the MMR depending on the population they serve.

Government health services consisted of fixed facilities providing curative care. Emergency obstetric care is available only in district or tehsil hospitals that are difficult to access for majority of rural women.

Basic health units or rural health centres provide prenatal care or family planning, the quality and sustainability of which is questionable. There is no organized system to provide health education or counselling to expectant mothers except for the lady health workers programme, which covers 48 per cent of rural areas.