An anatomy of women, children’s healthcare in Pakistan

In addition to shortage of facilities, attitudes also need to be changed for adequate healthcare of mothers and their newborns

By Muhammad Shahid

PESHAWAR, Pakistan, August 20, 2020: Life took a bad turn for Ahmed Khan when he decided, unwillingly, to treat his expectant wife at home, instead of taking her to a hospital.

He once consulted his mother to take his wife to a clinic of a gynaecologist. However, because of his mother’s advice and social pressure, he called a midwife home to handle the delivery case of his wife. Ahmed says cannot forget a healthy daughter that he lost soon after birth years ago.

The sexagenarian Ahmed (a pseudonym as he requested anonymity) recalls how he had made a tough decision while fighting his own conscience and bowing to his mother’s demand when his wife was going to deliver a baby.

“Decades ago, I requested my mother to let me take my wife to a lady doctor as she was going to deliver the first baby,” he recalls, but his mother said there was no issue at home and no need to take her to a health facility.

Ahmed Khan says he had to bow to his mother’s insistence, and called a midwife, an acquaintance, to his home.

“My wife gave birth to a baby girl who had sound weight and health; she was my first daughter. But she expired moments after birth because the midwife said she did not have all the required facilities necessary for delivery cases in the home,” he says.

He says he faced more anxiety and mental agonies when his wife suffered a miscarriage several years after losing their first baby, and this time lost twins, a son and daughter. After a long time, however, God bestowed the couple with a daughter and a son who are now of school going age.

The story is one of the thousands due to our society’s general attitude problem as a whole, because there have been instances in which a woman even hands money to her son-in-law to take her daughter for regular check-up by a gynaecologist but refuses the same facility to her own daughter-in-law in her home.

There are sometimes issues in a family, particularly the relations between the mother-in-law and daughter-in-law. Ms Bint-e-Hawa (not real name for anonymity) gets married and starts living happily before she falls victim to the syndrome of daughter-in-law versus mother-in-law bickering, which has been a ‘custom’ in most of Pakistani families.

Bint-e-Hawa, an orphan, was quite healthy before wedding. After marriage, dark circles appeared under her eyes and she became more silent with the passage of time at her in-laws’ home.

She got pregnant after marriage, but she lost her first baby in miscarriage as she complained she was subjected to all domestic chores at home.

A sister of Bint-e-Hawa’s husband would not work at all and Bint-e-Hawa was supposed to do all the household chores at home. A strange thing is that mother-in-law of Bint-e-Hawawould take extreme care of her own daughter as she would even pay her son-in-law for proper treatment of her pregnant daughter.

Like Bint-e-Hawa, there are many others facing a similar situation inside homes, particularly in rural areas. There was a time when people had little facilities. Though the health facilities are increasing with the passage of time, changing the attitudes in society still remains a challenge, resulting in a high maternal and infant mortality rates.

Maternal and infant mortality in Pakistan’s KP province:

The District Health Information System of Khyber Pakhtunkhwa, a province of Pakistan, has reported that 321 women have died during pregnancy or deliveries in the year 2019, with maternal mortality rate of 132 per 100,000 population.

Among other districts of Khyber Pakhtunkhwa, 11 maternal deaths have been reported from Peshawar, five from Swabi, eight from Abbottabad, five from Haripur, six from Mansehra, two each from Bannu, Lakki Marwat and Kohat, four from Nowshera, nine from Swat, and one each from Shangla, Upper Dir, Buner, Chitral, Malakand and DI Khan.

Similarly, a total of 8179 infants have died in the first four weeks of life across Khyber Pakhtunkhwa province during the year 2019. Of the total infant mortality reported during the first quarter of 2016, 129 kids have died in Swabi, 155 in Mansehra, 51 in Kohat, 143 in Abbottabad, 22 in Karak, 92 in Haripur, 47 in DI Khan, 31 in Chitral, 152 in Mardan, 39 in Malakand, 16 in Buner, 75 in Peshawar, 16 in Lower Dir, 49 in Nowshera, 107 in Swat, 10 in Tank, eight in Upper Dir, four in Battagram, five in Shangla, five in Lakki Marwat, 17 in Charsadda, 11 in Bannuand one in Hangu.

Cash incentive for mothers:

An official from the Maternal, Newborn and Child Health (MNCH) Programme in Khyber Pakhtunkhwa province of Pakistan, Dr Sahib Gul, says the authorities have been taking measures to bring down the maternal and child mortality rates in the province.

He said the Khyber Pakhtunkhwa government has made history by starting cash incentives for mothers delivering babies at health facilities. “In order to attract more people to use health facilities for deliveries and avoid deliveries at homes, now the provincial government pays Rs2,700 to a mother delivering baby at a health facility. This cash incentive for mothers is only provided in KP, not any other province of Pakistan,” he added.

He also said the cash incentive is not provided at teaching hospitals, but the rule is applied in all other health facilities. He said they had conducted several media campaigns to encourage people to use health facilities for deliveries, and one such campaign would be launched in near future.

Dr Iqbal Begum, a former head of Gynae Department at the Hayatabad Medical Complex, said that a normal delivery can be handled by a trained health worker at home, but other cases need to be taken to health facilities.

“A woman should use health facilities for delivery cases in order to have timely information if they have any disease during pregnancy and childbearing period,” she added.

The Journal of Pakistan Medical Association has also stated in a research that there are many families who still choose to deliver at homes and home deliveries pose a high risk of maternal mortality. The association says that family tradition and poor socioeconomic condition appear to be the main factor behind opting for deliveries at homes.

The study recommends that in order to make home deliveries safer, they should be conducted by trained midwives, who can conduct delivery in a clean and hygienic manner, prevent and recognise Postpartum Hemorrhage (PPH) and can refer the patient promptly to a hospital with emergency obstetric care facilities, in case of complications.

Obstetric fistula:

Another issue faced by women in the country is the obstetric fistula, which is a serious disease which causes a woman social segregation. Fistula problem can be treated through a surgery procedure.

Medical experts say that fistula is a serious injury of childbirth. It is a hole in the birth canal caused by prolonged, obstructed labour due to the lack of timely and adequate medical care. In most cases, the baby is either stillborn or dies within the first week after birth, and the woman suffers a devastating injury – a fistula that renders her incontinent.

According to the Fistula Project being run at the Lady Reading Hospital Peshawar, about 80 fistula patients are received every year and more than 100 have recovered to-date since 2015. The US-based Fistula Foundation states that the birth attendance by skilled staff in Pakistan is 49 percent. It also says that so far 21 fistula surgeries have been conducted through the Foundation’s funding in Pakistan.

According to the statistics of World Health Organisation, each year 50,000 to 100,000 women worldwide are affected by obstetric fistula. It is directly linked to obstructed labour, which is one of the main causes of maternal mortality.

Women who experience obstetric fistula suffer constant incontinence, shame, social segregation and health problems. The WHO estimated that more than two million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.

The WHO noted that fistula is preventable and can be avoided by: delaying the age of first pregnancy, the cessation of harmful traditional practices, and timely access to obstetric care. The WHO declared that preventing and managing obstetric fistula contributes to the Millennium Development Goal 5 of improving maternal health.

Dr Nasreen Ruby, a gynaecologist and former head of the GynaeDepartment at Lady Reading Hospital, told this scribe that fistula sometimes remains untreated as it is considered a taboo in our society.

“I once treated a fistula patient who had been living with it for 35 long years and her surgery was successful. She was ashamed of even seeking treatment,” Dr Nasreen Ruby recalled. She pointed out that sometimes women are even divorced due to fistula as they cannot control their urination, become incontinent and cannot even pray.

“In our country, we see law and order problems and displacement of people due to militancy and military operations. In such circumstances, accessing medical facilities becomes difficult. And fistula is caused by delayed childbirth and mishandling of deliveries by untrained staff,” she added. Stressing that surgery is the only treatment of fistula, she said sometimes surgeries in severe fistula cases are unsuccessful.

Razia Shamshad, known to many as the Fistula Survivor, has a story to tell: “Helping women suffering from fistula is my mission in life. No woman deserves to live in misery, especially when it is treatable.”

“I was born with poor sight. Living in poverty, the idea of me going to school was never entertained.”

Hailing from small village in southern Punjab, Razia had little say in the decision of her marriage. Following the strict family tradition, she was married soon after she reached puberty at thirteen. Razia was expecting her first baby within a few weeks of her wedding. When she was six months pregnant, her husband tragically died in a road accident. Devastated, alone and scared, Razia looked forward to holding her baby in her arms.

Not able to afford proper medical care, Razia delivered her baby after four days of excruciating labour, with a Dai (Traditional Birth Attendant – TBA) by her side. The baby had to be pulled from her womb and serious damage was done to Razia’s body causing obstetric fistula – a hole between the birth canal and bladder and/or rectum, which it is caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. It leaves women leaking urine, faeces or both, and often leads to chronic medical problems, depression, social isolation and deepening poverty.

“I was alone with my elderly father-in-law. People would either avoid me or just make fun of me. I never felt clean.” Determined to make her life better, Razia set-off to Karachi to the KoohiGoth Women’s Hospital that specializes in treating fistula and other conditions related to reproductive health.

“With the support of UNFPA, we were able to perform a series of operations to treat Razia before she was ready to lead a normal life but her determination was exceptional. She was resilient and strong and was able to pull through the difficult process successfully.” says Dr. Sajjad Ahmed, who was trained by UNFPA to perform fistula repair surgery.

Soon after her procedures Razia met her current husband and adopted a little girl not expecting to ever have more children of her own. However, Razia surprised herself and her doctors by conceiving again. The pregnancy was normal and through regular prenatal care she was able to deliver a healthy baby girl through a C-section.

Today, Razia lives with her family in Karachi and works as a volunteer at the Koohi Goth Hospital helping with new patients and assisting in their recovery after the surgery.

“I believe life experiences shape us into the people we need to become. My experiences have given me the courage and drive to help women who have lost all hope because of fistula.” Raziatold UNFPA about her work at the hospital. She has proved to be a source of encouragement to these women, “Never give up hope,” she tells them.

There have been interventions with regards to women’s rights in Pakistan. In January 2020, the Senate, the upper house of Pakistani parliament, passed a bill that not only increases paid maternity leave of working mothers but also grants paid paternity leave, for the first time in the country, to fathers working for either private or public sector. Pakistan People’s Party (PPP) Senator Quratulain Marri moved the bill on private members’ day that was passed by the house with majority of vote while the ruling Pakistan Tehreek-e-Insaf (PTI) government opposed it.

The Maternity and Paternity Leave Bill says that employees of every establishment; any public or private organization, corporation, autonomous or semi-autonomous body, and any corporate body or enterprise; shall be provided six months paid maternity and three months paternity leave “as and when applied” by them.

On their demand, the employees shall also be provided with an additional three months optional unpaid maternity and one month paternity leave, separately from their leave account.

The bill restricts the employer not to terminate the services of an employee merely on seeking leave under the provisions of this bill. In case, the employee violates the discipline and commits misconduct including extension of the leave without prior permission of the competent authority, then employer can take disciplinary action as prescribed under the law, reads the draft bill.

Stillbirths:

Stillbirths is another issue in Pakistan. It refers to the death of an infant in mother’s womb. According to the data of District Health Information System of the KP province, 2,857 stillbirths have happened in the year 2019. It may be mentioned here that the DHIS is still working on the data of the year 2020.

According to media experts, the main reasons behind the stillbirth are child birth complications, post-term pregnancy, maternal infections in pregnancy (malaria, HIV, etc), maternal disorders like hypertension, diabetes, obesity, etc, and congenital abnormalities.

It merits a mention here that vaccination is the key to saving the lives of mothers and children. According to a research study published in the National Library of Medicine, the maternal mortality ratio (MMR) shows the standard of maternal health worldwide. In Pakistan each year over five million women become pregnant, and of these 700,000 (15% of all pregnant women) are likely to experience some obstetrical and medical complications. An estimated 30,000 women die each year from pregnancy-related causes, and the most recent estimates indicate that the MMR is 276 per 100,000 births annually. The study also drew attention to the economic and social vulnerability of pregnant women, and stressed the importance of concomitant broader strategies, including poverty reduction and women’s empowerment. Undernutrition for girls, early marriage, and high fertility rates coupled with unmet needs for contraception are important determinants of maternal ill health in Pakistan. The study also examines factors influencing the under-utilization of maternal health services among Pakistani women, such as the lack of availability of skilled care providers and poor quality services.

In August 2020, the global body UNFPA claimed that maternal mortality decreased to 186 deaths per 100,000 live births. It claimed that maternal mortality ratio (MMR) in Pakistan has decreased from 276 deaths per 100,000 live births as per Pakistan Demographic and Health Survey of 2006-7 to 186, according to the latest Pakistan Maternal Mortality Survey (PMMS). The key findings of the first exclusive nationwide survey were released at a Webinar in Islamabad organized by the National Institute of Population Studies (NIPS).

The findings highlighted that improvements in health services in the last decade and enhanced awareness and utilization of antenatal and postnatal care by women are likely to have contributed to the overall decrease in the MMR.

The maternal mortality ratio (MMR) is lowest in Punjab (157 per 100,000 live births), followed by Khyber Pakhtunkhwa (165 per 100,000 live births), Sindh (224 per 100,000 live births), and Balochistan (298 per 100,000 live births). The MMR is 104 in Azad Jammu and Kashmir, and 157 in Gilgit-Baltistan. The ratio is also 26pc higher in rural areas – 199 deaths – than urban areas – 158 deaths, according to the UNFPA.

On the occasion, United Nations Population Fund Representative Ms Lina Mousa said: “The results are encouraging and provide reliable data for policy development and programme planning for maternal and child health.”

“Though there is a decline in the maternal mortality ratio compared to 276 per 100,000 in 2006/07, Pakistan has to do more for women who are least likely to receive adequate healthcare, residing in remote areas with lower numbers of skilled birth attendants or health facilities, and strive to achieve universal maternal health coverage,” she added.

Department for International Development (DFID) Country Director Annabel Gerry said she was proud to support an important study to assess the levels of maternal mortality in Pakistan.

COVID-19 pandemic:

Meanwhile, the UNICEF has declared that the world over, around 116 million babies were expected to be born under the shadow of the COVID-19 pandemic and almost a quarter of them—approximately 29 million—were likely to be born in South Asia.

The global body said that countries in South Asia with the expected highest numbers of births in the nine months since the COVID-19 pandemic declaration are: India (20 million), Pakistan (5 million), Bangladesh (2.4 million) and Afghanistan (1 million). The continuing rapid spread of COVID-19 across South Asia means new mothers and newborns will be greeted by harsh realities, including global containment measures such as lockdowns and curfews; health centres overwhelmed with response efforts; supply and equipment shortages; and a lack of sufficient skilled birth attendants as health workers, including midwives, are redeployed to treat COVID-19 patients.

While COVID-19 containment measures are essential, UNICEF has warned that it can disrupt life-saving health services such as childbirth care, putting millions of pregnant mothers and their babies at great risk. UNICEF says that although evidence suggests that pregnant mothers are not more affected by COVID-19 than others, countries need to ensure they still have access to antenatal, delivery and postnatal services. Likewise, sick newborns need emergency services as they are at high risk of death. New families require care to ensure the health and well-being of mothers, support to start breastfeeding, and to get medicines, vaccines and nutrition to keep their babies healthy.

Muhammad Shahid is a journalist based in Peshawar, Pakistan. He tweets: @peoplefriendly