It is a sad fact that Pakistan’s maternal and infant mortality rates are among the highest in South Asia. Pregnant women are unable to obtain quality services even at a primary care level due to the lack of properly trained and skilled healthcare workers in the community. A recently published report by Save the Children shows that 200,000 Pakistani newborns die each year, either during childbirth or on their first day of life. This rate, globally the highest, makes Pakistan one of the most dangerous places in the world to be a mother or baby. With regard to the maternal mortality ratio (MMR), Pakistan lags behind its neighbours in its Millennium Development Goal (MDG) commitments; maternal mortality in Bangladesh stands at 240, India 200, Nepal 170, Bhutan 180, Iran 21 and Indonesia 220. In Pakistan, it is 260 deaths/100,000 live births, as reported by the World Health Organisation (WHO) in 2010. Maternal health problems are further compounded by the dearth of skilled healthcare providers such as skilled birth attendants. Other crucial factors that prevent women in Pakistan from seeking healthcare include distance from health services, cost (direct provider’s fee as well as the cost of transportation), and women’s lack of decision-making power within the family. The poor quality of service significantly impacts the decision making of pregnant women also. Many social, environmental and policy matters also account for the high numbers of deaths among women and children. The widespread lack of education prevents people from making informed decisions about pregnancy issues and maternal and child health issues.
Other contributing factors that delay seeking help are cultural factors like unavailability of male members for accompaniment to the health facility or hesitancy to go to hospital without attendance or permission from in-laws. This is of major concern for a country like Pakistan which is the sixth most populous in the world, especially with its very high morbidity and mortality rates for children and mothers. The lack of a health infrastructure lies at the core of the problem, and there have been very few attempts by preceding governments to create new facilities, particularly in underserved locations. Established hospitals are overcrowded, leading to poor or inadequate quality of care. The lack of education among the medical staff is another factor. The goal of Pakistan’s Maternal, Newborn, and Child Health Programme, established in 2005 by the government of Pakistan, was to reduce the MMR to 140 maternal deaths per 100,000 live births by 2015 (Planning Commission, 2010) by providing adequate training to a new cadre of community midwives. The MMR in Pakistan stands at 260 maternal deaths per 100,000 live births, indicating the dire need to take immediate steps in improving reproductive health care and promoting women’s rights.
The importance of maternal health was recognised by the International Conference on Safe Motherhood held in 1987 and revisited at the International Conference on Population and Development (ICPD) conference in Cairo and in the Millennium Development Goals. The International Conference on Safe Motherhood included a declaration targeting a reduction in maternal mortality by at least half by the year 2000, while the ICPD targeted a reduction in maternal mortality to one-half of the 1990 levels by 2000 and a further one-half reduction by 2015. Unfortunately many developing countries, including Pakistan, are not on track to achieve these targets. Current statistics suggest that Pakistan is unlikely to meet the MDG targets set for maternal and child health by 2015. A study by the Population Council in 2012 indicated that nearly 700,000 women in Pakistan went to health facilities for treatment of post-abortion complications. These complications resulted from unsafe and poor quality of care offered to women by unskilled providers who manage the abortions. The study shows that many facilities do not have adequate equipment and supplies to provide quality care for complications and a majority are not equipped to provide round-the-clock services to manage severe complications. A nationwide study conducted by the Council estimated that 900,000 unsafe abortions took place in 2002. The Population Council research also indicates that 70 out of 100 women want to space or limit their children but only 35 out of 100 women are currently using any method, 34 out of 100 women are at risk of an unwanted pregnancy and this leads to three million unintended pregnancies that lead to almost 1.7 million abortions a year.
Since every third pregnancy in Pakistan is unplanned, many people continue having children without giving much thought to the requirements of raising another child that can become a healthy and productive adult and contribute to the development of the country socially and economically. This is what has been termed in many places as reaping the demographic dividend. Yet, there is a lingering aversion to the use of contraceptives. Women worry that their husbands disapprove of contraception, there is fear of detrimental health side effects of using contraception and concerns about the social, cultural and religious acceptability of using contraception exist. Even couples who want to have fewer children lack access to family planning advice. This unmet need also causes unplanned pregnancies, many of which end in unsafe abortions and maternal deaths. According to the Population Council, women who opt for abortions are married with four or more children and have exhausted their economic potential to produce more children. For them, abortion seems to be a better family planning method than using effective contraception. Increased contraceptive use could reduce the number of unsafely performed abortions and resultant deaths. Since 1998, there has been no census in Pakistan. Additionally it is unfortunate that the routinely collected information and research evidence that is available seldom makes its way into policy development and setting programme directions. What we need now is that at the federal level, the Ministries of Planning and Development and National Health Services sit together and come up with an overarching, broad and evidence-based strategically focused National Population and Development Policy that outlines guiding principles to address the issues of growing population and its associated effects. At the provincial level, the departments of health and population welfare and allied departments must develop provincial policies that they have been unable to produce and they must make these policies more attuned to ground realities. The policies should be focused on people rather than on figures and statistics, thus valuing and emphasising choice, social values, human rights and gender equality.
To conclude this discussion, I would say that access to quality health care is an urgent need in Pakistan, especially for new mothers and children under five. To help meet this need, Pakistan should work with public and private sector institutions and civil society organisations to improve basic healthcare services, develop innovative service delivery networks, and promote healthy behaviours. Efforts must focus on activities that safeguard mothers and children’s health, promote family planning and the healthy spacing of births, and strengthen provincial health care systems.
The writer is associated with the health and development sector and can be reached at [email protected]