A midwife plays a crucial role in making women aware about their reproductive health. She looks after a pregnant woman and her baby throughout the antenatal period, during child birth and also gives postnatal care. She also provides psychological assistance and helps the mother in family planning. Because of continuous interaction, the relationship between a midwife and a mother is more intimate than the relationship of any other person involved in the maternity care process.
Research has shown that women who have access to a midwife experience fewer pre-term births, fewer interventions during labour, and shorter hospital stays. The absence of trained midwives in Pakistan, moreover, is leading to maternal morbidity that results in infertility, chronic pelvic diseases and psychological disorders.
The United Agency for Population stated in the ‘State of World Population Report 2017’ that globally 28 percent or 127 babies per 100,000 live births die. In Pakistan, according to the Population Council — an international non-profit, non-government organisation — nearly 8.6 million women become pregnant, of which 1.2 million or 15 percent face obstetric complications.
According to the World Bank, Pakistan’s Maternal Mortality Ratio, a modelled estimate, is 178 per 100,000 live births. If we assess this figure province-wise, the situation becomes very alarming. According to the Punjab Health Department’s Annual Health Report 2013-14, Punjab alone suffers 227 maternal deaths per 100,000 live births.
This raises questions about the quality of obstetric healthcare services that are provided at the facility level. It also points towards the lack of a functional referral system at the district level. In the overall assessment, Pakistan is not spending enough on its primary healthcare services.
Child-birth has increasingly become a medical event leading to unnecessary medical interventions, like too many Caesarean Sections. These can cause severe infection, haemorrhaging, and organ damage. Research has also shown that most maternal deaths occur due to haemorrhage and pregnancy-induced hypertension.
Infection is the second most common killer of newborns. These infections can be transferred either from a mother to her child or because of an unhygienic environment
Similarly, infection is the second most common killer of newborns. These infections could be either transferred from a mother to her child or because of an unhygienic environment. Though no correlation is found between C-Section rates higher than 10 percent and maternal or newborn mortality rates, many countries including Brazil, Pakistan and India have seen the rate of C-Sections rise to 30 percent. This dilemma could be attributed to the declining culture of natural birth.
Midwives have for years played a supportive role. In a country like Pakistan, where 70 percent of the population is still rural, the availability of a qualified midwife becomes crucial. The situation is worse in places like Khyber Pakhtunkhwa and FATA. Midwives are required to be trained in these regions so that they can provide 90 percent of the healthcare at grassroots level.
According to the Pakistan Demographic and Health Survey of 2013-14, 32 percent women in urban areas and 60 percent in rural areas give birth at home. All of these births are not assisted by skilled attendants which leads to complications. Most midwives attending birth at home are the Traditional Birth Attendants (TBA) who are neither trained nor skilled. Due to their unhygienic practices and their lack of knowledge, complications usually arise. They are thus a dangerous option and a cause of high maternal mortality and morbidity.
According to Dr Asad Hafeez, DG Maternal Health, Pakistan needs more than half a million midwives to meet its present healthcare needs. He also said that Pakistan lacks the infrastructure such as colleges and schools required to train midwives. He believes that with the current setup, Pakistan cannot produce enough midwives in the coming 15 years. This challenge can be overcome by increasing the existing number of schools for midwives and raising the standards of midwifery and nursing.
Leading Gynaecologist Professor Sadiqua Jaffery said in a press conference marking World Midwifery Day in Karachi, “Midwives are playing an important role in developed countries in safe motherhood programs. It is important to replicate these programs to improve maternal and neonatal care in Pakistan.”
According to research conducted by the Pakistan National Forum on Women’s Health, at least 200,000 competent skilled midwives were needed in basic health units, rural health centres, taluka headquarters hospitals and tertiary care hospitals in the more than 85,000 villages in the country.
Founding President of the Midwifery Association of Pakistan, Imtiaz Kamal has been quoted in the media saying that midwives were paid dismally low salaries, and faced a hostile environment because doctors and medical students were reluctant to make them a part of their teams.
“We believe that by trusting, promoting and training skilled midwives, Pakistan will be able to achieve Sustainable Development Goals like other countries,” she observed.
Cognisant of the above quality gaps in midwifery, the Punjab Healthcare Commission (PHC) is undertaking measures that aim to bridge these gaps. The PHC has developed Minimum Service Delivery Standards for midwifery centres and other establishments that provide mother and child healthcare, and family welfare services. Once approved by the concerned authorities, the standards will be shared with all relevant category-III healthcare establishments in Punjab.
In order to fulfil its broad mandate of regulating healthcare service delivery across all types and kinds of healthcare establishments in Punjab, the PHC has categorised healthcare establishments into three broad categories that utilise bed strength as an indicator of the level of services offered. Midwifery centres, along with clinics of general practitioners, radiological and imaging diagnostic centres and other establishments offering outpatient care, have been categorised as category-III establishments.
The PHC’s efforts will go a long way in improving the quality of life for conceiving mothers and their newborns. The PHC looks forward to seeing Punjab’s healthcare establishments taking midwifery seriously, so the country has healthy women who can bring up secure and strong families.
The writer is a journalist and can be reached at [email protected]
Published in Daily Times, May 27th 2018.