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PAKISTAN: Special report on maternal mortality

MARDAN, 30 Jul 2003 (IRIN) - At the age of 27, Bak Sitara, a resident of Paluderi village in the district of Mardan in the North West Frontier Province (NWFP), is already a mother of three, and has endured the tragedy of two stillbirths. She is now seven months pregnant, but has been bleeding every fortnight for the past four years. "I went to the chemist and he gave me some tablets, but they haven't made a difference," she told IRIN. Asked why she had not consulted a doctor, she replied: "I don't need to go to a doctor, because my illness is not that serious."

Sitara's experience is not uncommon in this village. According to a recent survey carried out in Mardan by Pakistan's National Commission for Human Development (NCHD), at least 80 percent of the population has no access to health-care facilities. The most common problem affecting pregnant women was anaemia, the deputy district coordinator for the NCHD in Mardan, Dr Sadaf Zaffar, told IRIN.


The NCHD is tackling this serious problem in the district and throughout the NWFP by way of a pilot project launched in November 2002 with the aim of reducing maternal mortality. The project will cover 200,000 people, and provide women in particular with the necessary medical assistance. The project was established following a comprehensive local study of the district.

Under the programme, Mardan has been divided into 56 units of 400 homes, each having assigned to it two trained female health workers, two female traditional birth attendants (TBAs) and one trained male health worker. One female worker together with one TBA cover the needs of 200 homes of the unit's total per month, while the other female worker and her TBA colleague deal with the remaining 200. The male worker covers all the unit's homes.

"This is the best way to work on this issue as the health worker is always available, easily accessible, it is cheap on our logistical costs and adds to the sustainability," Zaffar said.

Each female family health worker is paid 2,000 rupees (US $35) per month and each male worker 2,500 rupees. "The men educate the men of the house on the needs of pregnant women," Zaffar explained.

As well as dealing with health issues, the women educate villagers about water sanitation, and also carry out vaccinations. "It is a very systematic project and there will be rigorous monitoring," he said, adding that the women chosen to take on the task must be educated to a certain level to ensure the project's success and its ability to attain its goal of reducing maternal mortality.

"We are training local village girls, registering every pregnancy, examining each pregnant woman on a monthly basis, and have selected indicators to help identify any risk in the pregnancy," country chief for public health for the NCHD, Dr Moazim Khalil, told IRIN in the Pakistani capital, Islamabad.

The health workers are trained to identify symptoms which may harm the pregnancy by examining the feet of the pregnant woman, checking blood pressure and for weight loss and anaemia.


There are a number of factors which cause maternal mortality that can be easily avoided, according to health workers. One of the problems faced by pregnant women in Mardan is resistance from the mother-in-law to allow the expectant woman to be seen by the health workers as they are used to attending to the mother-to-be's health needs themselves within the community.

"The mother-in-law rules the house and doesn't understand why the pregnant woman should be referred to hospital as she herself had given birth at home without any medical assistance, regardless of complications or stillbirths experienced by them," a female health worker, Rahida, told IRIN in Paluderi.

"Sometimes when I try and take the blood pressure of a patient, the mother-in-law refuses to give me permission, asking why we are not checking her blood pressure too," she explained, adding that a woman would only be referred to hospital if she was fatally ill. "The women don't know anything about their rights," she said.

She explained that pregnant women put themselves at risk by continuing to do heavy daily chores such as fetching wood and water, and knew very little about personal hygiene and dietary requirements during pregnancy.


Another crucial factor fuelling maternal mortality in Pakistan is the cost of transport to the nearest hospital. With most families in the village Rahida works in earning up to 1,500 rupees per month, and the fare to the nearest facility costing about 500 rupees, most husbands refuse to pay.

Such problems are also compounded by cultural traditions. Sitara told IRIN that her movements were restricted for cultural reasons so that she could not travel without her husband, who works hundreds of kilometres away in the southern city of Karachi. But she was grateful for the help and advice from the health workers. "I have learned a lot from the health workers about what I shouldn't eat during pregnancy, and about cleanliness," she said.

The situation in Mardan is just a reflection of how serious the problem really is country-wide. There are no accurate statistics on maternal mortality in Pakistan, as a comprehensive study has never been carried out. However, the rate is estimated to be between 300 and 700 deaths for every 100,000 live births, making it one of the worst in South Asia.

According to the Pakistan Population Assessment, January 2003, compiled by the United Nations Population Fund, 5.4 million women undergo pregnancy and childbirth every year, resulting in 4.5 million new births in a population of 145 million people.

The main reasons for the high rates of maternal mortality are lack of prenatal care, of properly trained birth attendants or medical facilities, and of transport to the nearest properly equipped hospital, while almost 80 percent of births in the country occur at home.

"There is a preference in this society to have a birth attendant who can do more than just the delivery, such as massage and general help around the house, which means that they are not qualified properly. But this has been a tradition in Pakistan for generations," a project officer for women's health for the United Nations Children's Fund (UNICEF), Dr Nabila Zaka, told IRIN in Islamabad.

"The difference in having someone properly qualified is that a skilled attendant can spot complications, such as haemorrhage, early on and make referrals. So it is a matter of life and death," she stressed.


One of the best studies presenting an accurate idea of the scale of the problem was carried out between 1991 and 1993 for the Aga Khan University. For this purpose, women living in high-risk districts were chosen across the country (except in Punjab Province due to financial restrictions).

These comprised four in the southwestern province of Balochistan, eight in the NWFP along with two tribal agencies, and samples from all across the southern Sindh Province. However, only some of the findings have been released to date. The study revealed that the most shocking statistics applied to the district of Khuzdar in Balochistan, where there were 690 maternal deaths for every 100,000 live births in a population of a million people.

"We do already know that the maternal mortality rate is high and exactly where it is at its worst, but we just don't have accurate statistics," Farid Midhet, the research director at the Population Council, told IRIN in Islamabad.

Training for traditional birth attendants has been continuing over the past five years in 32 villages of Khuzdar, covering 7,000 women, and Midhet said it had resulted in a 30 percent drop in maternal mortality. "Utilisation of health services has increased by 300 percent in this district," he said.

Midhet, who was one of the key researchers for the Aga Khan University report, stressed that the problem was just as severe in urban areas. "We found that in some urban areas of Karachi, the rate was close to 300 per 100,000 live births," he said. He compared these figures to the rate in developing countries in South East Asia, where an average of between 40 and 70 deaths per 100,000 live births obtains. "Even Bangladesh, previously known for high rates, is reporting a decrease." Some 10 years back, the rate in Bangladesh stood at a shocking 800 per 100,000 live births.

Another study, carried out by Pakistan's National Institute of Population Studies (NIPS), documented maternal mortality rates between 1991 and 1992 for a reproductive health and family planning survey. The average was found to be 533 per 100,000 live births - but that figure was not released until 2001.

"The estimates they [NIPS] give are 12 years old due to the method used in the survey, and this is also not a very accurate method," Midhet said, adding that the huge expense of such studies had prevented a country-wide survey being carried out. "We recently held a meeting with all the concerned health officials and presented a plan for a survey at a cost of over one million US dollars over a three-year period, and it will at least give us a benchmark."

Midhet commented on expensive efforts made over the past 10 years to reduce the maternal mortality rate, but says they have had very little effect.


Over a 10-year period between the 1970s and 1980s some 53,000 TBAs were trained by UNICEF and the government under the safe motherhood project. Each was paid US $0.90 for attending the training. "The big question is who exactly were these TBAs? They could have been housewives pretending to be TBAs, and there was no way of checking or following up, so it was a big waste of money and the maternal mortality rate continued to increase," Midhet stressed.

UNICEF believes that the evaluation carried out following the training showed improved knowledge and skills among the TBAs, but agrees that there is room for further training. "Not much work was done on developing the health system, for example on when a woman should be referred to hospital," Zaka said.

Midhet divided the TBAs into several categories. "It could be someone who just cuts the cord at the birth or cooks and cleans in the house in the run-up to the birth, and supervises women in the house to help deliver the baby in the house. Or there are the professional TBAs, who usually work in the local hospital and come to the house for the birth, but charge a heavy fee of US $10 [a monthly wage for some families]. So women opt for the cheaper inexperienced women to help with the birth."

He maintained that TBAs could not be trained to be community midwives. "They have to be able to read and write and understand some terms which cannot be translated into Urdu because there is no word in Urdu, and should be able to communicate on a professional level with doctors, which a TBA cannot do for cultural reasons," he said.

UNICEF is currently running three women's health projects in Sindh called "Women's Right to Life and Health". Under these projects, 24-hour medical services have been established for women, along with education on preventative measures against infections, with the right to privacy and confidentiality. "The preliminary findings are very encouraging and we're thinking of replicating the project," Zaka said. The agency is also supporting a women's health project run by the Asian Development bank by offering technical advice.


Back in Mardan, pregnant women now at least have some help at hand. Basnihaar, aged 19, is six months pregnant and has already had the misfortune of a stillbirth. "I have lower abdominal pains, but I haven't been to the doctor yet," she told IRIN. "I got some tablets from the chemist; he said I had a kidney problem, but the pain has not gone away," she added.

She said she had stopped taking unnecessary medicines after seeking advice from the female health workers. Basnihaar is also fortunate in having an understanding her mother-in-law. "I have taken on all the household tasks that my daughter-in-law was doing because I don't want her to suffer again," mother-in-law Benazir told IRIN. "I want her to have a healthy baby."

The NCHD plans to expand its programme to another 16 districts, including Narowaal and Attock in the Punjab, Pashin and Mastang in Balochistan, and Gotki and Thatta in Sindh by the end of June 2003 with a view to training 55,000 female health workers and posting them to rural areas.

Khalil maintained that education was crucial if the country were to succeed in tackling its growing maternal mortality rate. "I asked a group of health workers in a village how many mothers they would expect to die out of 100 births, and one doctor responded with 10 or 15. I asked if he thought this was too much, and he said no, this was to be expected. This is dangerous as it has become the norm."

Khalil said the NCHD could only expand further with more resources. "The cost per person per year for this three-year project is US $1.50, covering 14 million people in a total of 16 districts. This is a small amount and can be easily expanded if we can raise the funds."

The female health workers already employed under the NCHD project can only hope that their efforts are replicated in further efforts to save hundreds of innocent lives every year.

"The best thing about my job is to be able to help a pregnant woman and make sure she has a safe and healthy pregnancy. We are the first women in this village [Paluderi] to make women aware of such rights, and it is a real joy for all of us," one NCHD female health worker, Nighat Seema, told IRIN.

[taken from]

Date/Time Last Modified: 12/4/2003 6:25:32 AM

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