Outside Pakistan's Cities, Childbirth Often Deadly

by Zofeen Ebrahim

(IPS) KARACHI -- Writhing in pain and cringing deeper into the 'charpoy,' a bed made from rope, to hide her shame and her labor, she finally gave birth to a beautiful daughter. The baby was born in the wilderness.

Salma, the young mother, can never forget the night she gave birth in the countryside on her way to the city. -- Nor can we," says Sakina, the voluble village woman whose daughter-in-law went to Islamabad, capital of Pakistan, a month before her baby was due. "It is most embarrassing but, unfortunately, most common."

Carrying the expectant mother on a makeshift stretcher up the hill, a whole big convoy went with her. It included sturdy men who took turns carrying the bed over the uneven hilly terrain, as well as women to be at her side.

"It takes about three to five hours on foot depending on the weather conditions and whether it is day or night," explains Mubashir Ahmed, project coordinator of Concern Worldwide, a non-government organization that focuses on community mobilization, including for health.

Salma's case was the most recent and the impact still fresh. "The men were asked to move a little away, some were sent to fetch water from a nearby house. The women who were accompanying her made her squat on a big stone. It was agony for the poor girl, but both the mother and the child are now safe. Over here, it is only God's will that protects an expectant mother."

But Kaneeze, 27, of the same village was not so lucky. Mother of three, she miscarried her fourth child while cutting grass -- "I felt this acute pain in my stomach. I went home and found myself bleeding."

"It's God's will" is how she looks at the whole episode. She now wants to have another child, "but not so soon," she adds, and "I hope it's a son."

The women say they have to do double the work even when pregnant. "There is no respite even for a pregnant mother.

"We work from morning to night and even then, the work is not finished. We can't even find time to die peacefully, as there is always something more to do," adds Kaneeze.

The landscape in the picture-perfect village of Chapprian, in the Punjab province, where the cornfields sway in the summer breeze and streams abound in the rainy season, is marred by the absence of mother and child health care facilities and the woes of the women who suffer in silence from fistulae, sepsis, miscarriages, obstructed labor and postpartum hemorrhage, until death takes over.

Yet the village is just three hours northeast of Pakistan's capital Islamabad where, one can find the best maternal and child health care that money can buy.

"There are no adequate government-run health facilities. There is a complete lack of facilities for mother and child care, there is lack of awareness regarding family planning, the rate of routine immunization is low," says Mubashir Ahmed. "Knowledge about hepatitis and other communicable diseases is poor and people generally are not very conscious of personal hygiene."

But Chapprian is just one of the thousands of villages and towns all over Pakistan where women are afraid to give birth.

"I'd always linked giving birth to death. Quite paradoxical but this is what I'd seen all my life. I never quite understood why women bled or why they suffered fits. There is so much illiteracy in my village and even today there is no hospital, no doctor," says Fizza, a midwife in training at a Karachi midwifery school, who has come all the way from a remote village in the Punjab.

However, the UN Fund for Population (UNFPA) says the maternal mortality ratio in Pakistan, officially estimated to be 533 per 100,000 live births, can be curbed considerably.

This is possible if there are skilled birth attendants backed by emergency obstetric care -- in a country where about 60 women die daily due to pregnancy-related complications.

Majority of births are done by 'dais' -- traditional birth attendants -- who may not be able recognize or handle complications and this is further compounded by non-availability of emergency obstetric care.

"In Pakistan, eighty percent of the births take place at home and of these, about the same percentage of deliveries is performed by 'dais,'" said Dr Sadiqua Jaffery, president of the National Committee for Maternal Health and professor of Obstetrics and Gynaecology at the Ziauddin Medical University in Karachi.

In 1970, the government started a mammoth training program for 60,000 illiterate traditional birth attendants but this did not yield the desired results.

Perhaps this is the reason Dr Shershah Syed, secretary general of the Pakistan Medical Association and associate professor for obstetrics and gynaecology at Dow Medical College, Karachi says: "What is needed is trained midwives, not training traditional birth attendants and dais, which has proved to be an exercise in futility."

He says one cannot bank on doctors for reducing maternal death as "doctors, especially lady doctors, will never work in the remote areas from where we are getting the maximum number of maternal deaths -- the villages. Only midwives from that area will be able to work and provide basic obstetric care."

Most medical experts believe there is a need to focus on increasing emergency obstetric care and awareness about and access to post-natal care, skilled birth attendants, increased access to contraception, community mobilization for raising the age of marriage and support for adolescent sexual and reproductive health.

Indeed, one recommendation made at the First UN System Conference on Volunteerism and the Millennium Development Goals (MDGs), held in December in Islamabad, was the addition of a goal to address sexual and reproductive health.

Meenakshi Datta Gosh, principal advisor to the Indian government on sexual health and family planning issues, said, "We must provide women with options for contraception and young people with knowledge on safe-sex practices."

"This is a whole area overlooked by the Millennium Development Goals," Gosh said, referring to the set of numerical goals ranging from education to maternal mortality set by governments in 2000 to achieve by 2015. "We strongly urge the inclusion of a MDG to address this."