PAKISTAN: Looking at Maternal Health Through Gendered Lenses

By IPS Correspondents Reprint | | Print |

Zofeen T. Ebrahim

Karachi, Dec 20 2004 (IPS) - After more than four years of marriage, 26-year old Meeran Harchand finally got pregnant only to give birth to a dead child.

”It was a daughter who I never even got to hold. Look what she let me with in the bargain?” she asks.

Meeran’s dull eyes well up on her pale face as she begins to narrate her tale of woe. She still remembers the excruciating pain the night she went into labour, four years ago.

”My mother-in-law called the ‘dai’ (traditional birth attendant) who gave me an injection. After a few hours she gave up and asked my family to call a doctor. Since there was no doctor in our village, by morning my husband finally arranged for transport and took me to the nearest town. I was in so much agony I just wanted to die,” she tells IPS.

She developed obstetric fistula due to prolonged labour and didn’t realise why she kept smelling foul till much later when they’d come back to the village.

There was a hole, or fistula, between her bladder and vagina and another between her vagina and rectum. The damage left her body unable to control its normal excretory functions, and urine and feces were constantly dripping down her legs.

”I pleaded with my husband to take me back to the hospital. He finally did as he, too, was quite fed up with me. Twice I was operated upon but I’d still get wet and stink.”

Dr. Shershah Syed, head of the gynecological ward at the government-run Qatar General Hospital in the southern port city of Karachi, operated on her for the third time and successfully repaired her fistula.

With a population of about 145 million, of which 33 million are women in their childbearing age, every 20 minutes a woman loses her life while giving birth in Pakistan.

A major pitfall in saving lives is the poorly functioning health system and the failure to look at maternal health through gendered lenses..

For every woman who dies, some 40 others suffer illnesses, injuries and disabilities that plague them for the rest of their lives, says 86-year-old Imtaiz Kamal, who wears quite a few hats as secretary general of the National Committee for Maternal Health (NCMH), vice president of the Maternity and Child Welfare Association of Pakistan( MCWAP) and president of MCWAP’s Sindh Chapter. She is also fondly known as Pakistan’s grandmother of midwifery.

”We keep forgetting those who did not die but wish they had (because of what they have to endure now),” adds Kamal.

And these include women like Meeran suffering from incontinence, or those who have uterine prolapse – where the uterus descends into or beyond the vagina – pelvic inflammatory disease and infertility due to abortions carried out by unskilled birth attendants.

”Many of the women I see everyday often have tragic stories to tell of how they have been rejected by their families,” says Qatar General Hospital’s Syed.

According to the Pakistan Population Assessment 2003, a report by United Nations Population Fund (UNFPA), 80 percent of the total 4.5 million annual births occur at home.

”Over 90 per cent of these deliveries are conducted by ‘dais’,” says Dr. Sadiqua Jafarey, president, of the NCMH and professor of obstetrics and gynecology at Ziauddin Medical University.

Adds Syed: ” Even in towns and cities women refuse to go to male doctors and this has helped promote a league of untrained dais.”

Because of this, it comes as no surprise that the maternal mortality ratio (MMR) in Pakistan is high – which official figures put at 533 per 100,000 live births. In Pakistan, like in other developing countries, says Syed, the reason for high mortality and morbidity can be attributed to the three delays.

The first delay, the gynecologist says, occurs when the family decides to seek care.

”In our case, the mother-in-law plays an important role. This matriarchal institution is a powerful one, and not just in poor households. She is the one who decides if there is need to seek care, where to go and finally when to go,” he points out. ”Believe me, there is a clear difference between how she treats her pregnant daughter as opposed to her pregnant daughter-in-law. I see it everyday in my hospital.”

The second delay, adds Syed, is identifying and reaching a medical facility.

”The third delay happens if after you’ve crossed the other two barriers and make it to the hospital,” Syed continues. ”You do not receive adequate and appropriate treatment at the facility because none is available. Many facilities do not provide 24 hours obstetric care and they lack supplies and staff.”

According to Dr. Nabila Zaka, the project officer for women’s health at UNICEF, the major gender-related barriers that have furthered maternal mortality and morbidity are men’s ignorance of female health problems and women’s reluctance to go to facilities with male health care providers.

Imtiaz Kamal, monitoring one of UNICEF’s women’s health projects – Women’s Right To Life and Health Project, in Sindh – agrees with Zaka.

”The top most problem cited by the management in the four hospitals I visited is the shortage of female staff – that is doctors and nurses. There are practically no female registered nurses in the facilities situated in small towns, and none in the rural areas,” she reveals.

Adds Kamal: ”Female health providers have qualms about going to rural areas. Family disapproval and issues of their safety and security are the determining factors.”

”Many hospitals in the rural areas treat the women patients or the staff insensitively and either their needs are not heard or met.”

But is there a way forward to bring down maternal mortalities in Pakistan?

UNICEF’s Zaka is optimistic.

”We need to rope in everyone and create awareness, draw all the stakeholders – men, women, family, the community,” she says.

”Female healthcare providers are also an alternative in the rural levels if women are more comfortable with their female counterparts.”

However, for this to succeed, according to Zaka, female providers need to be given proper residential facilities, security and greater incentives.

”For them to be able to give their best they must be provided with functioning emergency obstetric care facilities,” she stresses.