The (many) problems with maternal health in Pakistan

A recently published report by a wire agency suggested that UN’s interventions regarding maternal and child health in Pakistan, as well as five other countries have been ineffective. The report substantiated the claims using two studies, one by the UN itself, suggesting that billions of dollars spent on maternal and newborn health were essentially useless. However, experts, including Dr Omrana Pasha, the leading author for the second study referred to above, titled Communities, birth attendants and health facilities: a continuum of emergency maternal and new-born care, say the interventions are ‘not ineffective rather insufficient.’ According to them, the lack of professional ethics among service providers is among the major causes perilously compromising the quality of healthcare in Pakistan. For a better understanding of the cause-and-affect in this particular aspect of the healthcare system, one requires greater insight into the experts’ research and observations. Lets first take the example of associate professor of Community Health Sciences at Aga Khan University (AKU) Dr Omrana Pasha and her team. They began working and recording data on maternal and neonatal health in various areas in Sindh close to a decade ago. During this time, the AKU team also conducted multiple training sessions with healthcare providers and doctors on prenatal, antenatal and emergency obstetric care. 'Death Audits' “We would conduct ‘death audits’, which is a review of the maternal and/or neonatal deaths in the centre,” Pasha explains adding: “Then we trained the healthcare providers how not to repeat mistakes or teach them skills for alternate life-saving methods which could be used.” But this was not enough. “We needed to train them on basic professionalism, something they should be taught in medical schools. This includes not being late for your shift or not sleeping in the call room or passing on important life-saving procedures to lower-level, untrained and unskilled staff.” The Founding Director of the Centre of Excellence in Women and Child Health at AKU, Dr Zulfiqar Ahmed Bhutta also shares his thoughts on the issue. “The studies should not be taken to indict the evidence base for interventions and approaches to reduce maternal and new-born mortality, which have worked well in many countries; instead we need to closely look at governance of the healthcare system in the context of the studies themselves.” Speaking on the dire need for better management of the staff and other medical provisions he says that many healthcare providers are absent or are not being supervised (properly). In addition, irregular stockpiles of drugs is a cause of concern. "Under such circumstances, even with all the training in the world, what can we accomplish?” he asks rhetorically.

And while there are no statistics, there is strong empirical evidence that implies poor training, mismanagement and lack of professionalism are among the deciding factors behind the unrelenting numbers of neonatal and maternal deaths in the country. “There were instances when critical mistakes with expecting mothers were repeated,” Pasha says of her experience with healthcare providers in district Thatta, one of the team’s research areas. “And on being evaluated and asked why they chose to use the same (unsuccessful) procedure again or why they did not make use of their training, some medical professionals would just say that they forgot!” Dais versus Doctors Getting people in rural areas to visit healthcare facilities, for prenatal, deliveries and antenatal care, when the quality of care is poor, drugs unavailable and health staff absent or inexcusably rude, has been a real challenge. In fact, it has taken years of hard work and convincing to change the traditional mind-set of giving birth at home by ‘dais’.

It would be unfair, and of course inaccurate, to solely blame a lack of professional ethics and poor management as the reason. There are other contributing factors. From a medical point of view Dr Shershah Syed, a well-known obstetrician and gynecologist with experience spanning over three decades, says the interventions need to be more focused on the three major causes of maternal mortality. Hemorrhaging (bleeding) Hypertension Infection Drawing on another example from Thatta when speaking of haemorrhaging or excessive bleeding, Pasha says at the time their study began there was no blood bank, public or private, in the area. Thus, even if the woman made it to the centre, the service provider was trained and other requirements were met, the failure to secure the needed blood in time could lead to her death. Today, the district has one private blood bank but Pasha says that its ‘not nearly enough’. Lack of round-the-clock services at rural healthcare centres, basic healthcare units and district hospitals is another important issue Syed, who is presently working at the Koohi Goth Hospital, points out. Head of gynaecology at Jinnah Postgraduate Medical Centre Dr Shereen Bhutta says lack of supporting infrastructure for skilled birth attendants is another area that requires urgent attention.

“No doubt that skilled birth attendants need to be worked and invested on more. Worldwide they play a huge role in improving maternal and neonatal indicators but they can not do so without a back-up support system including training and tools,” she says. Bhutta adds that since her expertise is as a service provider in a public sector hospital, she can best comment on the state of affairs there. There needs to be increased funding and then proper utilisation of that funding to improve standards. Another cause of concern is the limited pool of credible qualified midwives, Syed says. “We have barely 15,000 midwives who are credible. There are loads just roaming around but have no proper training and no skills. We need at least 100,000 skilled, trained and properly qualified midwives,” Syed adds. To address all these concerns, AKU’s Pasha believes that the government should have a two-pronged strategy towards healthcare in Pakistan. The government needs to strengthen the public sector but the nation cannot (and does not) solely rely on them. About 70 per cent of healthcare services delivered to Pakistanis are through private providers, Pasha says.

“Now you are faced with two options: One that you substantially improve public system. Or two, that the government regulates the private system to provide proper and good quality healthcare,” she suggests. The best option would be a combination of both, she adds. Since health is now devolved to the provinces, speaking about the situation in Sindh Pasha says that there is “very little regulation of the private healthcare system." "There are no laws per se, as far as I am aware, to specifically guide and standardise private healthcare workers and the quality of care. And if there is a law it is not being implemented.”