A Global Village
Issue 3 » In The Field

Pregnancy In Pakistan

The Forgotton Millenium Development Goal?

Najia Sultan, Imperial College London

Millenium Development Goal Five requires a 75% reduction in maternal mortality ratio (MMR) by 2015 for achievement. Together India, Pakistan and Bangladesh account for 46% of the world’s maternal deaths1. However, with only four years remaining before the 2015 deadline, Pakistan’s progress significantly lags behind its south Asian neighbours.

Maternal death as a result of hypertensive disorders is thought to account for up to 30% of total maternal mortality in Pakistan. Pre-eclampsia is the most serious of hypertensive diseases and affects up to 5% of pregnancies. The IEF will be launching two new projects in Pakistan in 2010: a ‘Community Screening Programme for Pre-eclampsia’ in Azad Kashmir in addition to a ‘Centre of Excellence for Maternal Health’ in an empty hospital in Jhelum, Punjab.

Pakistan has spent a great deal of its short sixty-three year history on the world stage. Unfortunately, much of the attention has been a consequence of tragedy – the 2005 earthquakes and 2010 floods being most recent examples. In the context of a volatile political and natural environment, it is perhaps unsurprising that the development of social and healthcare services have been sidelined. Less than 1% of GDP expenditure is on health, and medical services are widely thought to be inadequate in catering for a population of 170 million.

Together India,
Pakistan and Bangladesh
account for 46%
of the world’s
maternal deaths

Pregnancy, A Risky Enterprise
In 2000 Pakistan was one of 191 countries that endorsed the eight United Nations Millennium Goals (MDGs). The MDGs emerged from the United Nations (UN) Millennium Declaration and are arguably the most politically important pact made for international development. The goals were intended to improve the distribution and prioritisation of aid and have been categorised into over 20 targets and 60 indicators.

Goal Five requires a 75% reduction in maternal mortality ratio (MMR) by 2015 for achievement. Maternal mortality – defined as death during pregnancy, childbirth or in the 42 days after delivery – remains a major challenge to health systems worldwide. Together India, Pakistan and Bangladesh account for 46% of the world’s maternal deaths. However, with only four years remaining before the 2015 deadline, Pakistan’s progress significantly lags behind its south Asian neighbours. Investment in midwives and emergency obstetric care has meant India and Bangladesh were recognised by the UN’s 2008 MDG Report as achieving a ‘substantial decline’ in MMR. Pakistan, on the other hand, has made insufficient progress.

Truth in Numbers
30,000 women a year in Pakistan die due to pregnancy related causes and the maternal mortality ratio is approximately 340 per 100,000 live births. In reality this number may be even higher due to the under registration of deaths and the absence of official cause of death information. To put this into context, Britain’s maternal mortality rate was last at this level in 1937.

No doubt the practical implications of reducing maternal mortality in Pakistan are huge due to the variety of problems that need to be overcome in order to reach the MDG target. One third of the inhabitants of the seventh most populous country in the world live below the poverty line. Yet despite this, the majority of antenatal care is privately funded, and therefore remains beyond the reach of most of the population. There is also a general absence of appropriate antenatal care (defined by WHO as having had one or more visits to a trained person during the pregnancy), whilst 97% of British mothers can expect to receive routine antenatal care. In the Pakistani province of Sindh this drops to 63% in urban centres while in rural areas a meagre 15% of mothers receive antenatal care.

Britain’s maternal
mortality rate was last
at this level in 1937

The general acceptance of maternal death in labour is an additional psychosocial hurdle. A Doctor from the National Commission for Human Development, Pakistan, illustrates this issue: “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.”

There is considerable correlation between the causes of maternal death in developing countries today (haemorrhage – 21%, eclampsia – 18.6% and sepsis – 13.3%) and prominent causes in developed countries in the early twentieth century. This suggests that measures taken to reduce maternal mortality in the developed world fifty years ago may work today in regions with high rates of maternal mortality. As only 21% of women in Pakistan are literate , an educational approach will be needed alongside improvements in antenatal care to fully address the problems.

The International Education Fund
The WHO recognise that the presence of an intrapartum-care package can ‘prevent a large proportion of obstetric deaths’ and that ‘first level care does save lives and manage emergencies’. The provision of obstetric health care in the community by trained health personnel forms the backbone of any such efforts and it is with this is mind that Imperial College’s International Education Fund (IEF) intends to launch a project focussed on maternal health education in Pakistan.

The IEF is a young charitable organisation comprising of academics and students. Upon visiting Pakistan as part of a schools project three years ago, the IEF realised that health education was seriously lacking. Research identified maternal mortality as a particular area of concern and thus the IEF, in collaboration with Maternity Worldwide, will be launching two new projects in Pakistan: a ‘Community Screening Programme for Pre-eclampsia’ in Azad Kashmir in addition to a ‘Centre of Excellence for Maternal Health’ in an empty hospital in Jhelum, Punjab. Throughout the year the IEF will be raising awareness and funds for the Pakistan Maternal Health Project. Keynote lectures and sponsored activities will culminate in a trip to Pakistan to implement these screening programmes.

Good Intentions
Maternal death as a result of hypertensive disorders is thought to account for up to 30% of total maternal mortality in Pakistan. Pre-eclampsia is the most serious of hypertensive diseases and affects up to 5% of pregnancies. It can be fatal if left untreated yet is easily screened for. The IEF plan to use non-invasive testing (using urine dipstick and blood pressure measurement) to enable early detection of pre-eclampsia based in two rural hospitals in Azad Kashmir – the District Headquarters Hospital (Bagh) and the Combined Military Hospital (Rawalakot). The programme will include patient workshops and educational material to educate women and their families on the signs of pregnancy complications; and in the case of a diagnosis through screening, a prompt referral to hospital for appropriate treatment. Additionally, local midwives and healthcare professionals will receive proper training on standards of maternal care.

In a prominent 2005 programme that trained traditional birth attendants in Pakistan, rates of puerperal sepsis and haemorrhage as a complication of pregnancy were noticed to be significantly lower. There was also a reduction of about 30% in perinatal mortality in cases with a trained birth attendant. These methods clearly work.

In addition, 77% of total maternal mortality is recognised to be in mothers who lived greater than 40 km from the nearest hospital. In order to address this issue, an empty hospital donated to the IEF by a philanthropist in Jhelum (Punjab) will be used to create a local Centre of Maternal Health Excellence. Following a needs assessment conducted by a local charity, Kashmir Islamic Relief Fund (KIRF), the IEF propose preparing this hospital for dealing with obstetric emergencies and reducing local maternal mortality.

It is also intended that both projects will help to generate epidemiological data to enable effective targeting of future interventions. There is currently no national antenatal screening programme in Pakistan and detailed data on maternal health will help us to tailor guidelines to the specific needs of women in Pakistan. It is hoped that in time, similar programmes can be established around Pakistan.

This is an excellent opportunity for those with an interest in international development to get involved. Please email katherine.smith06@imperial.ac.uk for more information.

Najia Sultan is a fifth year medical student at Imperial College London and the current Head of Publicity and Marketing for the International Education Fund, an Imperial College student-led project tackling poverty and health in the developing world through education.

Comments

  • Posted by sabiha on Aug 21, 2013 9:42 PM

    s thanks Najia sultan for so useful topic i am also workinkg on this topic.i am a phd student.

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