S. N. B. Inam ( Department of Community Health Sciences, Ziauddin Medical University, Karachi. )
S. Khan ( Department of Community Health Sciences, Ziauddin Medical University, Karachi. )
Pakistan with a population of over 140 million1 is a federation of four major provinces, Punjab, Balochistan, the North-West Frontier Province (NWFP) and Sindh. It is a country that fails on almost every social and health indicator. It has an infant mortality rate (IMR) of 85 per 1000 live births2, an unacceptably high maternal mortality ratio of 340 per 100,000 live births2, a contraceptive prevalence rate of 24%3, with total fertility rate of 5.64, a female literacy rate of 26%5 and a less than 1% of GDP expenditure on health2. The ratio of 93 women per 100 Pakistani men compares unfavourably with a global ratio of 106 females per 100 males and is lower than the South Asian average of 94 to 1006. The compromised status of Pakistani females is further exemplified by the gender related development index (GDI), which takes into account inequality in achievement between men and women and gender empowerment measure (GEM), which indicate whether women are able to actively participate in economic and political life. Pakistan ranks 120 out of a total of 146 countries on GDI and on a GEM ranking of 94 countries Pakistan ranks ninety-second7. The reproductive risk index which scores countries separately on the percentage of women receiving prenatal care and the percentage of births attended by skilled personnel is 52.7 and the risk index ranking is 37 while that of neighbouring country Sri Lanka is 94 and 28.4 respectively8. These indices indicate the disadvantaged status of Pakistani women, particularly with reference to health.
In Pakistan, like other developing countries, the major causes of maternal mortality remain hemorrhage (21%), eclampsia (18.6%), sepsis (13.3%), abortion (11%), obstructed labour (8.7%) and others (27.4%)9.
Good antenatal care, its provision and accessibility can mostly prevent all the above causes that require emergency obstetrical care. In 1994, the International Conference on Population and development (ICPD) held in Cairo, emphasized the importance and need for maternal health care services that will enable women to go safely through pregnancy and childbirth to produce a healthy baby. One of the cornerstone of provision of good maternal health service is antenatal care that not only identifies risks and detects complications like hypertension and malpresentations, but also provides information on: i) recognition of danger signs and symptoms, ii) where to go
in case of emergency and iii) transportation to referral site10. Antenatal visits can play a critical role in establishing confidence between the woman, the family and the health care provider.
In developing countries only 65% women receive antenatal care compared to 97% in developed countries. In urban Sindh 63% women avail antenatal care as opposed to only 15% in the rural areas11. According to the Maternal and Infant Mortality Survey (MIMS)- Sindh of 3998 women, the three main reasons cited for not availing antenatal care were women’s perception of no complaints (44%), services not available (21.4%) and costs too much (14%). The article published in this issue indicates that social status and economic conditions were important determinants of utilization of antenatal services.
A study from Rajasthan, India also observed that socio-economic status and literacy levels influenced utilization of antenatal service12.
The importance of quality antenatal care cannot be questioned. But without availability of transport and efficient round the clock Emergency Obstetric Care (EmOC) facilities, it is not possible to reduce maternal morbidity and mortality. It is estimated that in Pakistan 1 in 20 women who suffer from complications of pregnancy reach a health facility where EmOC is available. This is due to three types of delays: delay in seeking care, delay in reaching to an EmOC and delay in starting treatment due to non-availability of trained health care personnel, blood, life saving drugs and equipment. In a survey of 48 health facilities in 4 districts of Sindh almost none were providing quality EmOC13.
How tragic it is that pregnancy and childbirth, a joyous event for women in developed countries becomes a source of lifelong disability or worse for women in the developing world. For a country like Pakistan where technology has advanced to produce nuclear bomb, it is ironical to have the MMR which Sweden had in the 1880s, political will backed by adequate resources is urgently needed to implement programs to reduce maternal mortality and morbidity through provision of good antenatal care and access to round the clock quality EmOC services.
1.Federal Censtis Report: Population Census Organization; Statistics Division Government of Pakistan: October 2000.
2.The State of The World Chrldrcn. New York, UNICEFF, 2000.
3.Pakistan Contraceptive Prevalence Survey 1994-95. Jslamabad: Ministry of Population Welfare (MoPW) and The Population Council, 1995.
4.Pakistan Demographic and Household Survey 1990-91. Islamabad: Government of Pakistan.
5.Pakistan Integrated Household Survey 1995-96: Islamabad: Federal Bureau of Statistics, 1996.
6.Human Development Center Human Development in South Asia. Oxford:
Oxford University Press,1997.
7.The Human Development Report: UNDP 1997,
8.PAl Report Card 2001: Washington D.C. Population Action International, 2001.
9.Society of Obstetricians and Gynaccologists (SOGP) Survey 1989.90 pakistan (unpublished data).
10.Matthews Z, Mahendra S. Kilaru K, et al. Antenatal care, care seeking and morbidity in rural Karnataka, India: results of a prospective study. Asia-Pacific Pop. 3., 2001; 16: 11.28.
11.MIMS- Sindh (1994) report of Household Socioeconomic, Demographic and Maternal Health Survey of Sindh Province Department of Community Health Sciences, Aga Khan University, Karachi. 1994.
12.Mondal, SK. Utilization of antenatal care services in Rajasthan: Observations from NFEIS. J. Fam. Welfarc,1997; 43 28-33.
13.Women’s Health in Pakistan: Fact Sheets 1997. Pakistan National Forum on Women’s Health. 3-5 November, 1997.