F.F.Fikree ( Population Council, New York, U.S.A. )
The death of Pakistani women during pregnancy, delivery or immediately after delivery and of her newborn is a calamity of incalculable dimensions not only for her family and community but, from perspective of health policy makers and planners of paramount significance to the health and well being of the country. What makes this tragedy unacceptable is the fact that the high maternal mortality ratios have remained essentially unchanged for the nearly three decades of data compiled from various hospital statistics in Karachi, Hyderabad and Peshawar as described in Dr Sadiqua Jafarey’s article in this issue. The reasons have much to do with socio-economic realities, culture and traditions that inhibit a woman from gaining access to maternal health facilities but equally so to the ineffective implementation of fairly well-defined government maternal health policies.
Nearly 99% of reported maternal deaths occur in developing countries, which account for 88% of the world’s births, and where maternal mortality is one of the leading causes of death among women of reproductive age. It is estimated that up to 98% of these deaths could probably have been avoided if these women had been able to make use of good quality health services during and immediately after delivery. Since the launch of the Safe Motherhood Initiative in 1987, reducing maternal mortality has become widely recognized and adopted as a public health goal, both globally and nationally1. More recently, the aim to reduce the number of maternal deaths was re-iterated in the Millennium Development Goals adopted by the member states of the United Nations2.
The effectiveness with which countries have been able to address maternal mortality has varied considerably overtime, according to the strategies adopted. However, no single factor can be held responsible for any improvements in maternal mortality. Having trained, experienced and skilled medical help through any obstetric or for that matter medical emergency is intuitive and makes perfect common sense; however the task that lies ahead for the scientific community is to determine exactly what such help should consist of, and how much of an impact it can have not only for reducing maternal mortality but also for other medical emergencies.
With respect to reducing maternal mortality, The Safe Motherhood Inter-Agency Group has chosen to focus primarily on skilled attendance - or skilled care - at birth as the most effective strategy to reduce maternal mortality. Focusing on skilled care during childbirth rather than restricting the strategy to the health care professional ensures that attention is paid to the broader issues that ascertain whether or not a skilled attendant can actually save a woman\'s life. These more structural paradigms include the policy and regulatory environment, the availability of drugs and supplies, and the existence of a functioning referral system.
Dr. Sadiqua Jafarey’s review paper in this issue gives us a unique opportunity to reflect on our past endeavors, critically evaluate the problems associated with a nearly stagnant maternal mortality ratios and develop evidence-based strategies that have short and long-term goals. Lack of insufficient nationally representative data on maternal mortality ratios, the enormous costs both monetary and manpower needed for such assessments should not deter us from utilizing currently available information as described in the article in this issue for initiating sensible and reasonable decisions on policy and program priorities.
As we move into the 21st century the real challenge facing our nation in the context of safe motherhood lies in implementing maternal health policies. The essential core of the Pakistan Safe Motherhood initiative should be an intersectoral multilevel programmatic framework that links the common women and men in the community, the obstetricians, midwives, nurses and educators and, is supported by a strong political commitment at the national, provincial and district levels.
1.SMLAG, Safe Motherhood Inter-Agency Group. 1987. Preventing the Tragedy of Maternal Deaths: A Report on the International Safe Motherhood Conference, Nairobi, Kenya, February. WB/WHO/UNFPA.
2.United Nations, 2000. Report of the UN General Assembly. Declaration of the Millennium Development Goals. U.N., N.Y.