Pakistan: Mothers dying like animals & buried as unceremoniously as when they are born
Sunday, November 30, 2008, Zil-Hajj 01, 1429 A.H
3. Political Economy
Sad but trueDespite the fact that a young mother dies every 20 minutes and about 30,000 women die every year due to preventable maternal causes, Pakistan still does not have a national maternal and newborn health policy
By Sheher Bano
A Telgu proverb says: "Bringing up a girl is like watering the plant in your neighbour's garden." Bitter but true. The condition of women in most developing countries like Pakistan can be best understood in the light of this proverb. The women in Pakistan, whether they are based in rural or urban areas, face multiple forms of violence, including sexual violence, domestic abuse, burning and disfiguring through acids, beating and threatening, honour killings, custodial abuse and torture, dowry-related violence, rape, female genital mutilation, etc.
A multifaceted issue, which finds its roots in biological, psychological and social fabric of the society, the effects of violence can be devastating for a woman's reproductive health, as well as for other aspects of her physical and mental well-being.
In addition to causing injury, violence increases women's vulnerability to a number of other health problems, including chronic pain, physical disability, drug and alcohol abuse, and depression. Women with a history of physical or sexual abuse are also at increased risk of unintended pregnancy, sexually transmitted infections and adverse pregnancy outcomes. Yet victims who seek care from health professional often have needs that providers do not recognise, do not ask about and do not know how to address.
In this scenario, women activists and health experts now term the death of a woman in pregnancy as a form of violence. "The women face discrimination and neglect at all levels in our society, the consequences of which are evident in their poor health indicators. This issue can be addressed only by increasing literacy, and raising awareness about women's empowerment and their rights," says Dr Samra Shaikh, who is working to improve women's reproductive health.
Recently, a mother of 11 children was brought to a government hospital at two in the night with non-progressive labour. Weak, pale, malnourished and anaemic due to multiple pregnancies, she could not succumb to the excruciating labour pain and died. Holding the youngest child, her husband said: "Allah ko yehi manzoor tha (This is what Allah had ordained for her)." However, nobody can understand the fate of those 11 children who were left stranded in the absence of their mother. The husband might get another wife, but the children will never get their mother back.
According to senior gynaecologist Dr Arifa Izhar, the awareness level regarding women's health is alarmingly low in our society. Most women are anaemic and weak, and they suffer from odaema (swelling of body due to water retention during pregnancy) and hypertension. Because of multiple pregnancies, these women are frustrated but they hardly follow doctors' advice. Dying like animals in hospitals, women in our country are buried as unceremoniously as they are born. After all, it is a routine that a woman dies during child birth.
The women in Pakistan experience discrimination since their childhood. Nobody celebrates their birth, they are given the left over food, they are not educated on priority basis and they are handed over in marriage without their consent. At times, the women serve as a good commodity to be exchanged in return for a beautiful bride for their brothers, fathers or uncles. During pregnancy, they are not given required medical care or nutrition. While giving birth to a child, unavailability of health care renders the women weak and even causes disability or death.
Recently, a young mother Shehla gave birth to a girl, her first child, after remaining in severe labour pain for two days at Pakistan Institute of Medical Sciences (PIMS), Islamabad. When hospital staff called up the father to take the child's custody, he did not show up. Shehla's mother-in-law, who had brought clothes for the minor, albeit for a male child, also left crying. After a few hours, when the father finally showed up, a nurse asked for sweets. "Had the child been a boy, I would definitely have given you something, but what can I give for a girl? I am already aggrieved, do not torture me," he rudely said. Shehla's husband was not illiterate, but was working at a very good post. So much for patriarchy and male chauvinism!
There are various reasons, including social, cultural, economic and legal, that lead to such types of violence. Legally speaking, the laws of the land are not favourable for women. As Justice (r) Majida Rizvi, puts: "There is need to repeal all such laws that are discriminatory against women. Under Qisas and Diyat law, the women's status as head of the family to settle the money matters is not recognised. Similarly, despite being legally declared as murder, the Karo Kari law has yet to see its implementation in true sense." According to religious scholar Dr Abbas Hussain, "Depriving women of the good opportunities in life should also be considered as violence against them."
Despite the fact that a young mother dies every 20 minutes and about 30,000 women die every year due to preventable maternal causes, Pakistan still does not have a national maternal and newborn health policy. According to the latest figures released by the National Institute of Population Studies, the maternal mortality rate (MMR) in Pakistan is 500 per 100,000 women, which means that the country is only better off than India (MMR: 540) and Afghanistan (MMR: 600).
The government has initiated many programmes for reducing the MMR in the country, including National Programme for Family Planning, National Nutritional Programme, Maternal and Neonatal Health Cell, etc, but these efforts have so far failed to bring about any visible improvement in the condition of women. According to Dr Nabeela Ali, chief of party, Pakistan Initiative for Mothers and Newborns, "Pakistan is signatory to the Millennium Development Goals (MDGs) and had pledged in September 2000 to meet the MDG target of reducing maternal mortality by three-quarters between 1990 and 2015, but despite the lapse of eight years we still have the MMR of 500 per 100,000 live births. Going by the same pace, we will not be able to achieve the target of 140 per 100,000 live births by 2015 as was pledged in September 2000. Extraordinary measures are required to achieve this MDG target."
Dr Nabeela says there is a dire need to accord the highest priority to health facilities for mothers. "75 percent of the births take place at home in rural communities and the postpartum period is quite critical for both the mother and the newborn, yet neither health programmes nor mothers and families recognise this vulnerability. Similarly, the main reasons for still birth are improper diet and no check-ups during pregnancy," she informs. The MDGs 3 and 4 deal with the health of women and children. It is widely believed that if these goals are achieved, then the condition of the country's women will improve, but Dr Shershah Syed disagrees: "I think until we achieve the MDGs 1 and 2, which deal with poverty and illiteracy, there will be no change in the MDGs 3 and 4. Unfortunately, no commission has been formed so far to monitor the progress of MDGs in the country."
Dr Shershah further says: "The women have never been a priority for the government. They get funds in begging only; all the work done in the country to improve the heath status of women is undertaken with the money provided by donors. A little focus on primary health care facilities at rural health units (RHUs) and taluka hospitals can yield great results, because about 70 percent of the country's population visits these for treatment. However, only six percent of the health budget is allocated to RHUs and taluka hospitals, while 85 percent goes to hospitals in cities that cater to only 15 percent of the population. It is all because of vested interests working at the policy and planning levels who allocate huge amounts to purchase expensive equipment for hospitals in cities, while women die in rural areas due to unavailability of primary health care facilities."
Jamil Ahmed and Babar T Shaikh write in their research article, printed in the Journal of the College of Physicians and Surgeons Pakistan (2008), that Pakistan traditionally spends lowest on development in general and health and education in particular. A large sum of the budget is being spent on the curative care and hospital cost in a scenario where one third of the population in Pakistan lives below the poverty line ($1) and the health facilities remain widely inaccessible to the masses. Also, Pakistan has over 98 percent of the out-of-pocket health expenditure, when over 75 percent visit the private sector for health care.
National public expenditure on health is $4 per capita, while total expenditure on health is $18 per capita. This reflects the high share (75.6 percent) of private health care spending. Social health insurance covers only five percent of Pakistan's population, but represents about 40 percent of federal and provincial governments' spending on health. The country spends 80 percent of its meagre health budget on tertiary care services (used by only 15 percent of the population) and only 15 percent on primary health care services (used by 80 percent of the population).
The health budget has always been low and stagnant in Pakistan; it has remained below 0.6 percent during the past few fiscal years. Reliance of the country's health care system on foreign funding and a stagnant domestic health budget paint a gloomy picture. The budgetary allocations for health in Pakistan are still much less than the World Health Organisation's (WHO's) recommended five percent of the country's gross domestic product (GDP).
Internationally, Pakistan is ranked 175th out of 177 countries of the world when it comes to health of mothers and newborns. Even some of African countries are better off than Pakistan, which takes pride in being a nuclear power. About 67 percent of the country's 164 million population lives in rural areas. With the present growth rate of 1.9 percent, fertility rate of 4.1 births and contraceptive use rate of 30 percent, the health facilities of the country do not match with the needs of the population.
Pakistan has 906 public sector hospitals and 5,290 basic health units, while the population-bed ratio is 1536:1. In all, there are 122,798 doctors, 57,646 nurses, 25,000 midwives and 96,000 lady health workers. Contrary to the rest of the world, where the number of nurses and paramedical staff is more than that of the doctors, in Pakistan it is opposite. Moreover, the number of midwives and nurses remained almost static from 1993 to 2004. Currently, there are 25,000 midwives in Pakistan. However, most of them are based in cities despite the fact that 70-80 percent deliveries are done at home in villages.
These figures call for an urgent need to have more qualified nurses and trained midwives. Priority should also be given to the training and placement of midwives in those rural areas where there are no health facilities for women. Improvement in the existing health facilities in hospitals, availability of transport facility and behavioural change at the household level are some of the critical areas requiring urgent attention. As a United Nations' statement says, "The world must save women, so that women can save the world." It is the collective responsibility of the society to make concerted efforts for decreasing MMR, because this will ultimately reduce violence against women.