Why Did Nasima Die?

The first thing that you notice as you enter the room is stale blood on the floor. Second is silence. “How can a woman in labor be so silent?” the thought enters your mind before you notice the third odd thing in this makeshift house in a slum in Karachi: A young woman lying still on a bed made of straws. Her eyes turned upward, her mouth slightly open and her legs spread wide. She is naked below her torso except for a worn out shawl which is draped around the middle of her body. Beneath the sheer cloth of the shawl, you can see her pregnant belly and a poll of blood between her legs. Standing by her bedside is a ‘Dai’ (Traditional Birth Attendant) who is casually taking a drag on a cigarette and chatting with a man in the room.

The man is Nasima’s husband. From their conversation you learn that Nasima has been trying to push the child out of her womb for 14 hours but the child won’t come out. They tell that she screamed out of pain whole night and fell asleep out of exhaustion in the morning. Nasima’s husband wants to take her to a hospital but Dai tells that it is unnecessary-Nasima is young (only 19) has already given birth twice at home and can easily deliver the third child at home too. While the two people discuss if she shall be taken to a hospital or not, you realize that the argument is useless because she is not breathing anymore. Sometime during the child birth, Nasima died without anyone noticing. Later on, she is taken to the hospital where doctors cut her open and pull out the dead baby. There are purple blotches all over baby’s body that appeared because of lack of oxygen inside his mother’s womb and because of the compression caused during the physical struggle that her mother went through to bring him in this world.

Pakistan’s dead mothers

I met Nasima while doing a story in Orangi Town which is the largest slum in Asia. I went to her house to get some insights from the residents only to find her dead. It has been seven years to this incident but the statistics of women dying because of pregnancy related complications in Pakistan remain grim. Of every 100,000 pregnant women, 260 women die every year because of complications that arise during pregnancy or during child birth or complications within 42 hours of delivering the baby. Most of these complications are preventable and treatable with timely maternal care.

Karachi: Another life lost - Nafeesa (pictured above) started loosing a lot of blood one week after child birth because all parts of her placenta were not removed after her C-Section. Source: Wendy Marijnissen

The Gynecology and Obstetric Ward at Jinnah Postgraduate Medical Center, one of the leading government hospitals in Pakistan, daily receives several such cases of pregnant women who could be saved if they had received medical treatment in time.

Sardara is one such woman. She started bleeding profusely after giving birth to a child at a government Health Unit in her village which is on 10 hours drive from Karachi. She delivered a healthy baby but started bleeding profusely a few hours after delivery. The doctors at the Basic Health Unit told that she had developed a complication which they were not trained to handle. They referred her to JPMC which is the only hospital nearby which is equipped with resources and trained staff to handle such cases. Sardara travelled 10 hours in the trunk of an open roofed pick-up van on the dilapidated roads that connected her village to Karachi. She kept bleeding the entire time. And although she reached in time to be admitted in the hospital, she died before she could receive treatment.

Dr. Ayesha Khalid, the gynecologist at JPMC who was treating Sardara told that Sardara had developed a common pregnancy related complication Postpartum haemorrhage (PPH) which was treatable if she had reached hospital even 5 minutes early.

A research study titled ”Maternal Mortality in Pakistan” published in the ‘Journal of Society of Obstetricians & Gynecologists of Pakistan” outlines three major medical conditions which directly cause the death of the pregnant mother: PPH, Puerperal Sepsis and Eclampsia. The reasons for these complications are many and range from malnourishment, bacterial infection during or after child birth, prolonged labor to the medical negligence of the birth attendant.

All three medical conditions however are not only preventable but easily managed by medicines if women receive proper medical care through a skilled birth attendant from the day the pregnancy starts till after the baby is delivered.

Health Experts recommend expectant mothers to have at least 4 antenatal visits to a doctor or skilled health practitioner for a safe pregnancy but a Press Release issued by The Demographic and Health Survey Program shows that more than 50 percent pregnant women in Pakistan visit a doctor only once while one third of the pregnant women do not visit a health practitioner before child birth at all.

The question here arises as to why women don’t go to a hospital for pre and postnatal check up?

Why don't mothers visit a doctor?

An analysis of Research reports and discussions with health practitioners and pregnant mothers leads to the inference that there are three major reasons that women don’t visit a hospital:

1- Three is little awareness about importance of maternal care, 2- Medical care is neither affordable nor accessible 3- Conditions of government medical units are very poor and people hesitate to seek help from there because of the behavior of medical staff.

Accessibility: Access to affordable health care is not uniform in Pakistan. According to Demographic Report by World Health Organization on Pakistan there is only 1 hospital for over 170,000 persons in Pakistan and only one maternal and child health care for 4,400 expecting mothers. This accessibility issues have severe consequences. Dr. Shershah Syed, Former Secretary General Pakistan Medical Association, in an interview during a television documentary told that his one pregnant patient had to travel on the back of a camel for three days to reach his hospital in Karachi because there was no hospital in the village that she lived in. By the time she reached the hospital her condition was so worse that the baby came out in pieces from her womb.

State of Government Health Units: Even In areas where government hospitals or health units are accessible, women prefer not to go there because Health Units cause them inconvenience. HU are either short staffed and doctor is absent when they visit the HU or otherwise HU lack necessary equipments and medicines and refer women to other hospitals in case of emergency which causes them inconvenience. In addition to this, the behavior of the health practitioners toward patients is very humiliating which discourages patients to visit the health unit. Rehana, a house maid says that she never goes to the BHU in her neighborhood because doctor there yells at her all the time. “I trust dai more. She treats me at my house and is nice to me”.

Awareness: Pakistani women lack awareness about maternal health care. One reason for this is illiteracy. UNICEF reports that approximately 40 % of female remain illiterate in Pakistan. With illetracy comes ignorance about health issues. The Press Release issued by Demographic and Health Survey showed that 70% of expectant mother did not think that it was necessary to have antenatal visits at hospital.

Are we saving the mother?

Reality is that we are not. Pakistan failed to achieve its target to reduce MMR to 140 deaths per 100,000 live births in 2015. And this failure is despite several vertical programs that the government launched to tackle multiple causes of MMR over years. One reason for this is that government is not investing time and resources in the policy based solutions to resolve major causes of MMR.

Health Experts Dr. Sania Nashter, founder of the think tank Heartfile in Pakistan while talking at a national television program “Sochta Pakistan” cited two major problems related to Health Policy on MMR. First, It fails to address major causes of MMR. Second, there is a lack of implementation of the policy.

The common understanding among health experts is that government is not committed to the health sector and this reflects in the ineffective health policy which does not addresses the real causes of MMR and does not employ integrated approach to resolve problems. Dr. Ayesha Khalid quotes Basic Health Units as an example which had a mushroom growth in some parts in the country to resolve accessibility issues but government did not include equipping Health Units with resources and medicines that could handle emergency cases. Addressing isolated causes of MMR without an integrated approach in the policy is not yielding desired results.

Dr. Fida Ali, Provincial Reproductive Health and Family Planning Coordinator, during an interview with Pakistani newspaper Express Tribune admitted that maternal health was not a “priority: of the government because of which the existing maternal health programs had failed at achieving their targets.

Curious Case of Pakistan’s Health Policy and Lack of Government Will

World Health Organization defines health policy as decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An analysis of Pakistan’s health policy suggests that there are weakness in decision making, planning, goal setting and implementation of the policy. The reason for this is that government lacks commitment toward health sector and the will to develop an effective policy.

In the thesis report titled: ‘Health Policy: what does it mean in Pakistan? Policy Actors’ Perspective,’ author Halema Masoud interviewed policy makers and implementers in health sector in Pakistan to determine how their attitudes were affecting policy. She found that the policy makers and implementers regard the health policy as a ritual and clearly state that health was not their priority. Her research also indicated that there was misperception of needs regarding health issues which affected the development of health policy to address causes of MMR.

The question arises as to why government is not interested in Health. A major reason for this is that the Institute if Democracy is weak. Pakistan had Military rule for most part after its creation. Democratic governments were never able to complete their tenure and were more focused on governance related matters than public service. Dr. Sania Nishter in “Sochta Pakistan” explains that this inconsistency in the democratic government process reflects in the frequesnt changes in the Health policy woith respective governments.

Another reason behind the lack of implementation and translating policy into goals is with respect to resource allocation. Pakistan spends major part of the GDP on Defence. In past five years alone Pakistan’s Defence budget has increased by around 11 percent per anum. In the budget 2015-2016, Governmentt increased spending by 860 billion rupees. Finance Minister Ishaq Dar in his Budget speech was quoted by the Dawn.com as saying that the budget was increased to meet the growing security needs. Pakistan has strained border relations with neighboring country India with which it had three wars since its creation. Pakistan’s border security issues have worsened after War Against Terrorism started in its neighboring coutnry Afghanistan.

In contrast to Defense, Pakistan spends only 0.9 percent of GDP on health sector.

This cut in the health budget to meet Defence expenses leaves Government with not enough resources to invest policy implementation. Annual report 2009-10 “Social Impact of the Security Crisis” of Social Policy and Development Centre stated that the higher military spending during war on terror “has reduced public spending on social services and caused slowdown in the pace of social development.” If this persists, Pakistan’s MMR is most likely to persist.

Save the mothers

Nasima died because there was no effective health policy to prevent the causes that led to her delayed health care. Pakistan need to develop and implement and Integrated Maternal Health Policy to meet its Sustainable Development Goal to reduce MMR. Government needs to commit to providing universal health care and launch a policy which causes of maternal deaths. Government also needs to spend more on Health Budget and make health a priority instead of focusing only on Defence. Government needs to take action or else mothers like Nasima will keep dying.