In Pakistan, despite the fact
that every health policy and program announced in the past two decades has
emphasized increasing the availability of female health, nothing substantial has
been achieved. However, the ground situation of staff and other facilities in
rural areas are still not according to requirement, a situation partly
attributable to security and safety issues.
Studies show that many women have no access to modern health services,
particularly during pregnancy and childbirth. According to research, family
planning or reproductive health clinics are accessible to only 10 percent of the
population, with only 5 percent living within easy walking distance, which is a
very small number.
To increase access and empower women, the Lady Health Workers program was
introduced in the mid-1990s that now covers 60% of the population and uses the
concept of community services and referral systems delivered to the thus
addressing lack of woman's mobility. The employment of female fieldworkers who
visit women in their homes has increased the uptake of services, especially
family planning and immunization, but little change has been observed in
antenatal visits or hospital deliveries.
According to a report, while the availability of female providers increased
substantially in the last decade, the availability of skilled birth attendants
remains so low that only about half of mothers received antenatal care during
their last pregnancy, and a colossal 80% of women in labour receive no
assistance from a skilled birth attendant during. This trend is observed more in
rural areas.
A study in Sindh province it was noted that out most of the facilities are open
for only 6 hours daily whereas 24-hour coverage is provided only by the district
headquarters hospital. Transport for referral is available at less than half of
the available facilities. Records of maternal health are found only in some
health facilities whereas only 33% of government hospitals are equipped to offer
obstetric care, thus patients consequently visit private hospitals for such
services.
Once complications in pregnancy become apparent, the mother's course, which may
lead to her death and the death of her infant, is determined. Thus delay in
giving healthcare to pregnant women occurs in more often than necessary which
thus turns out to be extremely fatal. Further delay in giving required care in
case of complication serves as the final nail in the coffin, quite literally.
Better staffing of peripheral health facilities and improved access to obstetric
services could reduce maternal mortality.
To address its high maternal mortality, Pakistan requires a pragmatic approach,
one that is culturally acceptable with a wide base of support in local
communities. Gender is a sensitive area of Pakistani society. Local traditions
and culture embody values predetermining gender values in society. There is
considerable diversity in the status of women across classes, regions, and the
rural/urban divide due to uneven socioeconomic development and the impact of
tribal, feudal, and social formations on women's lives. This has led to a low
level of resource investment in women by the family and the State. Recently,
emphasis of international maternal health efforts has been shifted to the
provision of accessible, affordable, and quality obstetric care services to save
mothers’ lives.
It is found that the majority of hospitals were not providing obstetric care
services and that most referral hospitals were geographically inaccessible to
potential users. Timely geographic access is especially important in obstetric
emergencies or complications at or shortly after delivery. In many rural areas
in Pakistan, the transportation infrastructure is underdeveloped, hindering the
transfer of patients. During such transfers to higher levels of care following
in-hospital emergencies, ambulances are extremely important. Half of hospitals
in our study did not have serviceable ambulances.
The working hours at the centers were inconsistent with the provision of
around-the-clock essential services, depriving and endangering the lives of many
in need. High staff absenteeism in many health facilities is another issue
needing immediate attention. Only a focused approach at local levels by proper
supervision, motivating programs, and skilled management can solve these
problems.
Once implemented, these measures will make a colossal difference by saving
women’s lives. These reforms need to be taken on smaller and broader levels,
such as district and union council levels. In Pakistan, especially in rural
areas where the majority of the population resides, women's mobility is
restricted and most women are uncomfortable discussing issues of pregnancy,
contraception, and reproductive tract infections with male doctors, resulting in
high unmet need. Many endanger their lives by eventually approaching unskilled
health workers.
However, the mere presence of a female care provider at a hospital is only one
part of the equation; her presence is no guarantee that she or anyone else is
capable of managing complicated deliveries or trained to recognize and treat
complications of pregnancy. This needs to be monitored by someone in authority
and who has a native background of the culture and has linkages with the local
community.
Nurses, midwives, auxiliary midwives, and other providers working in birthing
centers may not have the skills and competencies to perform all the six signal
functions that define a basic obstetric care facility, even if it was part of
their original training. The appropriate solution is to increase skilled workers
capable of managing these problems.
In Pakistan as elsewhere, a vast majority of the country’s doctors reside in and
serve urbanized areas, and this is especially true of women doctors. Rural areas
are underserved. The first step toward addressing the issue of women doctors in
underserved rural areas is to recognize the underlying core issues: poor salary
packages, inadequate service structure for women doctors willing to work in
rural areas, and security issues.
The government of Pakistan should offer better salary packages, improved and
transparent service structures, and scholarship programs to facilitate further
postgraduate studies to women doctors willing to work in rural areas. Another
issue of national level policy is security for these women. Unless the security
issue is resolved or proper measures are taken to manage it, it is unrealistic
to expect women to serve in rural areas. But one thing is certain that
increasing the availability of women doctors in these facilities will permit
many lives to be saved by prompt and skilled care.
Equally essential is community education. Women's education and health must be
emphasized through a long-term comprehensive approach. Women representatives at
the district level ought to take up this task of educating the local population.
Antenatal, natal, and postnatal care can be stressed most effectively by
sensitizing and involving important people around her (husband, mother-in-law)
and highlighting the importance of her role as chief caretaker of her offspring.
Otherwise, the decision to seek care at crucial times will always be delayed and
even service quality improvement in hospitals will be ineffective.
The gender sensitive dimensions of demographic and social change need to be
stressed further in all policies and development plans. The narrowing of gender
disparities will increase women’s wellbeing for which work ought to be done by
adopting the top-down approach.