By Zubeida Mustafa
MORE appalling than the state of the reproductive health of women in Pakistan is the ignorance shown by our policymakers and leaders of opinion about the silent suffering of women.
Dr Shershah Syed, the president of the Society of Obstetricians and Gynaecologists of Pakistan, who is one of the most outspoken critics of the government’s health policy, recalled the other day his encounter with political leaders before the 2002 elections. The PMA had arranged a meeting with party representatives to brief them about women’s health. Thus the doctors hoped to enlist the cooperation of the prospective parliamentarians in health matters after the election.
He was shocked when most leaders refused to believe the statistics he gave about maternal mortality. They rejected promptly the grim picture he painted as a lie. They alleged that he was exaggerating when he told them how women were suffering due to the inadequate facilities available for maternal and neonatal health.
The fact is that reproductive health has been a subject that has been shoved under the carpet. Until recently it was not even discussed openly – thanks to the prudishness and hypocrisy of our society – and there was little public awareness about it. The situation changed somewhat when Benazir Bhutto in her second term as prime minister set up the National Committee on Maternal and Neonatal Health (NCMNH) in 1994 with Dr Sadiqa Jafarey as the president. It was mandated to “analyse the problem of high maternal mortality and morbidity in the country and develop and demonstrate workable approaches with the objective of lowering the high rate of maternal deaths.”
This proved to be an uphill task. Dr Sadiqua Jafarey, the president of NCMNH and one of the most senior gynaecologists in the country who has devoted her entire working life to the cause of women’s health, says it is difficult to say whether the committee has made any impact on the maternal mortality rate (MMR) because there is no benchmark for it to follow. The National Institute of Population Study, Islamabad, has now conducted a survey the results of which are awaited.
“Our experience has been that the MMR in all major tertiary care hospitals has remained unchanged. But that could be due to growing awareness and more women with complications being brought to hospitals which neutralises any drop that might have occurred.”
Dr Jafarey feels that the NCMNH’s greatest achievement has been to create public awareness of the importance of women’s reproductive health in Pakistan. At least the issue is now being discussed and last week her committee focused its consultation on unsafe abortions, which are one of the major causes of maternal mortality after haemorrhage, sepsis, eclampsia and obstructed labour.
The NCMNH has shown the courage and foresight to bring the problem of unsafe abortions into the open since nearly a tenth of maternal deaths in the country take place as a result of the complications caused by the dangerous termination of pregnancies by unskilled dais.
Thanks to the NCMNH’s efforts the government announced in April 2005 the National Maternal and Child Health Policy and Strategic Framework (2005-2015) and an implementation programme last year.
This document focuses on the health interventions which are essential to save the lives of expectant mothers. Recognising the fact that most babies in Pakistan are born at home without any skilled supervision, the government seeks to train midwives, birth attendants and lady health visitors who work in the community. It has also been realised that inadequate emergency obstetric and neonatal care facilities in hospitals is also responsible for a high MMR – estimated to be 500 per 100,000 live births in Pakistan by the UNFPA’s State of the World Population, 2007.
The government has earmarked Rs31.5 billion to be spent in five years on this programme. Will this amount be forthcoming? The policy acknowledges that Pakistan spends too little on health – only 0.65 per cent of GDP. The internationally recommended figure is two per cent of GDP.
Another important factor that has been recognised but has not been addressed is the socio-cultural and economic causes of maternal mortality. The poor reproductive health of women in Pakistan reflects their abysmal status. When resources are scarce – be it in the national exchequer or in the family budget – it is taken for granted that the cuts will be exercised on the spending on women, be it their healthcare or education.
Closely linked to maternal health is the performance of the population programme. It may be designed primarily to prevent births and thus reduce the population growth rate, but the population programme has a direct bearing on maternal health by regulating the family size and the spacing of children. For it is now known that a woman’s reproductive health is determined to a large extent by the number of pregnancies she has had and the gaps between them. These are in turn influenced by the availability of contraceptives.
The contraceptive prevalence rate in Pakistan is dismally low (a paltry 20 per cent) and as a result there is a high unmet need. In other words, there are far too many women who are burdened with unwanted pregnancies because they have no access to birth control measures. It is a myth that people’s religious beliefs come in the way of planned parenthood.
Denying them contraceptive choices and facilities is at the root of our failed population programme which should be integrated closely with the maternal healthcare strategy – as Dr Nafis Sadik, the previous executive director of the UNFPA, never tired of recommending.
All these interrelated factors play on each other and multiply the impact of every factor. The need is to break the vicious cycle. This would explain why countries which show a low MMR also have a high contraceptive prevalence rate and a high literacy rate among women.
Will our policymakers respond to the challenge they face? They will have to show their commitment to women’s rights by translating it into better maternal and child health as laid down by the millennium development goals.