Maternal Mortality a Public Health Issue
Maternal mortality refers to when a woman dies during pregnancy or within six weeks after delivery. There are many factors such as biological, socio-economic, cultural and availability of quality Reproductive Health Services (RHS) in the country which contribute to the alarming figure of Maternal Mortality Ratio (MMR). Pregnancy is a normal process in which women experience some physiological changes as it is essential for fetal growth and development. During pregnancy women need healthy diet, antenatal checkup for pregnancy progress and identification of dangers signs and proper treatment. Unfortunately due to certain reasons these needs are not satisfied and resulted in death of the mother. This paper aims to in-depth analysis of the determinants of MM.
Significant of the Issue
Every year more than 500,000 women die during childbirth or from pregnancy-related causes worldwide. 99% maternal deaths occur in developing country (WHO, 2005) as RHS, and family planning services are not easily accessible and affordable. According to UNDP’s report Roca (2013) Pakistan has highest mortality ratio 260/100,000 per live births in the region.
Socio economic determinants
Poverty plays as a barrier to satisfy basic human needs and to access reproductive health services which contribute to maternal mortality. Current global economic crises adversely affected specially marginalized poor women. Escalation in fuel prizes made the food items so expensive that it is beyond the capacity of the poor to buy. Due to inadequate quantity and quality of food intake, the pregnant women suffer with nutritional deficiency anemia. A study conducted by Khan, Fatima, Imran and Khan (2010) in Rawalpindi, to assess the risk factors associated with the nutritional deficiency anaemia revealed that majority of the pregnant women were anaemic due to iron deficiency followed by folate and cobalamin and all these belonged to low socio-economic group. Moreover, these nutritional deficit anemic women are at greater risk of having postpartum hemorrhage and sepsis. Furthermore, cost of RHS such as formal fee, screening, purchasing of medicine and travelling acts as barrier for women to obtain care. In case of emergency obstetric complications the cost of treatment goes much high and causes the delay in treatment. A qualitative study by Ronis, Mehboob, Masood, Amjad, & Nishtar (2012) revealed that seventy percent of the patients sold their belonging or borrowed money in order to pay for delivery charges.
Poverty is a great barrier for pregnant women in approaching family planning and counseling services. National Institute of Population Study (NIPS) [Pakistan] and ICF International. 2013. depicts that in rural areas twenty percent of married women have an unmet contraception needs that increase the chances of unwanted pregnancies leading to abortion. A study conducted by Fawad, Naz, Islam, Zaffar, & Abbasi (2011) over the period of 5 years in Abbottabad calculated the MMR 1,057/100,000 live births. All the 78 patients who died belonged to low socioeconomic status and majority of them were illiterate.
Poverty effects female education as they cannot afford even primary education. These women are not aware of their reproductive health rights and utilization of RHS. According to Lynd, (2007) the literacy rate of youth between the age 15 to 24 years of Pakistan’s female is (53%) comparatively lower than the boys’ literacy rate (77%) in the same age group. In-fact educated women are more autonomous in decision making and utilization of quality ante natal and perinatal services. It is also illustrated in National Institute of Population Studies (NIPS) [Pakistan] and ICF International. 2013National Institute of Population Study (NIPS) [Pakistan] and ICF International. 2013. that the antenatal care is widely received by women with secondary or higher education. Moreover, an international cross sectional study was conducted by Karlsen, et al. (2011) revealed that lower levels of maternal education were associated with higher maternal mortality. This depicts RHS are not being utilize by illiterate women.
Cultural values are deeply rooted specially among poor and illiterate and it has significant impact on women’s health. It is cultural heritage that boys are nourished with rich food as compared to girls beside the fact girls that requirement good quality and quantity of food in order to carry out reproductive responsibilities. Moreover, in conservative families, women mobility is strictly prohibited even to obtain emergency obstetric care. As women are not financially empowered they totally depend on husband regarding their treatment. All the important decisions related to ante natal care, place of delivery and post natal visit are made by the mother in law or husband. Sometime the decisions related to reproductive health issue are made so late that pregnant woman’s condition gets worse. Moreover, women do not have the right to make independent decision for healthy timing and birth spacing which consequently lead to higher fertility one of the contributing factor to increase mortality. A qualitative study by Ronis et al., (2012) revealed that cultural norms in Pakistan restrict the women to opt RHS from female doctor only. Therefore their unavailability makes the services inaccessible.
Government has done much to decrease socio-economic gender inequalities on its part. As it is evident in the World Economic Forum’s Global Gender Gap Report by Bekhouch, Hausmann, Tyson, and Zahidi (2013) Pakistan is on ranked 64 out of 136 countries in political empowerment of women. Pakistan had secured the second lowest ranking in the overall measure of gender-based biases. The cultural heritage and ethnic diversity have been playing role in mediating gender inequality. In-fact boys are provided with nutritious food and good quality of schooling as compared to girls. A report by Bekhouch et al. (2013)14 million girls and 18.3 million boys enrolled in basic education in 2006, this depicts the accessibility and affordability of girl’s education. Moreover, gender inequality is also reflected by the accessibility, affordability and acceptability of RHS. According to UNDP’s report Roca (2013) in Pakistan 260 per 100,000 live births, women die due to pregnancy related causes reflects the commitment of the government to provide the RHS to marginalized women.
Early marriage is one of the customs which is mostly practiced in rural areas. Due to low socio economical resources parents cannot afford required amount of food especially to their daughters therefore, early marriages is considered one of the way to get rid of this burden. Thus early marriage leads to early pregnancy that is one of the factors contribute to MMR. Early marriages consequently lead high parity. The National Institute of Population Study (NIPS) [Pakistan] and ICF International. 2013. report indicated total fertility rate in rural areas is high (4.2) and it is age specific fertility which is strong indication of early childbearing. It is estimated that 30 percent of all marriages fall into the category of child marriage which is more common in interior Sindh (Dawn 2012-01-19). It is well reflected in PDHS 2012-2013, that eight percent of teenage girls became mothers or expecting their first child. According to Roca (2013) Adolescent fertility rate is 28.1per 100,000 live birth which depicts the strong evidence of early marriage tradition in Pakistan.
Early marriages consequently lead high parity. The National Institute of Population Study (NIPS) [Pakistan] and ICF International. 2013. indicates the total fertility rate in rural areas is high (4.2) and it is age specific fertility. Every time when a woman gets pregnant, the risk of dying increases. A study conducted by Rahim, Shafqat and Faiz (2011) also revealed that out of 268 deaths 47 percent were having more than five children thus supporting the evidence that maternal mortality is higher in grand multigravidas. These findings are consistent with the study of Fawad et al. (2011) out of 78 maternal deaths 49 patients were multigravida.
Skilled Birth Attendant
Due to dearth of skilled birth attendants (SBAs) in most of the rural areas deliveries are attended by unskilled traditional birth attendants (TBA) in Pakistan. These TBAs are not competently trained to detect dangers sign during pregnancy and delivery and to refer women for further treatment. The National Institute of Population Study (NIPS) [Pakistan] and ICF International. 2013. indicated that 67% of rural women received antenatal health care, while 41% women were assisted for deliver by SBAs. The reasons for less utilization of antenatal and delivery services are dearth of SBAs, geographical hindrance and long distance from health facility.
Obstructed labor, antepartum postpartum hemorrhage, sepsis and eclampsia are obstetric emergencies which need timely intervention. Mortality due to these cases can be prevented by proper antenatal care and detections of life threatening signs and timely referral to comprehensive emergency maternal obstetric neonatal care (EmOC) services. A retrospective, analytic study to analyze direct causes of maternal mortality over a period of seven years was conducted by Rahim et al. (2011) identified hemorrhage a leading cause followed by pregnancy induced hypertension, ruptured uterus and septicemia. A study conducted by Fawad et al. (2011) revealed that eclampsia was the leading cause of maternal deaths followed by sepsis and hemorrhage. Perhaps these precious lives could have been saved if the antenatal and natal services were provided or utilized. These studies calculated MMR 1311/100,000 and 1,057/100,000 live births live birth respectively a big figure as compared to UNDP’s report by Roca (2013) reported MMR 260/100,000 live birth.
Abortion is one of the most important direct medical causes of maternal mortality, accounts for 12-40 % of overall global maternal deaths (WHO, 1994; According to a study conducted by Sathar, Singh, and Fikree (2007) an estimated 890,000 induced abortions are performed annually in Pakistan and 6 to 13% deaths occurred due to complications of abortion like hemorrhage, sepsis and visceral injuries (Jafarey, 2002). A descriptive observational study conducted by Shaikh, Razia, Abbassi, Rizwan and Abbasi (2010) revealed that 230 women were admitted with complications of unsafe abortion over period of one year. These complications include bleeding, uterine perforation, and gastro intestinal injury due to the procedure. Of these 12% women died as they developed septicemia. Deaths due to abortion can be prevented if the safe abortion care services are available by the skilled birth attendants at the door step.
Poor Reproductive Health Services: It is quite encouraging that we have good health system that includes basic health unit (BHU), Rural Health Center (RHC) and Tertiary unit. Even though RHS services are available free of charges, BHU and RHC services are underutilized because of long distances to access. Moreover, poor referral system causes a delay in getting access and treatment. According Ali, Bhatti and Kuroiwa (2012) majority of the hospitals were lacking EmOC services and most referral hospitals equipped with EmOC were inaccessible. As in most of the rural areas broken roads and unavailability of proper ambulance services hinder the transfer of women in time. A cross-sectional survey on emergency obstetric care services facilities conducted by Ali et al. (2012) revealed that more than 50 percent of the public health facilities were lacking female doctor to provide Emoc services, thus creating a barrier for women to opt reproductive health services.
Summary of analysis
Maternal mortality is a public health issue that should be stem out. There are many factors which contribute to MM, and poverty is worse determinant that prevents female to receive education, have nutritious food and get access for reproductive health treatment. Reducing inequity and promoting female education is one of the key strategies to empower women and to bring their status equal to man. MM due to obstetric emergencies can be prevented by strengthening existing health facilities and increasing female skill birth attendants
Government and NGOs should have one focused agenda to invest in female education as this is their fundamental right. Empowering women with education consequently will improve their socio economic status and will reduce the gender inequity as well.
Incentive should be provided to poor women who attend antenatal services in order to eliminate costs issue.
Food supplement and medicine for correction of anemia should be free available to pregnant women.
All the stake holders should collaborate in ensuring family planning and counseling services as to reduce unintended pregnancies which leads to induces abortions.
Reproductive health services including Post Abortion Care (PAC) and family planning services should be made available, accessible and affordable within community settings.
Civil society, educationist and health professionals should raise the awareness regarding Child Marriage Restraint Act 1929 and its reinforcement, as child marriage is widely practiced in some parts of the country.
It is imperative to strengthen existing health care facilities in order to provide emergency obstetric care.
More skilled birth attendants should be trained and deployed who will provide twenty four hours services and make timely referral in case of emergency obstetric care.
Health professionals should focus on research as suggested by Travis, et al., (2004) that identification of common national and international barriers in several studies will guide the policy makers and donors to pay attention.
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