At the age of 27, Bak Sitara, a resident of Paluderi village in the district of Mardan in the North West Frontier Province (NWFP), is already a mother of three, and has endured the tragedy of two stillbirths. She is now seven months pregnant, but has been bleeding every fortnight for the past four years. "I went to the chemist and he gave me some tablets, but they haven't made a difference," she told IRIN. Asked why she had not consulted a doctor, she replied: "I don't need to go to a doctor, because my illness is not that serious."
Sitara's experience is not uncommon in this village. According to a recent survey carried out in Mardan by Pakistan's National Commission for Human Development (NCHD), at least 80 percent of the population has no access to health-care facilities. The most common problem affecting pregnant women was anaemia, the deputy district coordinator for the NCHD in Mardan, Dr Sadaf Zaffar, told IRIN.
PILOT PROJECT LAUNCHED
The NCHD is tackling this serious problem in the district and throughout the NWFP by way of a pilot project launched in November 2002 with the aim of reducing maternal mortality. The project will cover 200,000 people, and provide women in particular with the necessary medical assistance. The project was established following a comprehensive local study of the district.
Under the programme, Mardan has been divided into 56 units of 400 homes, each having assigned to it two trained female health workers, two female traditional birth attendants (TBAs) and one trained male health worker. One female worker together with one TBA cover the needs of 200 homes of the unit's total per month, while the other female worker and her TBA colleague deal with the remaining 200. The male worker covers all the unit's homes.
"This is the best way to work on this issue as the health worker is always available, easily accessible, it is cheap on our logistical costs and adds to the sustainability," Zaffar said.
Each female family health worker is paid 2,000 rupees (US $35) per month and each male worker 2,500 rupees. "The men educate the men of the house on the needs of pregnant women," Zaffar explained.
As well as dealing with health issues, the women educate villagers about water sanitation, and also carry out vaccinations. "It is a very systematic project and there will be rigorous monitoring," he said, adding that the women chosen to take on the task must be educated to a certain level to ensure the project's success and its ability to attain its goal of reducing maternal mortality.
"We are training local village girls, registering every pregnancy, examining each pregnant woman on a monthly basis, and have selected indicators to help identify any risk in the pregnancy," country chief for public health for the NCHD, Dr Moazim Khalil, told IRIN in the Pakistani capital, Islamabad.
The health workers are trained to identify symptoms which may harm the pregnancy by examining the feet of the pregnant woman, checking blood pressure and for weight loss and anaemia.
THE PROBLEM OF MOTHERS-IN-LAW
There are a number of factors which cause maternal mortality that can be easily avoided, according to health workers. One of the problems faced by pregnant women in Mardan is resistance from the mother-in-law to allow the expectant woman to be seen by the health workers as they are used to attending to the mother-to-be's health needs themselves within the community.
"The mother-in-law rules the house and doesn't understand why the pregnant woman should be referred to hospital as she herself had given birth at home without any medical assistance, regardless of complications or stillbirths experienced by them," a female health worker, Rahida, told IRIN in Paluderi.
"Sometimes when I try and take the blood pressure of a patient, the mother-in-law refuses to give me permission, asking why we are not checking her blood pressure too," she explained, adding that a woman would only be referred to hospital if she was fatally ill. "The women don't know anything about their rights," she said.
She explained that pregnant women put themselves at risk by continuing to do heavy daily chores such as fetching wood and water, and knew very little about personal hygiene and dietary requirements during pregnancy.
TRANSPORT AND TRADITIONAL PRACTICES
Another crucial factor fuelling maternal mortality in Pakistan is the cost of transport to the nearest hospital. With most families in the village Rahida works in earning up to 1,500 rupees per month, and the fare to the nearest facility costing about 500 rupees, most husbands refuse to pay.
Such problems are also compounded by cultural traditions. Sitara told IRIN that her movements were restricted for cultural reasons so that she could not travel without her husband, who works hundreds of kilometres away in the southern city of Karachi. But she was grateful for the help and advice from the health workers. "I have learned a lot from the health workers about what I shouldn't eat during pregnancy, and about cleanliness," she said.
The situation in Mardan is just a reflection of how serious the problem really is country-wide. There are no accurate statistics on maternal mortality in Pakistan, as a comprehensive study has never been carried out. However, the rate is estimated to be between 300 and 700 deaths for every 100,000 live births, making it one of the worst in South Asia.
According to the Pakistan Population Assessment, January 2003, compiled by the United Nations Population Fund, 5.4 million women undergo pregnancy and childbirth every year, resulting in 4.5 million new births in a population of 145 million people.
The main reasons for the high rates of maternal mortality are lack of prenatal care, of properly trained birth attendants or medical facilities, and of transport to the nearest properly equipped hospital, while almost 80 percent of births in the country occur at home.
"There is a preference in this society to have a birth attendant who can do more than just the delivery, such as massage and general help around the house, which means that they are not qualified properly. But this has been a tradition in Pakistan for generations," a project officer for women's health for the United Nations Children's Fund (UNICEF), Dr Nabila Zaka, told IRIN in Islamabad.
"The difference in having someone properly qualified is that a skilled attendant can spot complications, such as haemorrhage, early on and make referrals. So it is a matter of life and death," she stressed.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions