One of the best studies presenting an accurate idea of the scale of the problem was carried out between 1991 and 1993 for the Aga Khan University. For this purpose, women living in high-risk districts were chosen across the country (except in Punjab Province due to financial restrictions).
These comprised four in the southwestern province of Balochistan, eight in the NWFP along with two tribal agencies, and samples from all across the southern Sindh Province. However, only some of the findings have been released to date. The study revealed that the most shocking statistics applied to the district of Khuzdar in Balochistan, where there were 690 maternal deaths for every 100,000 live births in a population of a million people.
"We do already know that the maternal mortality rate is high and exactly where it is at its worst, but we just don't have accurate statistics," Farid Midhet, the research director at the Population Council, told IRIN in Islamabad.
Training for traditional birth attendants has been continuing over the past five years in 32 villages of Khuzdar, covering 7,000 women, and Midhet said it had resulted in a 30 percent drop in maternal mortality. "Utilisation of health services has increased by 300 percent in this district," he said.
Midhet, who was one of the key researchers for the Aga Khan University report, stressed that the problem was just as severe in urban areas. "We found that in some urban areas of Karachi, the rate was close to 300 per 100,000 live births," he said. He compared these figures to the rate in developing countries in South East Asia, where an average of between 40 and 70 deaths per 100,000 live births obtains. "Even Bangladesh, previously known for high rates, is reporting a decrease." Some 10 years back, the rate in Bangladesh stood at a shocking 800 per 100,000 live births.
Another study, carried out by Pakistan's National Institute of Population Studies (NIPS), documented maternal mortality rates between 1991 and 1992 for a reproductive health and family planning survey. The average was found to be 533 per 100,000 live births - but that figure was not released until 2001.
"The estimates they [NIPS] give are 12 years old due to the method used in the survey, and this is also not a very accurate method," Midhet said, adding that the huge expense of such studies had prevented a country-wide survey being carried out. "We recently held a meeting with all the concerned health officials and presented a plan for a survey at a cost of over one million US dollars over a three-year period, and it will at least give us a benchmark."
Midhet commented on expensive efforts made over the past 10 years to reduce the maternal mortality rate, but says they have had very little effect.
TRADITIONAL BIRTH ATTENDANTS
Over a 10-year period between the 1970s and 1980s some 53,000 TBAs were trained by UNICEF and the government under the safe motherhood project. Each was paid US $0.90 for attending the training. "The big question is who exactly were these TBAs? They could have been housewives pretending to be TBAs, and there was no way of checking or following up, so it was a big waste of money and the maternal mortality rate continued to increase," Midhet stressed.
UNICEF believes that the evaluation carried out following the training showed improved knowledge and skills among the TBAs, but agrees that there is room for further training. "Not much work was done on developing the health system, for example on when a woman should be referred to hospital," Zaka said.
Midhet divided the TBAs into several categories. "It could be someone who just cuts the cord at the birth or cooks and cleans in the house in the run-up to the birth, and supervises women in the house to help deliver the baby in the house. Or there are the professional TBAs, who usually work in the local hospital and come to the house for the birth, but charge a heavy fee of US $10 [a monthly wage for some families]. So women opt for the cheaper inexperienced women to help with the birth."
He maintained that TBAs could not be trained to be community midwives. "They have to be able to read and write and understand some terms which cannot be translated into Urdu because there is no word in Urdu, and should be able to communicate on a professional level with doctors, which a TBA cannot do for cultural reasons," he said.
UNICEF is currently running three women's health projects in Sindh called "Women's Right to Life and Health". Under these projects, 24-hour medical services have been established for women, along with education on preventative measures against infections, with the right to privacy and confidentiality. "The preliminary findings are very encouraging and we're thinking of replicating the project," Zaka said. The agency is also supporting a women's health project run by the Asian Development bank by offering technical advice.
Back in Mardan, pregnant women now at least have some help at hand. Basnihaar, aged 19, is six months pregnant and has already had the misfortune of a stillbirth. "I have lower abdominal pains, but I haven't been to the doctor yet," she told IRIN. "I got some tablets from the chemist; he said I had a kidney problem, but the pain has not gone away," she added.
She said she had stopped taking unnecessary medicines after seeking advice from the female health workers. Basnihaar is also fortunate in having an understanding her mother-in-law. "I have taken on all the household tasks that my daughter-in-law was doing because I don't want her to suffer again," mother-in-law Benazir told IRIN. "I want her to have a healthy baby."
The NCHD plans to expand its programme to another 16 districts, including Narowaal and Attock in the Punjab, Pashin and Mastang in Balochistan, and Gotki and Thatta in Sindh by the end of June 2003 with a view to training 55,000 female health workers and posting them to rural areas.
Khalil maintained that education was crucial if the country were to succeed in tackling its growing maternal mortality rate. "I asked a group of health workers in a village how many mothers they would expect to die out of 100 births, and one doctor responded with 10 or 15. I asked if he thought this was too much, and he said no, this was to be expected. This is dangerous as it has become the norm."
Khalil said the NCHD could only expand further with more resources. "The cost per person per year for this three-year project is US $1.50, covering 14 million people in a total of 16 districts. This is a small amount and can be easily expanded if we can raise the funds."
The female health workers already employed under the NCHD project can only hope that their efforts are replicated in further efforts to save hundreds of innocent lives every year.
"The best thing about my job is to be able to help a pregnant woman and make sure she has a safe and healthy pregnancy. We are the first women in this village [Paluderi] to make women aware of such rights, and it is a real joy for all of us," one NCHD female health worker, Nighat Seema, told IRIN.
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