World Population Day on 11 July with its theme “Family planning, is a right, make it real” was a bleak reminder for Pakistani health practitioners of the precarious state of maternal, neonatal and child health (MNCH).
Prime Minister Syed Yusuf Raza Gilani has said his government plans to reduce the annual rate of population growth to 1.55 percent from 1.8 percent over five years, but health practitioners say the efforts and money spent so far on family planning programmes have not achieved the desired results: Often, women only stop having children when their husbands or mothers-in-law say so.
A recent major survey showed a decline in births per woman since the early 1990s, but no improvement since 2001.
The Pakistan Demographic and Health (PDH) Survey 2006-07 - carried out by the National Institute of Population Studies and officially launched in Islamabad on 11 July in the presence of the prime minister - said the average number of births per woman in the early 1990s was 5.6 and this fell to 4.1 in 2004-06, but the improvement virtually stopped in 2000-01.
The survey is the largest household-based study (95,441 families) ever conducted by a research institution, and hopes to provide much needed information to policy-makers.
“We are disappointed because the government has spent lots of money - mostly borrowed or begged - on MNCH and yet indicators are so poor relative to countries such as Nepal, India and Bangladesh,” said Farid Midhet, former director of the health programme for the international Asia Foundation non-governmental organisation (NGO).
He remained sceptical of the estimated national MMR (Maternal Mortality Rate) recorded in the PDH survey at 276 maternal deaths per 100,000 live births, stating: “We believe this could be a slight under-estimate for various reasons… In all probability, there has been no significant reduction in maternal mortality since 1986.”
Midhet, who also formed the Safe Motherhood Pakistan Alliance, blames the poor results on the lack of coordination and planning: “The bureaucracy and the NGO sector working in MNCH have no leadership, supervision, accountability or direction.”
Many women want to space (20 percent) and control the number of births (52 percent), but lack access to family planning resources, the survey said, adding that only 22 percent of married women used modern contraception methods.
Convincing the “clerics”
“Short of forcing couples to adopt a more permanent method of contraception, there is no way we can achieve this figure,” said Abida Sultan, in charge of the government-run family planning (FP) centre at Qatar General Centre Hospital in Karachi.
“We have to convince the clerics to pass on the message as we have failed to bring the couples to our centres,” said Sultan. Having worked in family planning for years, she said while women are aware of the problems they face, more work is needed on men.
The PDH survey indicated only 39 percent of babies were delivered by skilled health personnel, with 60 percent of births handled by untrained persons, adding to the risks of maternal morbidity and mortality. Only 34 percent of all deliveries took place in health centres.
 Photo: Zofeen Ebrahim/IRIN  |
| A doctor examining an expectant mum at Qatar General Hospital in Orangi |
The survey also revealed that only 61 percent of women had made at least one antenatal care visit to a health professional - a doctor, nurse, or lady health visitor. Postnatal care (PNC) was not common in Pakistan, with only 22 percent of mothers reporting for PNC. The gap between antenatal and postnatal visits remains wide and is getting wider, according to Midhet.
Qatar Hospital’s outpatient clinic receives on average 500 women every day. “About 700-800 women register with us every month but only 350 actually come for delivery, of whom 200 may not even have registered.”
This phenomenon, explains Aneesa Fatima, an obstetrician at the hospital, means “women believe that they have to register and come for antenatal [check-ups] just in case they have complications at the last minute... Most prefer to deliver in the comfort of their homes assisted by traditional birth attendants. The common perception is that only the unhealthy and weak need to deliver at the hospital.”
“The government’s plan to double the [number of] lady health workers to 200,000 in the next five years is hopefully going to help bring the maternal deaths down,” said Rahila Khan, another obstetrician at the hospital.
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