A midwife plays a crucial role in giving awareness to women about their reproductive health. She looks after a pregnant woman and her baby throughout the antenatal period, during child birth and gives postnatal care. She also provides psychological assistance and helps the mother in family planning. Because of continuous interaction, the relationship between a midwife and a mother is more intimate than any other person involved in the maternity care process. Research has shown that women who have access to a midwife, experience less preterm births, fewer interventions during labor and shorter hospital stays. The absence of trained midwives in Pakistan is leading to maternal morbidity resulting in infertility, chronic pelvic diseases and psychological disorders.
The United Agency for Population stated in the State of World Population Report 2017 that globally 28 per cent or 127 babies per 100,000 live births die. In Pakistan, according to the Population Council——an international non-profit, non-government organisation——nearly 8.6 million women become pregnant, of which 1.2 million or 15 per cent women face obstetric complications. According to the World Bank Pakistan’s Maternal Mortality Ratio (modelled estimate) is 178 per 100,000 live births. If we assess this figure province-wise, the situation becomes more alarming. According to Punjab Health Department’s Annual Health Report 2913-14, Punjab alone suffers 227 maternal deaths per 100,000 live births. This raises question about the quality of obstetric healthcare services provided at the facility level. It also points out the lack of a functional referral system at the district level. In the overall assessment Pakistan is not spending sufficiently in its primary healthcare services.
Child-birth has increasingly become a medical event leading to unnecessary medical interventions, like too many Caesarean Sections, which can cause severe infection, haemorrhaging, and organ damage. Research has shown that most of the maternal deaths happen because of haemorrhage and pregnancy-induced hypertension. Similarly, infection is the second most common killer of the new-born. These infections could be either transferred from a mother to child or due to unhygienic environment. Though no correlation is found between C-Section rates higher than 10 per cent and maternal or new-born mortality rate, many countries including Brazil, Pakistan and India have seen the rate of C-Section rise to 30 per cent. This dilemma could be attributed to the diminishing culture of natural birth.
Midwives have for years played this supportive role. In a country like Pakistan, where 70 per cent of the population is still rural the provision of a qualified midwife becomes more important. The situation is worse in places like Khyber Pakhtunkhwa and FATA. Midwives are required to be trained in these regions for providing 90 per cent of the healthcare at the grassroots level.
According to the Pakistan Demographic and Health Survey of 2013-14, even now, 32 per cent women in urban areas and 60 per cent in rural areas give birth at home. All these births are not assisted by skilled attendants leading to complications. Most of the midwives attending birth at home are the Traditional Birth Attendants (TBA) who are neither trained nor skilled. Due to their unhygienic practices and lack of knowledge of complications that may arise, they are a dangerous option and a cause of high maternal mortality and morbidity.
According to Dr Asad Hafeez, DG Maternal Health, Pakistan needs more than half a million midwives (500,000) to meet the current healthcare needs. He was also quoted saying that Pakistan does not have the infrastructure in term of colleges or schools for midwifery. He said that with the current setup Pakistan cannot produce enough midwives in the coming 15 years. This challenge Dr Hafeez suggested could be overcome by increasing the existing number of schools for midwives and raising the standards of midwifery and nursing.
Leading gynecologist Professor Sadiqua Jaffery said in a press conference in Karachi on the World Midwifery Day that: “Midwives are playing an important role in the developed countries in safe motherhood programs. It is important to replicate these programs to improve maternal and neonatal care in Pakistan.”
According to research conducted by Pakistan National Forum on Women’s Health there were more than 85,000 villages and at least 200,000 competent skilled midwives were needed in basic health units, rural health centers, taluka headquarters hospitals and tertiary care hospitals.
Founding President of Midwifery Association of Pakistan, Imtiaz Kamal has been quoted in media saying that midwives were pathetically low paid and they face a hostile environment because the doctors and the medical students were reluctant to take them as part of the team.
“We believe that by trusting, promoting and training of skilled midwives, Pakistan will be able to achieve Sustainable Development Goals like other countries,” she observed.
Cognisant to the above quality gaps in midwifery the Punjab Healthcare Commission (PHC) is moving towards filling these gaps.
The Punjab Healthcare Commission has developed Minimum Service Delivery Standards for midwifery centres and other establishments providing mother and child healthcare and family welfare services. Once approved by the concerned authorities, the standards would be shared with the relevant category-III healthcare establishments across Punjab. In order to fulfil its broad mandate to regulate healthcare service delivery across all types and kinds of healthcare establishments in Punjab, the PHC has categorised healthcare establishments into three broad categories, utilising bed strength as an indicator of the level of services offered. Midwifery centres, along with clinics of general practitioners, radiological and imaging diagnostic centres and other establishments offering outpatient care, have been categorised as category-III establishments.
These efforts of the PHC will go a long way in improving the quality of life of the conceiving mothers and their new-borns. The PHC looks forward to seeing Punjab Healthcare Establishments taking midwifery as a serious business so that the country has healthy women to bring up secure and strong families.
The writer is a freelance journalist based in Lahore.