A typical day in the gynae ward of JPMC, Karachi, (Jinnah Postgraduate Medical Centre) sees 30 per cent critical and at times gasping cases, mothers on the edge of death. Most of these cases are of dying emergencies. Internal bleeding, ruptures, foetal death in womb, eclampsia and other complications keep the doctors and staff on their feet all day long. Among these cases are expectant mothers, new mothers, teenage mothers, and mothers with several older children. Some pregnant women come with older babies under two years old. The toll of these emergencies is devastating, not only for the individuals directly affected but also for their families and communities.

Large family sizes exacerbate the burden on maternal health by increasing the frequency of pregnancies, amplifying the risk of obstetric complications and adverse outcomes. Additionally, the physical and emotional toll of repeated pregnancies and childbirths can exact a profound toll on a woman’s health, predisposing her to a myriad of health challenges that elevate the risk of mortality.

The pain and suffering of losing a mother or witnessing a loved one’s fight for survival is an indicator of the urgency to tackle the root causes behind maternal mortality. The new mortality stats show the Maternal Mortality Rate (MMR) for Pakistan to be 154 deaths for every 100,000 live births. When comparing this rate to the MMR in developed countries, it is evident that maternal deaths are avoidable.

The United Nations Population Fund (UNFPA, Pakistan) data from 2020 provides a clearer view of the tragedy. “The maternal mortality ratio (MMR) is the lowest in Punjab (157 per 100,000 live births), followed by Khyber Pakhtunkhwa (165 per 100,000 live births), Sindh (224 per 100,000 live births), and Balochistan (298 per 100,000 live births). The MMR is 104 in Azad Jammu and Kashmir, and 157 in Gilgit-Baltistan. The ratio is also 26 per cent higher in rural areas at 199 deaths, than urban areas - 158 deaths,” states the report.

Health and Well-being is the third among United Nation’s Sustainable Development Goals (SDGs). The number one target set by the UN in this regard is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

Dr Nighat Shah, Head of the Dr Shireen Bhutta Centre of Excellence in Research at JPMC, feels that smaller families are good for the health of mothers and for reducing threats to their lives during pregnancies and childbirth. “Research and empirical evidence unequivocally demonstrate that smaller families play a pivotal role in safeguarding the health and well-being of mothers, thereby reducing the risk of maternal mortalities. The rationale behind this correlation is multifaceted and rooted in the principles of reproductive health and rights,” shares Dr Nighat.

Against the backdrop of Pakistan’s cultural and societal norms, which often prioritise large families, advocating for family planning becomes not just a matter of health but also of human rights. Empowering women with access to comprehensive reproductive healthcare services and education about contraceptive options is paramount. By enabling women to make informed choices about the timing and spacing of pregnancies, we can empower them to safeguard their health and well-being while also promoting sustainable development and gender equality.

“Family planning can be a leading factor in achieving the SDGs. It speaks of malnutrition, the economic situation of the families, livelihoods, poverty as well as education because women who are more educated are more likely to plan their families. If we want to achieve the SDGs, we should form a sound and comprehensive family planning programme. We should formulate a unified FP vision by integrating actions at policy level and on the ground,” says Dr Luay Shabaneh, UNFPA Country Representative in Pakistan.

“If we want to make a change and make a calibration between population and resources we should start at upper-level policy intervention with the reform of NFC (National Finance Commission) which needs to be target driven and support more allocation to the provinces with progressive performance in education of girls, gender equality, CPR (Cardiopulmonary Resuscitation) and other development targets. And if we want successful implementation of FP (Family Planning) programmes, we should focus on structural reform and shift our focus down to districts and tehsil level to make a real change on the ground,” stresses Dr Luay.

While acknowledging the importance of socio-economic considerations in discussions about family planning, Dr Nighat advocates for a greater emphasis on the critical issue of maternal mortality. She suggests a shift in perspective regarding the discourse on family planning. “The conversation about Family Planning, so far, has been focused on the socio-economic preferences of people. It talks about the necessity of family planning in the context of a better future for families, rightly focusing on the economic impact of large families. Although this perspective has yielded gradual but promising outcomes, it might be prudent to prioritise Family Planning as a means to reduce maternal mortality,” recommends Dr Nighat.

By prioritising family planning as a means to reduce maternal mortality, the conversation shifts towards emphasising the fundamental importance of reproductive health and rights. Access to contraception and reproductive healthcare services enables individuals to make informed decisions about their reproductive choices, including when and how many children to have, which can ultimately reduce the risk of maternal mortality by preventing unintended pregnancies and spacing births appropriately.

Importantly, this perspective recognises the intersectionality of socio-economic factors and maternal health. While socio-economic considerations are undeniably important in the context of family planning, they are intricately linked with maternal health outcomes. Women’s ability to access healthcare services, including family planning resources, is influenced by socio-economic factors such as income, education, and access to healthcare facilities.

Adopting a comprehensive approach to family planning - one that considers both socio-economic factors and maternal health outcomes - can lead to more effective and equitable outcomes. This approach involves not only addressing the economic implications of family size but also prioritising maternal health as a fundamental aspect of reproductive rights and healthcare access.

In summary, while acknowledging the progress made in discussing family planning in socio-economic terms, a greater focus on maternal mortality is a critical aspect of the conversation. By prioritising maternal health within the framework of family planning initiatives, policymakers and healthcare providers can work towards reducing the burden of maternal mortality and improving reproductive health outcomes for women worldwide.

In the face of adversity, there is hope. By embracing the principles of family planning and reproductive rights, we can chart a course towards a future where every mother has the opportunity to thrive, and no life is cut short prematurely. It is a vision worth striving for - a future where maternal health is safeguarded, families are empowered, and communities’ flourish.

At JPMC’s Gynaecology Ward 9B, the urgent cases that flood in daily serve as stark reminders of the critical need for action. Each life lost represents a profound loss to families, communities, and society at large. To honour these lives and prevent further tragedies, we must redouble our efforts to promote family planning initiatives and ensure access to quality reproductive healthcare services for all.

A BEACON OF HOPE

The Dr Shireen Bhutta Centre for Excellence in Research at Gynaecology Ward 9B is a pivotal institution located within the Jinnah Postgraduate Medical Center (JPMC) in Pakistan. Led by seasoned gynaecologist Dr Nighat Shah, the 60-bed Centre is dedicated to advancing maternal health and survival during pregnancy outcomes.

The centre is named after Professor Shireen Bhutta, senior gynaecologist who led the largest public-funded obstetrics and gynaecology department at JPMC in Karachi, Pakistan. She joined the JPMC in 1989. Professor Bhutta died in Toronto, Canada in September 2022 at the age of 60.

Taking her mission forward, the centre prioritises maternal health in order to reduce maternal mortality rates in Pakistan. With a focus on serving the most vulnerable segments of society, Dr Nighat Shah and her team emphasise the critical importance of providing access to quality healthcare services, education, and resources to underserved communities.

This centre is focused on patient friendly quality care, and believes in respectful and dignified care. This public setup free of cost centre houses ob-gyn subspecialties like maternal foetal medicine for high-risk mothers, high tech Infertility centre for couples who are having fertility concerns, gynaecology, oncology and urogynaecology.

The emergency section of the centre witnesses a staggering influx of patients, with up to 120 admissions daily and approximately 100 deliveries occurring each day. Many of these cases are critical, highlighting the urgent need for comprehensive maternal healthcare services.

The Kangaroo Mother Care ward, designed for preterm babies, premature neonates is essential for decreasing perinatal mortality in low resource setting. Additionally, the establishment of a neonatal ICU within the Gynae ward, in collaboration with the Sindh Institute of Child Health’s Dr Jamal Raza, underscores their dedication to saving new-born lives.

Through targeted interventions and community outreach programmes like conferences and advocacy campaigns, the centre works to raise awareness about the importance of maternal healthcare and family planning in context of research-based policies.

The centre acknowledges the invaluable support of various stakeholders, including the Sindh Government, JPMC, USAID, Pathfinders, Green Star, and others. Particularly noteworthy is the unwavering support of Executive Director JPMC, Professor Shahid Rasul, and the Vice Chancellor of the Jinnah Sindh Medical University Professor Amjad Siraj Memon, who has provided faculty and staff for the centre, advancing the centre’s mission.

Recently, the centre has embarked on exciting collaborations, including an MoU with a University Hospital Birmingham, UK. This partnership facilitates residents’ training abroad as part of a residency programme termed ‘Brain Gain’, emphasising their eventual return to serve the nation. Through such initiatives, the centre aims to enhance the skills and expertise of healthcare professionals while fostering global partnerships for the advancement of maternal health in Pakistan.

The Dr Shireen Bhutta Center for Excellence in Research at Gynaecology Ward 9B stands as a beacon of hope for maternal health in Pakistan. Through its commitment to compassionate patient care, innovative research, advocacy, and collaborative partnerships, the department is paving the way towards a future where every mother receives the quality healthcare she deserves.