or centuries, childbirth has sometimes brought tragedy instead of joy. In recent decades, both India and Pakistan have made great strides in reducing the number of women who die bringing new life into the world.

While the progress continues in India, Pakistan’s maternal mortality rate has risen for the first time in years.

Governments, non-governmental organisations and community groups in both countries are doing what they can to help more mothers survive.

A disturbing development

Until recently, maternal deaths in Pakistan had been declining steadily and sharply, falling from 286 deaths per 100,000 live births in 2000 to 140 per 100,000 in 2017, estimates by various international agencies, including the World Health Organisation suggest. The most recent consolidated numbers from the Pakistan Maternal Mortality Survey however showed that the rates had risen since then, to 186 per 100,000 in 2019.

This is still better than the overall rate from 13 years earlier but the rise is worrying for experts. A new survey is due in the next few months. It is feared that the rates will only continue to rise in the wake of a series of disasters, including the Covid-19 pandemic.

“There were large-scale disruptions in the healthcare delivery system at the height of the pandemic, thus severely affecting perinatal care. Things can only aggravate from there,” says Dr Shamsa Humayun, vice president of the Society of Obstetricians and Gynaecologists of Pakistan and the pro-vice chancellor of Fatima Jinnah Medical University, Lahore.

Once Covid infections waned, the country was wracked by seasonal dengue fever epidemics before devastating rains deluged a third of the country’s territory.

“The risk of transmission of water- and vector-borne diseases, compounded by lack of access to maternal healthcare services during floods, has potentially wreaked havoc,” she said.

But disease and flooding aren’t the only culprits behind rising maternal deaths. Population Council Pakistan – a non-governmental organisation focusing on population growth, family planning and reproductive health – links Pakistan’s annual growth rate of 2.4 percent to the maternal mortality rate, which translates to 11,000 maternal deaths annually.

“Approximately 3,800 mothers can be saved each year simply by catering to the unmet demand for contraceptives to increase contraceptive use from the current 34 to 52 percent,” sas Samia Ali Shah, the council’s project director.

She says Pakistan’s overall fertility rate of 3.6 children per woman is the highest in South Asia. Because of the unmet need for family planning, each couple of childbearing age has an average of one unintended child.

Certain areas in Pakistan fare worse than others when it comes to maternal mortality. For example, Balochistan has the highest MMR among provinces, at 298 deaths per 100,000 live births, compared with 157 for the Punjab. Rural areas generally do worse than urban ones. Among moms who die, obstetric haemorrhage is the most common cause, followed by blood pressure disorders.

Throughout the country, a lack of funds – both on an individual and societal level – exacerbates the problem. According to a report by the Punjab Economic Research Institute, Pakistan spends less than 1 percent of its gross domestic product on healthcare and has lower levels of public health spending and per-person health spending than other countries in the region. Families face high out-of-pocket costs that make quality maternal health services inaccessible for many expecting mothers.

The location of health services also makes a difference. About a fourth of the primary care facilities in the Punjab are located at a distance of more than 10 kilometres from most villages. This burden the households in terms of cost and time. Experts and surveys show that maternal health services are used more often by mothers who are affluent, educated and urban than those who are poor, uneducated and rural.

Similarities and

differences

Maternal deaths in India also fell steeply for decades – from 398 per 100,000 live births in 1997-98 to 97 per 100,000 in 2018-20, despite many of the same challenges Pakistan faces: a lack of healthcare access in rural areas, malnutrition and difficult geography in a country that sees more than 25 million births a year.

India’s latest maternal death rate is lower than Pakistan and has shown no sign of rising again.

Experts say that’s because of a continued focus on the problem, and a boots-on-the-ground strategy to help women get the care they need.

“We took a three-pronged strategy on MMR. First, improving institutional deliveries and standard operating procedures; increasing the frequency of visits by accredited social health activists (ASHAs), grassroots healthcare workers who go door to door offering health services and attend to the women who were not going to hospitals for deliveries. The basic issue was of improving the standards both at the level of the caregiver and in the delivery rooms. We devised an incentive system for ASHAs in such a way that they got good money only if they visited throughout the nine months,” said former health secretary CK Mishra, who was among those who oversaw the progress.

A campaign by ASHAs, in which they went door to door doing some basic blood tests on pregnant women and referring them to higher level care when required, also generated confidence among women, he said. In addition, there were anganwadi centres set up under a government programme to reduce childhood malnutrition that provided free meals to pregnant and lactating mothers. This was done under the National Food Security Act 2013.

Certain areas in Pakistan fare worse than others. Balochistan has the highest rate, at 298 deaths per 100,000 live births, compared to 157 in the Punjab. Rural areas generally do worse than urban ones.

“States also upped their game,” Mishra said.

Across the country of 1.4 billion, more pregnant women received care from health professionals. According to the latest National Family Health Survey, a government assessment conducted every few years, 78 percent of new mothers received post-natal care from a doctor, nurse or other healthcare professional within two days of delivery. The number of births in hospitals rose from 79 percent in 2015-16 to 89 percent in 2019-21.

Outreach

Governments in both countries have realised that a key to reducing maternal mortality is reaching out to the most vulnerable moms.

India’s recent successes in family health have a lot to do with a landmark reform in 2005, when the National Rural Health Mission was started and healthcare workers went door-to-door in communities to provide basic healthcare at their doorsteps. Various incentive schemes under the mission ensured that more women were financially able to go to the hospital for deliveries.

States modified schemes under the mission’s umbrella to fit local needs, according to a 2010 article in the Indian Journal of Public Health by the chief UNICEF officer in Chennai. The more developed states in South India modified a conditional cash transfer scheme designed to motivate women to give birth in the hospital. To target those at greatest risk and allow the money to go further, they limited it to women below the poverty line up to the first two births. A few states with particularly high maternal death rates, meanwhile, allowed all women to partake in the scheme.

Another programme that helped reduce maternal deaths in India, is the Janani Shishu Suraksha Karyakaram, which entitles all pregnant women delivering in public health institutions to free delivery, including cesarean sections. They also get free medicines, diagnostics, blood and transportation between their homes and healthcare facilities.

India’s federal Mother and Child Tracking system monitors pregnancies and immunisations for mothers and newborns, generating work plans daily for the women health workers on the ground.

Provincial governments in Pakistan are also trying to increase their outreach and offer more services to women in local communities.

Dr Khizer Hayat Khan, director of maternal and child health for Khyber Pakhtunkhawa, says the government has employed 16,500 lady health workers, who are going door-to-door to raise awareness of maternal health issues. He says community midwives are also spreading the message of family planning.

Khan says that pregnant women should make sure they have four antenatal visits before giving birth to prevent pregnancy complications. Currently, he says, many families face what he calls 3 Ds – delay in reaching care, delay in seeking care and delay in receiving care.

Since the floods, he says, the Health Department has provided medicines and more health workers in certain affected areas.

Pakistan’s latest maternal mortality survey has shown that a staggering 12 percent of all deaths among younger women are due to pregnancy and childbirth complications.

“This isn’t a result of any fatal disease but just a phase in a woman’s life (when she is) otherwise very healthy. This only goes to show that we, as a society, do not value our women,” observes Dr Azra Ahsan, the eminent gynaecologist and public health expert, who is currently a technical consultant and vice president of the National Committee for Maternal and Neonatal Health.

She says the system does not have the capacity to stem the number of deaths among women of child-bearing age. Cultural barriers at the societal level and a lack of commitment and professionalism at institutional levels contribute to this otherwise preventable disaster.

She says Pakistan has not made progress commensurate to the amount of global funds poured into the nation’s mother and child health sector over the last two decades.

“The WHO, the UNICEF, the UNFPA, Bill and Melinda Gates Foundation among other global institutions invested a lot of money and scores of local NGOs are providing community service. Yet, the desired results remain elusive,” she says.

In spite of similarly uneven reduction in maternal mortality across provinces and the urban and rural areas, India hopes to achieve its target of an MMR of 70 per 100,000 live births by 2030. “I don’t see that happening in Pakistan,” Ahsan says.

Amer Malik is an investigative journalist associated with The News International, Pakistan. A fellow of East West Centre, he also contributes to various international media outlets. He tweets at @AmerMalik3

Wisal Yousafzai

About the project: These stories are part of a three-year programme coordinated by the East-West Centre to encourage Indian and Pakistani journalists to identify important stories of common interest in the two countries.