"After my first delivery at the city hospital, women from my village questioned me with surprise that why did I go to the city hospital for the delivery when it was possible at home? They said that if they could have deliveries at home, why couldn't I?"
So said 25-year-old Shabnam* to me. For Shabnam, who lives in a village of Sindh province, delivering babies in a hospital is a privilege that most other women living in the same village do not have. She belongs to a family that has their own transportation and can afford the expenses to take women to well-equipped hospitals in big cities. For the majority of the women, delivering babies at home and seeking the help of unskilled midwives is a common and affordable alternative.
Over half of Pakistan’s entire population lives below the poverty line, with women and children suffering the worst in this scenario.
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Although Pakistan’s key social indicators – education and health – have been showing progress over the years, the maternal, infant and child mortality rates still do not meet the 2015 MDG target.
Mortality on all levels has witnessed gradual decline, yet the curbing of infant mortality rates has remained a hard nut to crack, staggering way behind the expected targets.
The year 2014 came with adverse influence of the problems that Pakistan has been facing for a long time now. Amid the web of natural disasters and terrorism, Save the Children (UK) declared that Pakistan has the highest first day deaths and still births in the world — another blow to the country's failing status.
The report further disclosed that about 40.7 per 1000 babies are either still borns or die within 24 hours of their birth, due to lack of available skilled care, one of the reasons which has exacerbated the situation in rural areas where the majority of the country's population lives. This unskilled care comes from local elderly women called daai(s), who are usually illiterate and lack scientific training.
The obvious fact is access to health and education in villages depends on the village's proximity to these facilities. The more isolated the village, the more are its people dependent on daais. But even in the case of villages not too far away, the proximity is not helpful if they are not physically connected with nearby cities.
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The main cities in rural areas are supposed to be connected with villages via a web of connecting roads, but this web is very weak in rural Sindh, where the majority of villages are deprived of proper roads. As a result, transportation becomes almost impossible, blocking the flow of social services into the villages and constraining villager’s lives.
The situation is even worse in the northern districts of the Sindh province, known for having a rigid and tribal culture where tribal clashes are common. Dr Safiullah, who had been working with Save the Children (US) as a medical officer in Shikarpur district until September 2013, narrated the situation:
"During my job in STC, my team and I encountered several problems in accessing villages without 'pakka' roads – we could never reach the villages that did not have any roads at all. Although those villages were not very far from us, the absence of roads made our access impossible.
"These cut-off villages have a very conservative culture where women are not taken out for healthcare; neither can any doctor or nurse visit them, as there is no pathway to reach these scattered communities."
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The Maternal, Neonatal and Child Health (MNCH) program has been launched to address the deteriorating situation of maternal and child health in Pakistan. Funded by the government of Pakistan and other renowned international organisations such as DFID, USAID and UNICEF, the programme has been showing progress in terms of capacity building, particularly in the Sindh province.
The very first cohort of 1500 community midwives has been deployed in different areas of Sindh. These midwives are trained through intense training of anti-natal, natal and postnatal care from registered nursing schools and are ready to undertake the practice in their own communities after receiving their diplomas.
Dr Sahib Jan Badar, the provincial head of MNCH program in Sindh is very hopeful about the future of the MNCH program, she elaborated the current ongoing efforts to control first day deaths:
"When MNCH started five years ago, we just had nine nursing schools, now the number has reached to 25, which is very encouraging. Almost every district has one nursing school in order to train local women as midwives. Once our midwives are ready to practice in their respective communities, we provide them with the birthing station – a small labour room – at their houses.
"All equipment in the birthing station is provided by the MNCH program. Our midwives are also trained in dealing with umbilical cord infections, the second most prevalent cause of first day deaths. Some of our midwives deliver 40 babies in a month without any death. We also train our midwives to document all deliveries and keep a record. They are required to send these records every month and we maintain it online."
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However, the biggest challenge to the MNCH program is still the same: to reach out to the scattered communities in the rural areas where, due to a lack of literacy, it is difficult to recruit educated young women – the basic selection criterion for midwives.
This program also requires sustainability; patronage from the provincial government, provision of vehicles and other relevant facilities, as well as monthly salaries to midwives. This is how the targeted pool of midwives to spread services to vast areas can be ensured.
*Name changed to protect identity.