Pakistan: Motherland

Alefia T Hussain
How the earthquake has aggravated the lack of healthcare for expecting mothers.
Too much happened too quickly at 8.55 am on the deadly October 8. With the most idyllic parts of Kashmir and NWFP jolted, millions of people went missing under sliding mountains and man-made structures.
Only cries of 'help' filled the air. 'Help!' At first loud and desperate, but fading gradually... close to 80,000 were silenced forever and many orphaned, widowed, crippled or rendered homeless by the worst ever earthquake in the history of the country.

In the midst of this struggle for survival on 8/10, something miraculous happened. A new life came into being... Just when the earthquake hit, the gynecological staff of Mansehra's district hospital were in the process of delivering a baby, "until doors and window panes of the labour room began to rattle," says Chand, a lady health visitor (LHV) at the hospital. Those were, of course, the first signs of the earthquake. Still calm, they waited for the shocks to halt. "But they wouldn't stop," she adds. The expectant mother panicked and her labour pains stopped.

Panic was declared inside the labour room within seconds as the tremours continued and intensified. The woman in labour was moved out of the room and placed in the open area between the midwifery and the gynaecology ward of the hospital. These sudden movements disturbed the natural process underway. The lady doctor therefore had to induce labour pains. But the earthquake that turned everything upside down was unable to turn the child's positions. At the end, they were able to deliver the child normally.

That perhaps was one miracle. Cases of miscarriages, premature labour, stillbirths and excessive bleeding are reported aplenty. For instance, in the same district hospital, almost a month after the tremblor, eight-month pregnant Husin stared into empty space of the women's ward. Her face was expressionless, one that has undergone immense pain and suffering. Chand introduced her as a fresh arrival from Rajwal, a village between Kaghan and Naran. "She is bleeding," Chand explains. Most of the talking for Husin was done either by Chand or her husband due to the language barrier. "We had to travel a long distance to get to the village camp in Balakot. Most of the travel was treacherous. Compounded by the shock and grief of losing some of the close ones to the quake, this has complicated her pregnancy," said her husband.

Husin sat on the iron bed that did not have a mattress because the man in charge of the hospital store was off for Juma break. Smack opposite her, in the overcrowded ward, an intrauterine death (IUD) had occurred. The mother had been there for the past three days.

At some distance from the district hospital, Gul Bibi gave birth to a normal baby after premature labour at the Italian Field Hospital. "Official at the Balakot camp village referred us to this hospital," says her husband Mir Ahmed.

Many pregnant women suffered massive injuries in the quake, says Dr Qais Mahmood, provincial officer for the United Nations Population Fund, while talking to Tini Tran of the Associated Press of Pakistan.

"The first issue is that women are coming for care not because of pregnancy-related issues but for other injuries. The biggest challenge we have is that we have ladies coming in with multiple fractures. Then during examination we find out about intrauterine deaths," he says.

Those are just a few lucky ones being treated at hospitals in Mansehra. United Nations estimates some 17,000 earthquake-affected women in Pakistan are expected to give birth in the next two months. About 1,200 of them will face major complications and about 400 will require surgical assistance.

UNFPA, the United Nations Population Fund, warns that the health and safety of these pregnant women and adolescent girls are in jeopardy due to the shock and trauma they suffered in the quake, the harsh living conditions they now face, and their limited access to basic health services and emergency obstetric care.

Anis Haroon of Aurat Foundation visited the earthquake affected areas last week. She laments: "Even before the devastation, Pakistan had an inadequate healthcare system. Various basic health units (BNU) were merely buildings. Nothing significant took place inside them. Now after the earthquake, nothing remains."

She adds: "For one, there are not enough female doctors and volunteers working in the (quake-hit) areas to treat the women-related health issues." The shortage of female medical staff and community workers is also one of the major challenges for UNFPA as many maternal health providers are injured, displaced or killed.

The district hospital Mansehra is in a shambles. The walls around the maternity ward are cracked and the space inside cramped as it is packed beyond capacity and the staff overworked.

In field hospitals set up in the open areas of the town, cases of child birth are of low priority. Because, "I assume other cases are much more critical," says Dr Mercedes Tatay of Medecins Sans Frontieres (Doctors Without Borders). Besides, Italian Dr Heike Tobien maintains that "Pakistani women are sturdy and take child birth in a stride."

However, in an effort to reach out to people in remote areas, the UNFPA has dispatched a mobile unit comprising a female doctor and a nurse-midwife. A gynae/obstetric mobile unit of Governor Mobile Hospital FATA was also spotted in Mansehra. The truth is that even in the best of times, Pakistan's statistics on maternal health are dismal. United Nations estimates that throughout the country 540 mothers die for every 100,000 live births roughly due to poor pre-natal care, lack of properly trained birth attendants or medical facilities, to name a few. Almost 80 per cent of births in the country occur at home. "I have no money for medical facilities or dais," says seven-month pregnant Naureen, a resident of a remote village Kookmar in district Abbottabad. Unlike her previous four deliveries that were done by midwives in Lahore for Rs 1500 to 2000, this time she plans to seek assistance from elderly women of the village. She hopes by the time the baby arrives she has some kind of a makeshift shelter to keep herself and the newborn warm. She spends nights in a tent with her three sons and a daughter and others in the family. Naureen's husband is a naanbai who works at a restaurant in Wah Cantt for Rs 120 a day. The quake brought her double-storey house down, like most of the houses in her rustic neighbourhood. Child births at home are a norm in the rural areas of the country. Pakistan's few and scattered maternal health care programmes have in the past approached the issue only half-heartedly. But this time because of the crisis caused by the quake, health and welfare of pregnant women should take top priority.

Husin after the recommended week's treatment at the hospital will return to her "home in the tent village in Balakot", says her husband. So will Gul Bibi and others. But the most pertinent question, of course, is: are those flimsy, makeshift shelters appropriate for a mother and her newborn to live in for most part of the harsh winter season?

Originally published on 20 November 2005 in The News on Sunday.