Country case study
Dying to give birth: the Pakistan Liaison Committee’s strategies to improve maternal health in Pakistan
GK Siddiqui, Royal Free & University College Medical Schools, London, UK. Email firstname.lastname@example.org
Please cite this paper as: Siddiqui G, Hussein R, Dornan J. Dying to give birth: the Pakistan Liaison Committee’s strategies to improve maternal health in Pakistan. BJOG 2011; 118 (Suppl. 2): 96–99.
Pakistan has one of the worst maternal mortality ratios worldwide: 260–490 women die for every 100 000 live births in Pakistan. The Pakistan Liaison Group (PLG) was formed to work with and through the international office of the Royal College of Obstetricians and Gynaecologists (RCOG). It works with the RCOG representative committee in Pakistan to improve the health of women. It aims to contribute to improving maternal morbidity and mortality through strategies directed at improving the education and training of health professionals. In addition, the PLG aims to promote changes in the legislature to allow for the notification of maternal deaths so that accurate figures can be obtained, and so that health parameters can be accurately assessed and, in the long term, a confidential enquiry into maternal deaths can be initiated.
Pakistan is a country of four provinces: Sindh, Punjab, Baluchistan and the North-West Frontier Province. Each province is further subdivided into administrative functional districts. Pakistan’s public health delivery system functions as part of an integrated health infrastructure with a hierarchal organisation. The majority of healthcare providers (female health workers, female health visitors, midwives, nurses and doctors/medical officers) are employed in the public health sector, which is centralised under the federal and provincial ministries of health.
Although pregnancy is a normal condition that most women would hope to experience, it can be associated with serious morbidity and mortality. The most frustrating aspect of the high maternal mortality rate in Pakistan is that most maternal, as well as early newborn, deaths could be avoided if preventative measures were taken and effective care was provided by competent trained healthcare providers. For each woman who dies, many more develop serious conditions that affect them for the rest of their lives. Sadly, not only do women die but their children also, inevitably, suffer immeasurable harm. No wonder then that the improvement of maternal health is enshrined in the millennium development goals as one of the essential prerequisites for development and poverty reduction.
Pakistan has one of the worst maternal mortality ratios worldwide, and estimates suggest that 260 women die for every 100 000 live births in Pakistan, with this figure rising to 490 deaths for every 100 000 live births in certain rural regions. One in every 89 Pakistani women dies from causes related to childbirth, as compared with one in 8000 in the developed world.1,2
Three common causes of poor health in women and children in Pakistan are very high fertility rates, a high unmet need for family planning services, and very low numbers of skilled birth attendants. Despite having one of the best public health infrastructures in Asia, Pakistan’s poor health statistics point to a glaring lack of quality in the care dispensed and shortcomings in the implementation of ‘standard’ principles. The scarcity of skilled health personnel is a major contributory factor.3 Furthermore, a poorly funded and structured health service delivery system, especially at the district level, exacerbates the problem of getting the right care to mothers and newborns at the right time. The implementation of robust training programmes and the development of appropriately targeted curricula for healthcare professionals produce marked improvements in their knowledge and skills, which, in turn, translate into improved healthcare outcomes.4,5 However, for the full potential of such initiatives to be effectively realised, it is essential to accurately assess training needs and consider other contextual factors that could influence the outcome of these programmes.6
The Pakistan Liaison Group
The Pakistan Liaison Group (PLG) of the international office of the Royal College of Obstetricians and Gynaecologists (RCOG) is a body of obstetricians and gynaecologists who are of the Pakistani diaspora, or who have an interest in helping the women of Pakistan. It was set up in 2008, with a body of 20 members at both trainee and consultant levels. It is an independent organisation that works with the international office of the RCOG and through the representative committee of the RCOG in Pakistan. it meets three times a year, and is made up of a chair, a secretary and a treasurer. All members use the PLG as a platform organisation through which to coordinate their efforts to assist in healthcare delivery, skills transfer and education to improve the health of the women of Pakistan. In partnership with the Government of Pakistan and the Society of Obstetricians and Gynaecologists of Pakistan, it has formulated strategies to improve the ability of the nation’s healthcare sector to better meet the needs of mothers, and to increase demand for maternal and reproductive health services through education and training.
The PLG aims to formulate strategies and initiatives that focus on the key areas of:
- • enhancing public health facilities;
- • training more health workers in maternal and newborn care;
- • raising awareness among mothers, fathers, and families about reproductive health;
- • and establishing partnerships and alliances with civil sector organisations and influential community opinion makers to support maternal health initiatives.
Improving service delivery in obstetrics
The PLG has aimed to improve the service delivery of obstetric care in Pakistan by scaling up and capacity-building the skills of healthcare providers involved in the care of pregnant women. It is the aim of the PLG to commence a 3-year educational programme to improve emergency obstetric core skills for doctors and midwives. A pilot of the Liverpool School of Tropical Medicine (LSTM)–RCOG Life-Saving Skills Emergency Obstetric Skills Course (LSS EOC) was held between 26 and 28 April 2010. A total of 32 participants and two observers attended. A team of five external (UK-based) facilitators and one person for administrative support facilitated the course. Local organisation was aided by colleagues from the Society of Obstetrics and Gynaecology, Pakistan. Evaluation showed that participants valued the course, giving an overall score of eight out of ten for lectures and breakout sessions, with a mean overall score, for the use of time, enjoyment and ease of learning, of 8.5 out of 10. Knowledge assessment via multiple choice questionnaires (MCQs) showed improved knowledge in seven out of eight modules, and skills assessments showed significant improvements in all stations tested in all eight participants assessed. The course was used to consult with a wide range of stakeholders to demonstrate the training package and identify local facilitators. The aim of the LSTM–RCOG LSS EOC and newborn care training package is to increase the competency of trained skilled birth attendants to provide the signal functions of EOC and early newborn care (NC). The provision of skilled birth attendance (SBA) and EOC, coupled with NC, is a key strategy to reduce maternal and neonatal mortality and morbidity. A skilled birth attendant is defined as an accredited health professional, such as a midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.7
At least 80% of all maternal deaths result from five complications that are well understood and can be readily treated: haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortion.8,9 An estimated 15% of all pregnant women develop serious obstetric complications, which are usually unexpected and are life-threatening unless women have access to EOC.10 Suboptimal care contributes to maternal and neonatal deaths, and this includes the incompetence of available staff to recognise and manage complications of pregnancy and childbirth in a timely and effective manner.11–13
Similarly, in-depth assessments of the availability and coverage of EOC have shown that in many situations staff lack competency and skills, and for this reason are unable to provide all of the signal functions of EOC and essential NC.12–14
The combination of lack of knowledge and lack of skills is a key reason why beneficial evidence-based practices have still not been adopted in many resource-poor settings. Healthcare professionals as well as health service managers have a crucial role in implementing these interventions and ensuring that they are accessible to all pregnant women and newborn babies.15
In Pakistan and other parts of Asia it has been highlighted that the delivery of care to pregnant women is provided not only by midwives and specialists in obstetrics, but also by medical officers (doctors), most of which are male, especially in the rural setting, and who have little or no practical training in emergency obstetric life-saving skills. This raises the problem of access to care for women who would find it unacceptable to be managed by a male healthcare provider. In addition, these male medical officers have little or no training in EOC and hence provide substandard care.16 With this in mind, the PLG have made a recommendation to the Pakistan Medical and Dental Council (PMDC), which is the regulatory body in Pakistan responsible for the licensing of doctors. The strategy presented was to make EOC training a core component of medical training, and to include this component in all medical school curricula in Pakistan. This policy was adapted from a model introduced by Professor Robert Pattinson in South Africa, where practical emergency obstetric skills were introduced as a core requirement for all final-year medical students. The PLG proposed that the passing of an EOC course would become a prerequisite for gaining medical licensure. This will tackle the problem of the lack of training and skills at the grass-roots level, as most doctors will have to manage the care of pregnant women, including those with life-threatening emergencies, without any specialist training, and indeed without achieving core competencies in dealing with obstetric emergencies. This policy was approved in April 2010.
Notification of maternal deaths
A vital part of the PLG/RCOG mission is to work towards the notification of maternal deaths in Pakistan. Maternal mortality is an indicator of the status of women, their access to health care and the adequacy of the health system in responding to their needs. In countries where there is no civil registration of deaths, there is no auditable standard. Pakistan currently has no civil registration of maternal deaths and it is therefore difficult to obtain accurate figures for maternal mortality. We envisage that the implementation of the civil registration of maternal deaths in Pakistan would allow us to gain insights into the actual scale of the problem and indeed create the basis for an auditable standard. A working party comprising local obstetricians and gynaecologists in Pakistan, members of PLG, RCOG and other stakeholders in maternal health was formed in February 2009. This working party proposed the notion of maternal death notification to the speaker of the Provincial Assembly of Sindh. Under rule 102/103, a resolution was passed. The assembly was of the view that maternal mortality and morbidity levels are unacceptably high, and supported the goal that ‘No women should die while giving life’. It recommended that the provincial and federal governments should address the interlinked root causes of maternal mortality and morbidity, such as poverty, malnutrition, and lack of accessible and appropriate healthcare services, education and gender equality, and also recommended that a human rights perspective should be integrated into the initiatives developed. As part of the resolution, it was proposed that a ‘tick box’ should be added to existing death certificates that could be used to record the death of a woman in childbirth or up to 42 days postpartum. This proposal was passed in the province of Sindh on 23 December 2010, and we hope that it will also be passed at the Federal Government level to include all of the provinces of Pakistan.
Furthermore, we would envisage that these initiatives would go beyond merely measuring the scale of the problem. We would hope that policy makers in Pakistan would ask ‘Why do maternal deaths occur and what can be done to prevent them?’ Answering such questions is as important as knowing the precise level of maternal mortality, as outlined in the World Health Organization (WHO) document ‘Beyond the Numbers’. When these questions have been answered, we may be able to offer more focused strategies to prevent these silent tragedies.
There is an essential need to improve the training and education of all health professionals, at both undergraduate and postgraduate levels, involved in the delivery of medical care to pregnant women and newborns. Along with improvements in curricula and training, it is imperative to review the methodology of training and to develop the provision of continuous medical education. A modified form of educational programme, using the best evidence-based teaching methods, with an emphasis on practical hands-on training, could be implemented. Such a programme could result in significant reductions in maternal and neonatal mortality.4,17
Emergency obstetric life-saving skills pertaining to the five main causes of maternal death are the key to this educational exercise, which it is hoped will increase the numbers of skilled birth attendants with improved knowledge and thus an improved ability to deliver optimal care to the pregnant women they serve.
Maternal death notification is a pivotal step in improving maternal health in Pakistan. It is possible to prevent maternal deaths even in resource-poor countries. Knowing the level of maternal mortality is not enough, but it is a start. The data obtained will eventually enable a search to be carried out for the reasons behind the deaths of women in Pakistan, and this information will then allow us to develop solutions to specific problems in each region and setting.
Disclosure of interests
The authors have no conflicts of interest to disclose.
Contribution to authorship
G.K.S. is the main author. R.H. and J.C.D. contributed to the article.
Details of ethics approval
No funding was received.