For Pakistan’s five million expecting mothers, the pandemic brings dangerous disruptions
Mehreen Shahid
As Pakistan battles Covid-19, one of the grave and often underreported implications of this pandemic is the disruption of essential maternal healthcare access and delivery services for the over 5 million annual deliveries in the country, out of which about half take place at home or at a community-based health facility in rural areas.
A woman in her seventh month of pregnancy and scheduled for her third antenatal visit at the village Basic Health Unit in preparation for her delivery, is no longer able to make that visit. The government, in an attempt to control the spread of infection, has closed off hospitals and primary healthcare facilities with most providing emergency care only for limited hours. This situation becomes even more grave when women in labor or in emergency conditions can no longer physically access a healthcare facility or deliver with a skilled birth attendant.
While pregnant women are prevented from seeking essential antenatal care for nutrition, health and wellbeing, many are also forced to deliver with unskilled family midwives, called dais, resulting in increased fatalities due to excessive blood loss during and after delivery, which is already the leading cause of maternal mortality in Pakistan. Needless to say, this year we will see a sharp rise in the annual rate of maternal mortalities which already stand at 14,000 deaths, one of the highest rates in the South Asian region, and globally as well.
Those who are able to access primary healthcare facilities, mainly Basic Health Units which comprise 2-3 small rooms with a single delivery table, will be in an an environment where social distancing is not possible, where protective gear is not provided to skilled birth attendants, and where basic items like delivery kits are not currently available. In these circumstances, both pregnant women and frontline healthcare workers are not only extremely vulnerable to catching and spreading Covid-19, but also risk the life of newborn babies, which the system is ill-equipped to handle.
The situation is further exacerbated as the kind of disease impact on pregnant women and infants is currently unknown, with evidence yet to be analyzed and documented, making it impossible to prepare in advance for potential complications.
While exposure to Covid-19 and its health implications are the primary concern, there are socio-economic factors that also negatively impact pregnant women within their households. Women who are victims of domestic violence now have to endure the abuse on a daily basis with no respite and shelter, and the situation worsening due to the loss of income by the household’s daily wage earners.
As part of my work, I have counselled pregnant women who have miscarried as a result of violent abuse, because their husbands could not bear their constant pregnancy related symptoms. Many more such cases are and will happen across the country, as women are now unable to get the break they need to physically survive and to keep their unborn children safe. An additional implication is the extreme nutritional deprivation that pregnant women face, as their health needs cannot be a household priority when compared with the urgent need for basic food items necessary for survival.
Many development agencies in tandem with the government are providing support to address this crisis.
The World Bank has pledged a $200 million grant to strengthen health systems and to enhance infection prevention, but the timeliness and effectiveness with which funds are mobilized remains to be seen. Historically, bureaucratic procedures and lack of governance have significantly stalled implementation both nationally and provincially, eventually leaving the system exactly as it always has been.
At this point, the government should proactively ensure that necessary authorizations are pre-approved to prevent procedural delays and coordinate with all provinces to collectively identify and target high priority areas in need of support. This will also enable the exchange of useful information, the lessons learnt and success stories across provinces as Covid-19 is a national public health crisis and should be considered as such with collective ownership and accountability.
A coordinated and targeted approach by the government will ensure that essential maternal healthcare needs are addressed, especially at the community level where physical access constraints are a primary deterrent. In that case, properly equipped skilled birth attendants in protective gear should provide antenatal checkups and delivery services through household visits with exceptions made for complicated cases that require a healthcare facility or a hospital referral.
This is the only way social distancing will be possible, while ensuring pregnant women are not deprived of essential services, as the crisis rages on and the duration of its disruptions remains uncertain.