- The Washington Times - Thursday, September 24, 2009

A young woman, home alone, began bleeding after childbirth. Her husband wasn’t there to give her permission to leave the house, as is customary in Pakistan, so she waited for his return.

Once he came home, he carried his dying wife to a health care facility where he soon became a widower.

This is not an uncommon story in Pakistan, according to Dr. Sadiah Ahsan Pal, a professor of obstetrics and gynecology in Karachi. At a recent lunch on Capitol Hill, she discussed the high rate of maternal mortality in Pakistan.

The Congressional Caucus for Women’s Issues sponsored the event along with Women’s Policy Inc., a nonprofit, nonpartisan organization that champions key women’s legislative issues, in cooperation with the Global Health Technologies Coalition, a diverse group of nongovernmental organizations. A grant from the Bill and Melinda Gates Foundation supported the briefing.

“We are a victim of an unstable political environment,” Dr. Ahsan said in an interview after the event. “The past conflict with India [and] the Soviet-Afghan war have adversely affected our already crumbling infrastructure, with millions of refugees who never went back after the war ended.” Dr. Ahsan was referring to the Soviet-Afghan war of 1979-89, a conflict between the Soviet Union supporting the Democratic Republic of Afghanistan’s Marxist government and the Pakistan-backed Islamist mujahedeen resistance.

“The current situation of Taliban threats, recent earthquake as well, does not encourage development, education or improvement in our economic situation. Stability in our gov ernment and home environment will go a long way in improving the situation,” Dr. Ahsan said. The border region of Pakistan and Afghanistan continues to be a source of instability as insurgents fleeing coalition forces in Afghanistan are taking shelter in the border region.

“There has to be greater budgeting for health and education, plus development of infrastructure all over Pakistan, especially in the rural areas, where the situation for mothers and children is the worst, ” Dr. Ahsan said. About 0.6 percent of Pakistan’s gross domestic product is spent on health, according to the World Health Organization.

Dr. Christopher J. Elias, a physician and president of PATH (Program for Appropriate Technology in Health), said severe bleeding caused by childbirth results in the death of 150,000 women annually and remains the leading cause of death among women who die during childbirth worldwide. PATH is an international nonprofit organization working to create and sustain culturally relevant solutions for poor health and postpartum hemorrhage (PPH).

Three factors contribute to the rising number of deaths from PPH: lack of education among new mothers, lack of access to health care facilities, and facilities that are poorly equipped. This perpetual cycle of maternal mortality also affects the children. Newborns around the world without mothers are 10 times more likely to die within two years than newborns whose mothers survive, according to the World Health Organization.

Dr. Ahsan said at the luncheon that 1 Pakistani woman out of 89 dies of maternal causes, most commonly PPH. Seventy percent of childbirths take place at home because almost two-thirds of the country’s population is rural. The lack of access to transportation, poor roads and a mountainous topography result in many women walking miles to obtain care, she said. Because of these conditions, the children also suffer from health problems. One baby in 11 in Pakistan will not live to see his or her fifth birthday.

Pakistan produces a steady stream of qualified doctors, yet many of them leave the country to pursue more enticing opportunities, according to Dr Ahsan. Thus, Pakistan has many lower-skilled health care providers who are often limited in what they can legally administer to patients. Proper maternal health care is arguably “the most inequitably distributed product in the world today,” Dr. Elias said.

PATH seeks to ensure the efficacy of children’s vaccines and assure access to clean water and teaches neonatal resuscitative techniques for health care providers, according to “Solutions That Save Lives,” a PATH pamphlet. As technologies become available, PATH partners with local and national leaders to improve health care delivery and ensure providers use and sustain these new tools.

“It is frustrating to know the solutions are there and yet nothing is being done,” Dr. Ahsan said.

She referred to oxytocin, a hormone that contracts the uterus during childbirth. Oxytocin, given in medication form, has been clinically proven to reduce PPH-related mortality, according to another PATH publication.

During a panel discussion, Dr. Elias said that while many women give birth at home in low-resource settings, a disposable injection device called Uniject can be very helpful. Uniject administers vaccines. Also, its use to administer oxytocin is indispensable in attempting to reduce death during pregnancy. Uniject is simple enough for a village health worker or midwife outside hospital facilities to administer. Richard Greene, representing the U.S. Agency for International Development, also touted the effectiveness of Uniject.

Dr. Ahsan said Pakistan is making good use of Uniject in combating the spread of hepatitis B. A one-time injection of the appropriate medication helps reduce the risk of spreading this hepatitis because the needle cannot be reused; it collapses once the vaccine has been injected. Uniject also ensures accurate dosage through its pre-filled syringe; this makes application more user-friendly. This resource is crucial for a country lacking trained physicians, according to Mr. Greene and Dr. Elias.

Even with available vaccines, improper storage of such drugs can ruin their effectiveness. Refrigerated preservation, though necessary, remains costly in such a hot climate, Dr. Ahsan said.

“The challenge is how to take a proven intervention and make it available in weak health systems,” Dr. Elias said. There are available tools, yet continued investment and commitment is critical to reduce maternal mortality.

• Robyn Wethington is a student at the University of Missouri in Columbia.

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