Creating networks of care to support mothers and children in rural Pakistan
By Fatima Raja
KHANPUR, Pakistan– A row of women sit in a brightly decorated waiting room at the Khanpur Basic Health Unit. Outside, in the lush grounds, fruit trees sway in a cool breeze offering relief from the summer heat. The women are waiting for their monthly antenatal checkups or have brought their babies for a postnatal visit.
Inside, Dr Aisha Iram, the Medical Officer at BHU Khanpur, smiles down at Mahvish. Only seven months of age, Mahvish squirms at the cold touch of the stethoscope and her proud mother holds her close. "Mahvish was born by C-section at the Headquarter Hospital in Sheikhupura City," says Dr Aisha. "We knew her mother's case history – she had had a prior C-section as well – and told her to go straight there for her delivery."
Dr Aisha is one of only four women doctors who head a Basic Health Unit, a rural primary care facility in Sheikhupura District – a critical shortfall in a society where women often go without antenatal or postnatal care, or consult traditional birth attendants known as dais, rather than see a male doctor. As a result, according to a 2004 survey, fewer than a third of deliveries in Sheikhupura were attended by skilled birth attendants. Only 43 per cent of women receive antenatal care from skilled attendants, and 25 per cent receive postnatal care. These low figures contribute to the high rate of maternal mortality in Sheikhupura, reflecting the national figure of approximately 320 deaths for every 100,000 live births.
Despite this, most doctors, especially women, prefer to work in cities or overseas where pay-scales are usually higher. Lack of security and mobility, and urban facilities such as education, are other major deterrents.
Dr Aisha herself was born and bred in nearby Sheikhupura Town, yet she has travelled a long way to practice in this rural community. She read medicine in Moscow and won a gold medal and a scholarship for further study. Unlike many young Pakistani professionals, she chose instead to return. "In my heart I belong to one country which is Pakistan, and another country which is Russia," she says. "But I decided to come home."
Dr Aisha entered a residency programme at Lady Willingdon Hospital, a tertiary-care hospital specialising in obstetrics and gynaecology in Lahore, about 60 kilometres from Sheikhupura. Here she found out about the Punjab Safe Motherhood Initiative.
The Punjab Safe Motherhood Initiative is a pilot project with the government of the Punjab Province which seeks to reduce maternal and infant mortality in Sheikhupura District by rotating ten female postgraduate doctors to the district's hospitals. These young women conduct deliveries at two secondary level hospitals in the district's major towns. Equipped with a mobile ultrasound unit, they visit 12 rural Basic Health Units every month to provide on-site antenatal care.
"These linkages can make the difference between life and death," says Dr Tahir Manzoor, the Health Specialist at UNICEF's provincial office in Lahore. “We can train people in the communities, we can even have doctors working there, but in an emergency, the only thing that may save a woman's life is prompt and appropriate referral."
When Dr Aisha was rotated to Sheikhupura, she was also exposed to a secondary aim of the Safe Motherhood Initiative: to familiarise young doctors with rural medicine and its rewards. Here she was not only serving her community, she could make a concrete difference. After completion of her residency, Dr. Aisha decided to join a Basic Health Unit (BHU) in a remote village of Sheikupura as Incharge of the health Facilty. Though a junior doctor, as the medical officer at BHU Khanpur, she says, "I realised that I'm in charge. I can take it in any direction I want." Moreover, she could commute from her family home in Sheikhupura Town 16 kilometres away, eliminating problems of security and mobility.
When Dr Aisha first came to Khanpur, she faced hostility from women of the community who preferred the attention of long-standing dais to doctors they feared were dishonest. Fortunately, Dr Aisha's ties with the district helped. "My family belongs to the Jat clan, which is populous in Khanpur," she recalls. "My relatives talked to the influentials here. Seeing the local connection they gave me a chance and I have had no problems since."
As the hostility subsided, Dr Aisha started restocking the BHU and setting up a labour room. She conducted informal surveys of medical needs and habits. With community-based Lady Health Workers, she set up discussion groups on the needs of pregnant women, from the importance of saving funds to how to tell if a woman is undergoing complications that need special care.
They showed results. As women accepted Dr Aisha's expertise, the number of antenatal visits rose from about 800 in 2006, the year she joined, to over 3,700 in 2007. Many women now come for eight or more antenatal visits, and continue for postnatal care.
With her experience at Lady Willingdon, she tapped into the Safe Motherhood Project's most significant achievement: a referral network. "I conduct some normal deliveries here and arrange transport just in case," she says. "For women with complications, I tell them to go to Sheikhupura or Lahore. There have been times when I sat in the car and went with the woman because she was nervous." Through the Safe Motherhood Initiative, she could call dedicated help-lines to request ambulances and alert doctors in higher level facilities to her patients' cases so they immediately received the appropriate emergency treatment.
"These linkages can make the difference between life and death," says Dr Tahir Manzoor, the Health Specialist at UNICEF's provincial office in Lahore. “We can train people in the communities, we can even have doctors working there, but in an emergency, the only thing that may save a woman's life is prompt and appropriate referral." With the success of the Safe Motherhood Initiative, similar projects have been initiated in two other districts by Government of the Punjab with the help of UNICEF and UNFPA.
Dr Aisha is one of several young women who has passed through the Safe Motherhood Initiative and now intend to practice in their home communities. With a full awareness of their own communities' needs and ways, they bring an unprecedented level of care to rural areas. The Initiative provides a model for creating a system whereby local doctors are fully integrated into a network that reaches from homes through to tertiary care hospitals, and ensures that the appropriate level of care is available to rural mothers.