Problems during Pregnancy & Labour in Pakistan

Address for correspondence:
Dr Manzoor Ahmed Butt
Family Physician, Researcher & Trainer,
Maqbool Clinic, Research & Training Centre,
Dhoke Kala Khan, Shamsabad,
Rawalpindi-Pakistan.
Postcode-46300
E-mail: manzor60@yahoo.com
drmanzoorbutt@hotmail.com

The conditions of Pakistani women, constraints on them and lack of opportunities available to them are very obvious to all. Pakistan is one of the countries where maternal mortality rate and foetal mortality rate are very high. About 246 women die every week due to complications of pregnancy / labour; and those who survive are left with chronic pelvic infections and even Vesico-Vaginal fistula. Major causes are lack of adequate medical facilities, ignorance, poverty, inadequate diet, early marriages, and large number of children.

I will focus on the first cause, namely lack of adequate medical facilities.

The most important factor in this category is lack of working lady doctors. Female doctors are only available in major hospitals of main cities. Many of them leave this profession after marriage on compulsion of their husbands. To be a doctor is one of the most difficult professions for females in Pakistan because it involves interaction with men, odd hours of work and overnight absence from home .The situation is very dire here and most women have only nurses as health professionals, available to them.

In Pakistan, the term "Nurse" includes the following categories:

1) Classified Nurse: The female must have passed high school examination in science to get admission into this course. She takes a four years course in Nursing during which she has to reside in hospital .She does not pay anything for it, rather she is given an attractive monthly stipend throughout the course. Despite all of these facilities, only girls from poor backgrounds enter these courses. Such nurses are only present in big city governmental hospitals and very expensive private hospitals. Due to proper education and training, they work ethically and are aware of the importance of working within own limits.

2) Lady Health Visitor (LHV): The female must have passed high school examination in science to get admission into this course. She takes a short course of about two years and she is basically trained in women's health and midwifery. They are meant for villages and towns but are rarely found there. They usually practice in cities as lady doctors. Most of them exceed their professional limits and are involved in criminal abortion.

3) Locally Trained Nurses: This is the most available variety. Some of these women are high school graduates but most of them have usually obtained 'middle passes' or less. They are neither adequately educated nor properly trained. They are absolutely not aware of their limits. They work in clinics and many private hospitals. Seniors among this category work as lady doctors and are involved in criminal abortion.

4) Lady Health Worker (LHW): These were trained by government to induce health education and create awareness about women's health. Females need to have obtained only middle passes as a local resident. Unfortunately, they also forget their limits and start acting as lady doctors.

5) Midwives or Traditional Birth Attendants (TBA): In Pakistan, TBAs are absolutely uneducated and non-trained. They not only unaware of their limits but also do not understand the importance of the referral network. Many of them have a very miserly and greedy nature. They are a major cause of maternal mortality and morbidity. They cause damage to mothers and newborns not only by their lack of knowledge and skills, but also due to their unending greed. They do not understand the importance of sterilization and use dirty hands on women and on newborns. They cut the naval cord with un-sterilized knives and tie it with dirty pieces of cloth or thread. They insert harmful weeds and their own made medicines in the vagina and freely inject Oxytocin I/M as a tonic or power injection before delivery.

Many nurses belonging in categories 2, 3 and 4 and almost all in category-5 make the lives of their clients worse not only due to medical reasons like Pelvic Inflammatory Disease and other complications but also cause social damage. To give just one example, Vesico-vaginal fistula (VVF) is a frequent medical outcome of obstructed Labour. This causes hatred and misery to sufferers by their families and husbands, ending in divorce as a social outcome. Unfortunately, there is no monitoring system available here that can keep them to their limitations..

I am working on the following two aspects to address this situation:

1) To create awareness in people about all the risk factors.
2) To educate and train nurses belonging to categories 2, 3, 4 and 5 not only in midwifery but also in understanding the referral network and needs of association with nearby doctors or hospitals.

I am educating the existing TBAs and Local Nurses in health education, STDs, family planning, breast self examination, antenatal care, importance & methods of sterilization, normal vaginal deliveries, immediate handling & care of newborn and postnatal care. This area has a lot of girls and married women who have completed high school education and are interested in such training and professions if they can be taught these skills with some stipend and further help to establish themselves as TBAs and Local Nurses. This would not only raise the health status of women but would also provide an opportunity for economic growth of this gender.

Recently, I have started introducing the knowledge and skills to save lives of mother and child to about one hundred girls who are under education in a homeopathy college. The course is in simple local language and is offered in two phases, namely The Fundamental Course and The Advance Course. I do not charge any money for this course rather I am providing all the education material free from my own humble income from clinic. The syllabus is as follows:

Life Support in Obstetrics {Fundamental Course}
Sterilization and asepsis, Anatomy (maternal & foetal), Menses, Gynaecological examinations, Breast, Family Planning (both regular & Emergency), Antenatal Care, Rhesus incompatibility, Pre-Eclampsia, Eclampsia, CPR,

Life Support in Obstetrics {Advance Course}
Foetal growth & well being, Vaginal bleeding during pregnancy (Ectopic pregnancy, Miscarriage & abortion, Antepartum Haemorrhage, Post Partum Haemorrhage, Placenta Praevia, accidental Haemorrhage, Hydatidiform mole), Twin pregnancy, Labour (normal & abnormal), Various methods of delivery, Puerperium, D&C, E&C, Resuscitation of newborn.

I have devised the course in simple local language and everything is going smooth but I am facing difficulty in getting slides, CDs and videos depicting various aspects of vaginal delivery. My single source of strength and continued support is no one else but Dr Lesley Pocock who has played a vital role in arranging various materials related to antenatal care, breast problems, immunization of child and child emergencies. She has acted as coordinator between me and various experts in the field. My very special thanks to her.