Against all odds

Maternal healthcare remains a challenge under the harsh conditions of Thar.
by Farahnaz Zahidi Moazzam

Somewhere in a posh neighbourhood in the bustling metropolis called Karachi, a mother gets up dizzily at the sound of the alarm, and gets ready for the day ahead. A regular day where she will drop off her two children to an upscale school after they have a hearty breakfast of pancakes and eggs, and get ready for her 10 O’ clock appointment with an obstetrician who will give her the regular antenatal checkup as this mother is expecting for the third time. She has been listening to her doctor’s advice -- her diet is wholesome, her sugar and blood pressure levels are fine, and she is getting the needed dose of vitamins, sleep and care at home.

At a distance of six and a half hours by car from Karachi, down the National Highway, in the heart of the district of Tharparkar, in a small village called Mithrao Chakar, another mother gets up early in the morning. It is twilight and she wakes up to burn a small lantern and gets ready for the day ahead. A regular day where she will walk a good ten kilometres and collect water from the nearest pond, and bring it in three clay pots, two of which will be balanced on her head and one under her arm. She will cook one, or if in luck, two meals for her family.

Her family consists of her husband, his aging mother, and seven children, while the eighth is on way. Their meals will consist of bajray kee roti (bread made of pearl millet), dried red cayenne pepper, and steamed wild vegetables she had gathered and stored after the rare rainy season. Her pregnancy is in its seventh month, and her youngest child is 20 months old. She has obvious signs of anemia and malnourishment.

Both these women belong to the country. Their stories are symbolic of the disparity between the economic conditions of the people of Pakistan, particularly between the urban and rural sectors.

The International Women’s Day (IWD) is celebrated on the 8th of March, and is a global day celebrating the economic, political and social achievements of women past, present and future. The first International Women’s Day event was run in 1911. The year 2011 is the Global Centenary Year. As this day celebrates the success and courage of women of the world, this write-up celebrates the women of Pakistan, particularly of Tharparkar. The success of these women and the people helping them is in fighting the odds and living with dignity.

Tharparkar’s landscape is that of a desert. Droughts are not uncommon here, and this is one of the most food-insecure regions of Pakistan. The sight of the women of Tharparkar in colourful clothes is familiar to anyone who has seen any documentaries or photographs of the region. Reds, purples, fuchsias, yellows……the women are dressed in a myriad of colours, wearing white bangles covering their entire arms.

Krishan Sharma was formerly manager of the project of HELP (an NGO in this area and a member of GAVI Alliance Consortium) focused on alleviating malnourishment among children between the ages of one to five. According to Sharma, this use of bright colours is a psychological defence mechanism. “The more barren and colourless their lives, the more they have a need to dress in these brightly-coloured clothes. That is the only colour in their lives,” says Sharma, pointing obviously towards how hunger and poverty suck the colours out of life.

Malnourishment among mothers is a common phenomenon in this area, especially in the Nagarparkar region. Anemia and lack of proper nutrition makes the mother weak and prone to pregnancy-related complications. HELP (Health, Education and Literacy Programme) has taken on board LHWs (Lady Health Workers) who try and aid not only the task of rehabilitating malnourished children, but also the mothers. Sometimes, the smallest of things like a much-needed capsule of folic acid a day to ward off anemia or teaching these women to sustain by preparing nutritious but economical food can save lives.

A whopping 20.3 percent of the women of Pakistan die in pregnancy, childbirth and the puerperium (the period following childbirth, lasting approximately six week).

According to PDHS 2006-07 (Pakistan Demographic and Health Survey) there are 276 maternal deaths per 100,000 live births. The leading cause is postpartum haemorrhage while obstetric bleeding causes 27 percent of maternal deaths. Over 14 percent of MM (Maternal Mortality) is caused by puerperal sepsis (an infectious disease that afflicts women in the postnatal period). Infectious agents enter the birth canal of the woman during complicated childbirth. Inflammation of the vagina and of the uterus or the cervix occurs first, and then the infection may become generalised sepsis. This cause is followed by eclampsia. Eclampsia is a life-threatening complication of pregnancy and results when a pregnant woman previously diagnosed with preeclampsia (high blood pressure and protein in the urine) develops seizures or coma. About 10 percent MM cases are due to eclampsia.

Commuting is one of the most difficult prepositions in Tharparkar. Absence of proper roads means that one either walks for hours on foot, or mounts a horse or camel, or has a four-wheel drive vehicle. Sometimes, the nearest health facility may be 40 kilometres away. Against this backdrop, often a pregnant woman with a complication has to travel on a camel’s back or carried by relatives to a hospital in emergencies. Many women lose the battle of life on way. Two-thirds of all births occur at home. In rural Pakistan, 74 percent of the births are at home (PDHS). In this situation, training TBAs (Traditional Birth Attendants) also known as daais seems an intelligent option. PVDP (Participatory Village Development Programme), an NGO and also a member of the GAVI Alliance consortium, is doing this to help improve the quality of maternal health in this poverty-ridden area.

Lali, a TBA, is one of the two daais of Mithrao Chakar who got basic but crucial training by PVDP. Experience is etched over Lali’s face, alongside the wrinkles that have formed due to the harsh weather of this region. The services 63-year-old Lali provides include the delivery, massage of the mother for four days, bathing the mother and the baby, washing the mother and baby’s clothes, and cooking khichri. “I keep checking the mother after 7th month of pregnancy, and try and determine the position of the baby,” explains Lali. And what does she charge for all of this? A mere Rs100 and one chaadar.

When asked what kind of training Lali and other TBAs get, Dr Ramesh Kumar, Health Coordinator PVDP, says that previously all TBAs used to make women in labour lie down on layers of sand so that the bodily fluids excreted during delivery were absorbed. But the chances of Tetanus were very high back then. Now, they encourage and make sure that all women have received Tetanus vaccines to avoid the possibility of her contracting Tetanus from the soil during delivery. “We give TBAs little ‘safe delivery kits’ that are life savers with simple yet indispensable things like gloves for the midwife, a plastic sheet to spread under the woman to avoid contact with soil, a sterile blade, sterile thread to tie the umbilical cord, sanitary pads etc,” says Dr Kumar. Simple changes that have saved scores of lives.