Innocent lives in danger

Life was never easy for Zaiba. After two years of marriage, 26-year-old Zaiba finally conceived a baby. Hailing from a small remote village in Bajaur District, Khyber Pakhtunkhwa (KP), she grew up in abject poverty with her three brothers and four sisters. She was then married off to an unemployed sick young man from a neighbouring village. Uneducated herself, Zaiba is dependent on her father-in-law to provide for her and her husband while she stays at home and helps her mother-in-law with household chores.

On one night at the end of her pregnancy term, Zaiba started feeling a nagging pain in her back. She sought medical help from a private clinic for which she had to travel four hours by road to the nearest city. “The doctor gave me 3 injections and 2 tablets and told me I would be fine in a few hours. I did not get better! I went to a Lady Health Visitor (LHV) at another place and she gave me two drips and told me to keep walking in order to deliver the baby,” narrates Zaiba.

Several hours passed before she told her she needs to go to the MSF facility in Timergara (a six-hour drive away from the clinic) because her situation was beyond their abilities to care for.

What Zaiba did not know was that she had been terribly mishandled by both the TBA (traditional birth attendant) and the LHV.

“Zaiba received a very high dose of Oxytocin and Misoprostol tablets which induced premature labour. When she arrived at MSF, the baby’s heartbeat was weak and the patient had developed complications. The baby was in severe distress and the patient was bleeding. Luckily, we delivered the baby, and since his oxygen levels were low, we kept the baby in the neonatal care. His birth weight was 4 kg – too big for a normal delivery for a woman as petite as Zaiba, therefore delivered through an emergency c-section,” tells Esther, MSF’s midwife manager at the maternity unit in Timergara.

“Unfortunately, after two days of fighting for his life, her baby did not survive, Zaiba was admitted at MSF in the post-op ward for several days till her urine was clear. Gradually, Zaiba started walking and eating. But enduring the traumatic loss of her baby will not be easy for her. We wish she could reach to us on time,” adds Esther.

Zaiba’s mother-in-law is in tears. She regrets not bringing Zaiba to MSF directly when she did not get better after the first three injections she received. However, thinking they could save the expense of travel, they decided to keep on waiting – till the situation got out of hand. “My husband is the only earning member of the family and he works in another city. We paid the LHV Rs 1,300/- and it cost us Rs 5000/- just to get here after driving almost 7 hours. But all our hard-earned money was wasted. Wish we took the right decision on time,” laments Zaiba’s mother-in-law.

After her near-death experience, Zaiba is finally gaining her strength back – enough to feel angry about what she was put through by the LHV and TBA before she came to MSF. “If I could, I would go back and strangle them for what they did to me! They kept saying push and walk till I collapsed due to exhaustion,” says a livid Zaiba. She is also receiving counselling with regard to birth control and spacing since she needs to allow her body to heal from this trauma.

There are so many unaware women like Zaiba who paid a heavy price for using oxytocin in the shape of losing their child. Oxytocin is a medication which is used to begin or improve contractions during labour. If used incorrectly, can lead to the uterus rupturing and neonatal death. In Khyber Pakhtunkhwa, exposure to unregulated treatment with labour-inducing medication is common. Despite carrying high risk for mother and child, the traditional birth clinics tend to use this drug without much caution.

Key Facts
* Oxytocin is a hormone that is on the World Health Organization’s Essential Drug List due to its role in preventing bleeding after birth. In certain cases, it can also be used to induce and augment labour. It is known under the brand name Syntocinon in Pakistan.
* When used to induce labour, Oxytocin should be administered only by a doctor in a controlled environment like a hospital and patients must be monitored closely to detect complications.
* Oxytocin is widely available in Pakistan – for prices as low as 10 rupees. Women or family members often ask for it before and during labour, and are administered ‘hot injection’ or ‘garam teeka’ by people who are not authorised to do so.
* Misuse of Oxytocin is known to carry severe risks of uterine rupture for mothers, and death and serious injury to new-borns.

Facing challenges

Misuse of labour-inducing medication such as oxytocin has been identified in Pakistan and other countries as contributing to maternal and neonatal mortality. In rural areas of Pakistan, especially Khyber Pakhtunkhwa, health care workers who are trained to administer the labour-inducing medication are not always available and patients mostly rely on unskilled health care workers who are not authorised to use labour-inducing drugs. There is no strict monitoring on implementation of regulation, distribution and sale of labour-inducing medications, which are available without prescription. There is a strong need to sensitise community and community-based health workers regarding the adverse effects of oxytocin and other labour-inducing drugs and to make them aware that these drugs should only be administered by authorised health workers in appropriate facilities where patients can be closely monitored.

In a bid to create awareness and to provide medical assistance, MSF (Médecins Sans Frontières or Doctors Without Borders), an international humanitarian NGO, has been actively involved with Timergara District Headquarter Hospital (DHQ) since October 2010. This assistance includes support to the Maternal and Child Health (MCH) department, which is primarily run by the Ministry of Health (MoH) staff, in the form of human resources, provision of medical and logistical supplies as well as rehabilitation of the emergency operating theatre, recovery room and acute post-operative wards and full support to sterilisation, hygiene and waste management. The hospital is meant to cater to the inhabitants of Timergaga, which is a city in Lower Dir district, Khyber Pakhthunkwa (KP). However, patients also come from neighbouring districts, as well as the Federally Administered Tribal Areas (FATA). All services are provided free of charge.

“A day will not go by without us receiving two or three patients who have received oxytocin or some other labour-inducing drug before admission. The majority of those women arrive with serious complications, often requiring some kind of surgical intervention,” reveals an MSF

Midwife activity manager at DHQ.

Saving lives

Many lives can be saved if the risks of complications are detected in time and if emergencies are treated quickly. In the KP province, as in the FATA, women who are refugees, displaced or poor have very little access to high-quality obstetrical and gynaecological care.

In 2011, after evaluating obstetric and gynaecological needs in Peshawar and neighbouring rural areas, MSF decided to build a hospital for women, furnished with a labour and delivery room and an operating room. The Hospital provides essential obstetric care for women including screening, prevention and treatment of disease during pregnancy and/or labour and delivery.

Peshawar is home to many Afghan refugees. Many of them live in refugee camps where the healthcare facilities are limited. MSF’s hospital in Peshawar places special emphasis on Afghan refugees to improve their access to quality healthcare services.

Shareefa Noureen is an Afghan refugee living in Pakistan. She moved to Pakistan a year back after getting married to her cousin. The family of her in-laws moved to Pakistan after a member of the family was killed in Dast-e-Barchi. Shareefa’s husband is a bread seller in the city. She came to MSF’s Women Hospital Peshawar for the delivery of her first baby.

“I didn’t know much about the hospital. Our neighbour told me about MSF and that their hospital has good doctors. My baby is delivered now, and I am very happy. I shall be discharged from the hospital soon,” elucidates Shareefa.

Shareefa had a normal delivery, but she was kept under supervision after she had unexpected bleeding. “After the delivery, she had more bleeding than usual which we normally call Postpartum Haemorrhage. We took her to the operation room to control the bleeding, and she is doing fine. There can be various causes of bleeding but the main reason is when the uterus doesn’t contract after delivery. Shareefa suffered from the same situation, but with quick medical care, the bleeding tear was repaired. She was given a dose of oxytocin to help with contractions as per the MSF medical protocols,” explains Kathrine, an MSF midwife.

“The doctors and midwives have good ethics and good behaviour here. If I had been at another hospital, I fear they would have not given me this much care and attention. Also, other hospitals are expensive and this is free of cost here,” appreciates Shareefa.

Hundreds of women have been treated at the MSF Women Hospital in Peshawar so far including Tasleema who came to the Hospital for the delivery of her third baby. She travelled for more than six hours from her hometown, Parachinar, in Kurrum to Peshawar for the delivery. As she was worried due to her prolonged labour, she looked for the appropriate medical facility and came to know about the MSF hospital through her relative. Her relative, who also had her baby delivered at the MSF facility, advised her to go to MSF hospital.

Tasleema had a normal delivery with the help of the doctor’s advised limit of oxytocin. “I am happy that MSF doctors have supported me during the labour and I had a normal delivery, other hospitals were saying that they would conduct a c-section delivery,” expresses Tasleema.

“We have a syringe pump of oxytocin and a 500ml ringer. Through the specific procedure, we gave it to Tasleema, and it was increased every 30 mins as advised by the doctor,” describes the nurse who was present at the duty.

“If we notice no progress when it comes to initiation of contractions, we start oxytocin. The drug is given in an appropriate quantity under the supervision of a doctor in our medical facility. If given incorrectly, labour inducing drugs can prove fatal,” she adds.

However, patients don’t seem to understand the repercussions of misuse of oxytocin. “Patients ask for oxytocin to speed up labour. Women even leave against medical advice when we explain that we cannot give them this drug just because they ask for it. Some patients go away at the beginning of labour and come back two hours later fully diluted, having received hot injection,” discloses another nurse at Peshawar Women’s Hospital.

Creating awareness

It is often believed among people that use of labour-inducing drugs can speed up the process of labour; can provide relief from the labour pains; and will shorten the length of the labour, even if oxytocin is administered by an unauthorised person. To counter this misconception, MSF is raising awareness in several ways. “Our health promotion and outreach teams in Peshawar are engaged with patients and community members directly on this issue, communicating to them and making them aware of the benefits and potential risks of misuse. We are also working with media to develop radio spots to pass this message to the wider community. We have also been working with local stakeholders such as non-governmental organisations, research and teaching institutions and regulatory bodies to raise awareness of and find appropriate solutions to the problem of oxytocin misuse,” informs Dr Gul Khalid, MSF’s Medical Coordinator. “Sadly, labour-inducing drugs are easily available, and administration consequently lacks accountability mechanisms to ensure that health workers are correctly and safely administrating the drugs,” she adds.

Talking about measures that need to be taken in order improve correct use of labour inducing drugs, Dr Khalid suggests, “The government should ensure that access to labour inducing drugs is controlled safely. Trainings of TBAs (traditional birth attendants) on safe patient care during delivery should also be encouraged as this group of women often are the first responders to support deliveries in the communities.”

No doubt, tighter regulatory control measures for the use of labour-inducing medication, as well as better training and awareness among healthcare workers and the community are critical to improve this situation.

Photo Credits: Khaula Jamil & Zahra Shoukat

Erum Noor Muzaffar is the editor of You! magazine. She can be contacted at iram29@hotmail.com