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October 18, 2017

Delayed access


October 18, 2017

Globally, each day around 1,600 women die from complications relate to pregnancy and childbirth. Like the rest of the developing world, Pakistan’s mortality indicators exhibit similar trends.

Pakistan is the third largest contributor to the global toll of maternal mortality. The health of mothers and newborns in Pakistan is typified by death and disability from complications related to pregnancy and childbirth. These health risks are far greater in the country’s remote and rural areas. A closer examination of factors associated with high maternal and neonatal mortality levels reveals transport barriers as one of the major factor to timely access to health facilities or to skilled healthcare providers.

Various studies establish a strong relationship between timely access to transportation with lower maternal and neonatal deaths. Moreover, it has been shown that approximately 80 percent of maternal deaths can be averted by timely accessing the essential maternity and basic healthcare services. Global data reveals similar issues in countries like India, where half of the reported maternal deaths occur on the way to a health facility.

Various factors attribute to lack of access to transport  that can move women to healthcare facilities. Lack of adequate and affordable transport is recognised as a key barrier for women in the community. This problem is more evident in the rural areas of Pakistan, where geographical contexts are challenging: poor rural roads, mountainous terrain or isolated areas during the rainy season.

The cost of transport plays a major role in deterring pregnant women from seeking care during pregnancy and delivery, or in emergency. Even when a vehicle is available, its cost may inhibit its utilisation in certain cases.  People living in remote and rural areas prefer going to nearby traditional birth attendants or midwives instead of wasting time in finding a transport during emergency situation. Also women residing in high mountainous or hilly areas are brought down on doli carts on rope, which is their traditional vehicle, and then they are carried in some intermediate transport; this results in a delayed arrival to the healthcare facility.

Apart from the unaffordability and lack of round-the-clock availability of transport facilities, the distances between home and health facilities also contribute as a major hindrance to access to healthcare, most importantly in rural areas. In Pakistan, health facilities that are equipped to deliver maternal services are usually at the tehsil and district levels, far from the reach of many communities. 

A review of maternal deaths at a tertiary hospital in Pakistan revealed that long distances contributed to 40 percent of maternal deaths. In these cases, distance is a greater barrier than cost, as efforts are made to save the life of the mother regardless of expense. The problem of distance becomes worse if the efficiency and quality of road infrastructure is poor. During the rainy season, travel time can increase substantially as roads may become flooded with water.

It is evident that cultural and social norms also inhibit women from seeking healthcare outside their home and using transport to reach a skilled healthcare facility or a skilled healthcare provider for themselves or their children. Furthermore, transport choice in the context of community cultural practices is also a factor. Vehicles which are open or without curtains, or taxis in which a woman has to sit close to the driver, are not considered suitable to use.

Women’s autonomy also plays a key role in contributing to further delay access to healthcare service due to lack of experience in using transport facilities. Women living in remote and rural areas are usually not allowed to visit a health facility alone or even to make the decision to spend money on healthcare. Since men are the primary decision-makers and in control of all the resources, they decide when and where woman should seek healthcare. Disapproval or absence of the male of the family can translate into women not being able to reach healthcare facilities on time.

The problem of transport barriers is additionally complicated by the lack of ambulances services at public health facilities. It has been evaluated that a major proportion of maternal or neonatal deaths would have never happened had there been proper and functional ambulance services. Although various social organisations have introduced private ambulance services, they are either unaffordable to be used by marginalised communities or they have limited coverage area and are functional only in urban areas and major cities.

Although there have been many initiatives in the past by the government, there is a dire need to take a holistic approach to solve the issue.


The writer is a public health consultant.

Email: [email protected]



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