The writer is an anthropologist and a development professional based in Islamabad, working at the Rural Support Programmes Network (RSPN).
As an anthropologist and a development professional, I gain energy from witnessing the success and prosperity of the underprivileged in rural Pakistan. While I was on field visit to rural Sindh, I came across a woman who for over 12 years dreamt of giving birth to a child who would have a life of more than two days unlike her previous children.
Maternal and neonatal health has been compromised for long in Pakistan. A plethora of reports shows that achieving MDG 4 (reducing child mortality) and MDG 5 (improving maternal health) is a sorry state of affairs. On reducing child mortality, the World Health Organization (WHO) recommends a maximum of 10 percent Caesarian Section (C-section) rate associated with decrease in neonatal deaths.
A report by the Pakistan Demographic and Health Survey (PDHS) shows that Pakistan has touched 22 percent C-section rate as of 2018, despite the high charges of this surgical procedure. So, who are those fortunate mothers who afford to bear the cost of a C-section independently to keep themselves and their babies alive?
I found the answer in my anthropological study – ‘Knowledge, Perception and Decision Making about C-section: A Local Perspective of Post C-section Mothers’, (Mphil. Anthropology dissertation, Quaid-i-Azam University, Zakia Rubab, 2020 Islamabad) – on knowledge, perception and decision making about caesarean section, 2020. The data revealed the answer as the famous notion ‘too posh to push’ elite, celebrities and medically insured mothers. However, the dilemma falls in the fate of destitute and marginalised women, who either do not have access to medical facilities in times of pregnancy and childbirth or are too poor to avail the required medical treatment to save their babies.
A comparative international study using the Demographic Health Survey data from 45 developing countries including Pakistan found huge poor-rich inequalities in maternity care with low coverage in rural and poor communities.
A qualitative study on ‘Local Perception about Caesarean Section among Post Caesarean Section Women in Pakistan’ (2021) explained that perceptions about C-section are attached with mixed connotations primarily related to political economy, ease for the doctor, and certainly less time for delivering the baby. In traditional societies, true motherhood is attached with natural birth whereas C-section mothers were tagged as ‘artificial mothers’, which affected post-C-section mothers who endured the intricacies of surgical procedure.
The issue shows two sides of the coin: C-section becomes inevitable when there is threat to the life of a mother or the child. ‘’Particular complications call for emergency C-sections and there must be timely decision making regarding the choice of childbirth method or there is risk for both mother and child’’, says a gynecologist. The study revealed that some women undergo severe complications that the only way out for childbirth is C-section. Unfortunately, not all households – particularly in rural Pakistan – are economically stable enough to opt for C-section.
According to rising trends and inequalities in cesarean section rates in Pakistan, the country has failed to achieve the target of 75 percent reduction in maternal deaths until 2015. Also, a 2-15 percent increase in C-section procedures showed disparity in socio-demographic characteristics. The highest educational level and richest wealth quintile showed maximum increase in C-section rate.
Achieving MDGs 4 and 5 require strengthening of public healthcare systems particularly in low-income countries (LIC) where the economic instability of the rural population results in catastrophic health issues. That lower socioeconomic strata households are deprived of accessing due healthcare facilities is an established fact. Therefore, either economic strengthening of the lower socioeconomic strata population or provision of health insurance to the destitute population is necessary.
In addition to macro-level health insurance, we require micro-level health insurance available to remote/rural populations of Pakistan. One such initiative to uplift the health and happiness index among rural women of Pakistan is taken up by the European Union’s Sindh Union Council Community Economic Strengthening Support (SUCCESS) programme in Sindh. SUCCESS is succeeding with quality support to the destitute for stabilising their economic development covering all aspects holistically.
Aneela, a 30-year-old woman of Piyaro Magsi, district Larkana Sindh, who was struggling to keep her children alive after delivery shared her story. She had eight childbirths, but none survived more than two days. It was the biggest wish of her life to have healthy children who would not die in front of her eyes just after birth. She was giving birth every time with the hope that this child would survive but there was nothing that could save them.
Her doctor told her that she had some complications and the only way to keep her children alive was a caesarian section. Aneela could not afford the hefty amount for C-section. Arranging a sum of Rs30,000 seemed impossible to her.
Aggrieved and destitute, Aneela found a glimmer of hope when she talked to a member of the Community Organisation (CO) formed by the Sindh Rural Support Organisation (SRSO) under SUCCESS. The CO leaders served as a bridge-builder between Aneela and the Rural Support Programmes (RSPs) thus reaching for Micro Health Insurance (MIH) component of SUCCESS programme. This programme extended financial assistance to Aneela and several other women who were fighting their fortune for health and happiness. She received her health insurance card through the CO and this time used it for a C-section when she was expecting a baby in December 2020. “I am extremely happy now, I feel like flying in the air. I used to cry and lament before, but now I feel as if it’s Eid… I got a healthy baby who has survived’’, says Aneela.
The study found several case studies like Aneela’s, who were struggling with their vulnerability and fate on roads to healthy motherhood and childbirth. Tormented and eager for assistance, they found a gateway to hope without staking their dignity. SUCCESS focuses on economic strengthening of rural women and making them financially independent hence to keep their pride up and not continue to be liabilities on others.
A total of 137,130 poor families with around one million people are insured and 21,729 patients are treated with Rs313 million under SUCCESS-MHI component, in which 353 cases (18 percent) were claimed in the domain of obstetrics/ gynecology as of 2018. The beneficiaries of the programme said that there had been health camps, vaccinations, reproductive health sessions, Covid-9 awareness and precautionary measures sessions in the village from time to time.
Although these programme districts of a province cannot be a representation of the entire country, these small initiatives will colour the horizon once we stand united for the bigger cause. Partnership between the government and civil society is indispensable for the future of the people of the country. More effective public health policies and initiatives like SUCCESS, Sehat cards etc are required to combat the plight of healthcare of the poor and marginalised communities. The public healthcare sector needs serious upgradation in service delivery and facilitation to the lower classes. Aneela sacrificed her eight babies because she had no money to pay for a C-section. There are hundreds of heart-wrenching stories of many Aneelas who have foregone their children at the hands of poverty and the cruelty of our medical system.
The government and the civil society, in collaboration with all stakeholders, must make public health insurance a prime priority without disparity (in ethnicity, caste, creed, class, strata or gender). Planning, development and implementation of Standard Operating Procedures (SOPs) and plausible healthcare policies concerning the health of rural populations is yet to be completely delivered in Pakistan.
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