By Dr. Sadaf Nazir
MBBS
Medical Assistant/Medical Editor

Maternal Mortality
and
Gynecological Care in Pakistan
زَچگی کی شرح اَموات
اور
پاکستان میں اَمراض نِسواں کی نِگہداشت
मातृ मृत्यु दर
और
पाकिस्तान में स्त्री रोग संबंधी देखभाल

Maternal mortality ( death of a woman during pregnancy or childbirth) remains a major public health challenge in Pakistan. Despite efforts over the last two decades to reduce deaths related to pregnancy and childbirth, Pakistan still has one of the highest maternal mortality ratios globally.

 

Statistical figures:

• MMR for Pakistan(excluding AJK and GB) 186 deaths per 100000 live births for 3- year period before the survey.
• This represents a significant decline from earlier decades (from 276 per 100,000 live births in 2006–07) but is still well above the SDG target of <70 per 100,000 by 2030.  

Current Situation in Pakistan:

27 mothers die daily

9800 maternal deaths annually

Everyday 675 newborns die

246300 newborn death annually

Stillbirths 190000 each year

Every 50 minutes a Pakistani women dies due to some pregnancy related condition.

Causes of Maternal Deaths:

• Obstetric hemorrhage : it means heavy bleeding .A major contributor, especially postpartum (42 days after delivery). 
• Preeclampsia and eclampsia: High blood pressure disorders of pregnancy. 
• Sepsis and infections: Including unsafe procedures and inadequately managed deliveries. 
• Indirect causes: Such as pulmonary embolism, anemia, Diabetes, Heart diseases,stroke, lower respiratory diseases, kidney diseases, and complications from existing medical conditions.
• Unsafe abortion
• Obstructed labor

Where does the problem lie:

Gynaecological care challenges:

“Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants”

1. Lack of access to reproductive healthcare: A large number of births at villages occur at home without a skill attendant ( usually called a ‘Dai’ دائی). This lady has no medical knowledge and we can call her as a quack very firmly convinced villager that she is an expert in delivery babies and luckily she did but what if some complicated case such as obstructed labor or pregnancy with other medical issues occur. It will lead to the demise of pregnant lady. Thousands and thousands of ladies die at hands of these unskilled attendants.
2. Lack of Routine Antenatal Care:

Current WHO recommendations total number of antenatal visits must ne 8 in number

First trimester : 1

Before 12 weeks

Second trimester: 2

• • Around 20 weeks
  • Around 26 weeks

Third trimester: 5

• • 30 weeks
  • 34 weeks
  • 36 weeks
  • 38 weeks
  • 40 weeks

The number of visits tell us the importance of these visits like how important to monitor pregnancy throughout. But women in our country came to hospital at last trimester. Some women came on the day of delivery with diabetes and hypertension or other complications making it difficult for a doctor for herself and her family.

3) Limited Screening and Preventive Services:

• Low access to screening and preventive services such as regular pelvic exams, cancer screening (e.g., cervical cancer), and reproductive health checkups means many problems go undetected until advanced stages.
• Lack of HPV awareness and vaccination programs contributes to higher risk of cervical cancer mortality over time (important in gynecological care context, even if direct Pakistan data is limited).

4) Septic Conditions :

These conditions are far more better in private setup but if we talk about the government hospital in Pakistan this condition is literally worst.

Hygiene is poor like if there was some word below poor we can also use for that. The bedsheets, the floor, the windows, the walls, the chairs, the table, everything was contaminated. Doctor used to discharge patient as early as possible because they knew that patient will get hospital acquired infections.

• Women in lower socioeconomic strata often delay or skip care due to financial constraints, increasing risk of severe outcomes. 

5) Socio-Cultural and Gender-Based Constraints

• Limited autonomy for women’s health decisions; needing permission or male accompaniment delays seeking care for gynecological and reproductive issues. 
• Early marriage and high fertility expectations increase risk of complications (more pregnancies, closely spaced births). 
• Patriarchal norms and low status of women can prevent discussion of sexual/reproductive health issues, leading to late presentation of serious gynecological conditions. 

6) Education and Health Literacy

• Low female education rates correlate with less use of contraception and maternal/gynecological services; educated women are more likely to seek care and understand warning signs. 
• Poor health literacy also reduces awareness of cancers, infections, and the importance of routine screenings.

7) Economic conditions:

• Cost of care, transportation, and clinic fees deter many women from seeking timely gynecological visits or treatments.
• Women in lower socioeconomic strata often delay or skip care due to financial constraints, increasing risk of severe outcomes. 

8) Reproductive Health Risk Factors

Certain medical conditions and complications are direct risk factors for mortality:

• Postpartum hemorrhage, sepsis, and eclampsia remain major causes of death during pregnancy and childbirth — these relate closely to both obstetric and gynecological care. 
• Septic miscarriage and unsafe terminations contribute to morbidity and mortality due to infection and lack of emergency care. 
• Uterine rupture and other emergency gynecological conditions can be fatal without rapid access to surgical care. 

9) Cultural Practices Affecting Risk

• Consanguineous marriages and reproductive norms may influence women’s health behaviors and autonomy, indirectly affecting access to care and utilization of services. 

10) Demographic and Age-Related Factors

• Very young or older maternal ages are associated with higher risk of complications and poor outcomes.
• Higher parity (multiple pregnancies) increases risk for obstetrical and some gynecological complications and infections. 

11) Lack of Training:

A lack of training is also the contributor in this regard. Especially a lack of emergency obstetric care.

These gaps contribute to inadequate response during critical emergencies like obstructed labor or hemorrhage.

2. Healthcare System Weaknesses

• Poor access and quality of primary and gynecological care, especially in rural areas or low-income neighborhoods, reduces early detection and treatment of complications.
• There are inadequate trained specialists, equipment, and blood supply in many public hospitals, which worsens outcomes for surgeries and emergency care in gynecological emergencies. 
• Overburdened facilities and COVID-19 setbacks also strained care availability and reduced quality of antenatal and gynecological services. 

The total public health expenditure is 1% of a GDP.

Our health care system is always compromised due to low budget despite the most important factor in any country overall progress.

• Uneven distribution of services: Urban areas have better facilities compared to rural district. Rural areas hardly have one substandard hospital with lack of equipment and lack of skilled doctors

How can we manage women with obstetric complication which can only be deal by an expert specialized doctor.

What are the National and International Efforts:

Government Efforts:. Pakistan has partnered with international agencies like UNFPA to strengthen maternal health services by:

• Training community midwives and Lady Health Visitors
• Scaling up maternal health interventions targeted at low-income, vulnerable populations
• Improving antenatal and postnatal care accessibility  (UNFPA Pakistan).
• Family planning and population management.
• Women’s Empowerment

Impact of Collaboration

• Improved maternal health indicators
• Increased availability of skilled birth attendants
• Greater awareness of reproductive rights
• Strengthened healthcare infrastructure
• Reduction in preventable maternal deaths

• Progress: The country has made progress, with a 33% decline in mortality between 2006 and 2019. The Lady Health Worker program plays a key role in community-based care.
• Challenges: The COVID-19 pandemic, financial constraints, and insecurity in specific regions have hindered progress, with a notable, temporary rise in mortality recorded around 2019-2020.
• Goal: The country is working toward the Sustainable Development Goal (SDG) target of reducing the MMR to less than 70 per 100,000 by 2030.

In conclusion, Pakistan has done a good job of lowering its maternal death rate throughout the years using a variety of strategies, but it is still one of the few nations with a relatively high rate. Therefore, the national and provincial governments must collaborate with international organizations to fully fund new facilities, educate to produce more qualified healthcare workers, educate the public about the advantages of specialized care, and finally offer financial assistance to those who would otherwise be unable to afford said services in order to continue lowering the rate.

Although challenges remain, ongoing efforts are improving healthcare access and maternal outcomes.

By taking this big step, Pakistan is working to reduce MMR under 70 in 1 lac by the year 2030. It would definitely a substantial decline.

References

All statistics and evidence cited in this article are drawn from recognized surveys, peer-reviewed studies, and reputable global health sources. 

1. World Health Organization. (2016). WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO.
2. United Nations Population Fund. (2022). State of World Population Report. UNFPA Publications.
3. Pakistan Bureau of Statistics. (2018). Pakistan Demographic and Health Survey (PDHS). Government of Pakistan.
4. World Bank. (2021). Maternal mortality ratio (modeled estimate, per 100,000 live births) – Pakistan. Available at: https://data.worldbank.org

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