Door-to-Door Obstetric Care Faces Hurdles

With LHWs diverted to other duties, pregnant women face greater risks

LAHORE/KARACHI/PESHAWAR:

For the average low-income girl rushed into marriage with minimal knowledge of contraception, pregnancy and the complexities of childbirth, the door-to-door visits of a lady health worker (LHW) were literally nothing short of a life saver. However, like all good things, welfare initiatives too come to an end fairly soon in Pakistan.

In 1994, the government launched the Lady Health Workers Programme, with the aim of improving maternal and infant health outcomes. Each LHW was responsible for offering at-home consultation on family planning, prenatal care, childbirth and postnatal newborn milestones to nearly 1,000 to 1,500 married women in their community.

After the Covid-19 outbreak however, the government started utilizing the services of LHW's for the vaccination campaigns of coronavirus, measles, typhoid, pneumonia and polio and the awareness activities for dengue thereby depriving pregnant women and their unborn babies of dedicated healthcare and exposing them to multiple health complications.

Sakina Bibi, a villager from the suburbs of Lahore, recounted the tragic loss of her grandchild due to childbirth complications. "Since our village lacks medical facilities, the lady health worker was our savior. During the initial days of my daughter's pregnancy, she would visit us regularly. However, over time, her visits became infrequent, and her guidance limited. After seven months my daughter had a preterm stillbirth," sorrowfully shared Sakina.

Similar was the case down south in Sindh, where low-income women of reproductive age had to face gaps in healthcare delivery since 24,000 LHW's were distracted from their obstetric duties and were assigned to vaccinate children for eight days in a month. Currently, there are 3,000 LHW's and more than 400 lady health supervisors deployed in Karachi.

In this regard, Halima Laghari Zulqarnain, Central President of the Sindh Lady Health Workers and Employees Association and Pakistan Community Health Workers Federation, told The Express Tribune that the provincial health department was giving stepmother treatment to lady health workers.

"it is not the job of lady health workers to vaccinate children. The LHW's primary task is to provide basic health facilities to newborn babies and pregnant women in rural areas. However, instead of facilitating the workers in their actual job, the government redirected them towards other campaigns," regretted Zulqarnain.

The plight of LHW's was equally deplorable in Khyber-Pakhtunkhwa (K-P), which continues to be one of Pakistan's most unfortunate provinces, where maternal and child health remains alarmingly neglected. Despite the government's claims of improving healthcare, thousands of mothers continue to die during childbirth every year while even more newborns bid farewell to the world way before they can even celebrate their first birthday.

Ayesha Khan, President of the Lady Health Workers Association revealed that LHW's once played a pivotal role in community healthcare since they knew every mother and child in their assigned areas, providing timely advice and ensuring antenatal care. "They were a key force in population control, but systematic neglect has undermined their effectiveness. Furthermore, many LHW positions remain vacant, exacerbating the crisis," she informed, while adding that the focus on polio eradication had overshadowed broader health challenges.

"Ignoring LHWs could lead to long-term repercussions, as the province continues to grapple with high maternal and infant mortality rates," she foretold.

According to the Pakistan Demographic and Health Survey, 1,900 mothers die annually in K-P due to childbirth-related complications. However, proper use of contraceptives could save up to 800 lives each year. Similarly, the infant mortality rate stands at 53 deaths per 1,000 live births but timely family planning could prevent 16,700 infant deaths annually.

Dr Sadia Usman, a gynaecologist, was of the opinion that early marriages and a lack of effective prenatal counselling were the primary factors leading to infant and maternal mortality. "The majority of maternal and infant deaths occur in rural areas where lady health workers bear all the responsibility. When you engage a recruited LHW in other work, she is distracted from her primary duty. Almost 90 per cent of all maternal deaths among women aged 15 to 45 years occur due to preventable medical complications like high blood pressure or postpartum haemorrhage," claimed Dr Usman.

According to information obtained by The Express Tribune, more than 250 women and 15,000 infants die during every 100,000 childbirths in Pakistan, with Punjab, contributing to 31 per cent of the deaths and Azad Kashmir and Gilgit-Baltistan reporting 69 per cent of all deaths.

Dr Naveed Akbar Hotiana, a paediatrician at the Ganga Ram Hospital and Fatima Jinnah Medical University, confirmed that ventilators, modern incubators and other necessary facilities for premature babies were missing in remote areas. "By the time a newborn is brought to a tertiary health centre, a lot of time has passed. Due to this reason, there has been an increase in the mortality rate of newborn babies. If lady health workers are made more active, the rate of maternal and child mortality can be significantly reduced," opined Dr Hotiana.

Sharing the LHW's side of the story, Rukhsana Bibi, a lady health worker, conveyed the difficulties she faced in her job after the government employed her for other services. "Sometimes we were assigned duties for dengue and polio campaigns while other times we were included in pneumonia, measles and Covid-19 teams. After all this, we also have to visit women door-to-door and advise them on their reproductive issues," lamented Rukhsana, who protested against her meagre salary and heavy workload.

"LHWs are overburdened with multiple responsibilities while their salaries are delayed for months. Moreover, the government has failed to implement a service structure or increase their pay in the budget," confirmed Khan.

On the other hand, Balochistan's lady health workers (LHWs) occupy the lowest rung of the province's overstretched healthcare system. They are mostly underpaid, employed on precarious contracts, and met with hostility in many neighbourhoods, where going door-to-door is often a risky ordeal thanks to the looming threat of violence. In fact, several LHW's have been targeted in attacks over the years, making their already difficult job even more perilous.

In 2014, four polio vaccinators were killed during a militant attack in Balochistan, three out of which were lady health workers. However, safety issues are not limited to the southwestern province since LHW's in Sindh face similar risks while performing their duties during campaigns against polio and other diseases.

"A LHW was raped during a polio campaign in Jacobabad two months ago, on which our association also protested," revealed Zulqarnain.

Dr Khizar Hayat, Provincial Coordinator for the Maternal, Newborn and Child Health (MNCH) Program, acknowledged the program's challenges but insisted on the government's commitment to reviving it. "New LHW's are being recruited in Kohat, and soon other districts will see an increase in their numbers as well. Their duties include tasks assigned by the government, whether it's polio or other campaigns. We have collective targets to achieve,"" said Dr Hayat, while speaking of the province which currently has 17,000 LHWs.

Addressing the grievances, a spokesperson from the Health Department Punjab confirmed that from 2019 to 2023, various additional tasks had been assigned to lady health workers. "At that time the staff was less, however, today there is separate staff for each campaign and the burden on LHW's is less," they responded. With additional reporting by our correspondent in Quetta