By: ZOFEEN T. EBRAHIM
KARACHI: Forty-something and childless, Naseem Bibi lost her 10th child on Wednesday.
“Bibi’s is an extremely unfortunate case; she’s lost babies in succession and has been grieving for a long time,” said her obstetrician, Dr Halima Yasmeen, at the Jinnah Postgraduate Medical Centre (JPMC).
“You never get over the loss of a child; you can only come to terms with it.”
She has seen many mothers and babies dying in the last 13 years that she has worked at the JPMC, deaths that could easily have been prevented.
While considerable progress has been made in child health and reduction in neonatal and childhood deaths, in the past two decades, there is a resigned acceptance to stillbirths or deaths that occur during labour or delivery.
“The grief of a stillbirth is unlike any other form of grief,” wrote Dr Richard Horton, editor in chief of The Lancet, in a series on these deaths titled ‘Bringing stillbirths out of the shadows’ in 2011.
“It’s different because there are no happy memories to sustain you, no sense of who that person was and what they meant to you. Instead, you’re left grasping at something permanently just out of reach, that might have been, that should have been, that wasn’t,” wrote Sarah Hughes, 38, mother of two, in the Observer, who delivered a daughter, only for her to die.
In Pakistani society where mourning for the death encompasses various rituals over a period of days, and which often brings forward immense friends and family support, there is little or a perfunctory display of bereavement for a baby who dies during birth.
Even the devastating consequences it can have for the mother remain unrecognised.
According to the World Health Organisation, death of a baby is termed stillbirth, as opposed to miscarriage, after 28 weeks of gestation. But most rich countries count stillbirths at around 22 weeks’ gestation.
Globally, around 2.6 million babies die before coming into the world annually with 98 per cent occurring in developing countries.
In Pakistan, which has the second highest rate of stillbirths (after Nigeria), every day close to 500 newborn lives are snuffed out even before they take their first breath in this world.
“According to the most recent Pakistan demographic and health survey (PDHS) of 2012-13, the perinatal deaths (stillbirths and newborn deaths within the first week) is about 75 per 1,000 pregnancies of which about half (35/1,000) is due to stillbirths. But there is no information on how many of these are due to complications during delivery and how many due to other causes,” says Dr Farid Midhet of USAID’s Pakistan’s MNCH Programme (MCHIP), while talking to Dawn.
The global rate is 19 per 1,000.
But more than that, stillbirths are a highly sensitive indicator of the quality and accessibility of obstetric care.
Most stillbirths in Pakistan occur during delivery. Dr Midhet, also a demographer says, in Pakistan, where home deliveries (51.8pc) by unskilled birth (47.9pc) attendants are still common, these deaths could probably be attributed to the inability of the birth attendants to revive a non-breathing newborn.
In addition, it appears that the causes of stillbirths cannot be separated from those that kill mothers.
According to Dr Zulfikar Bhutta, founding chair of the women and child health division at the Aga Khan University, globally 45pc of these deaths can be prevented by adopting 10 cost-effective health care interventions.
Based on randomised trials and observational studies on stillbirths, these include: folic acid fortification; insecticide-treated bed nets; preventive treatment for malaria prevention during pregnancy; syphilis detection and treatment, detection and management of hypertensive disease of pregnancy, diabetes in pregnancy and foetal growth restriction; identification and induction for pregnant women with more than or equal to 41 weeks of gestation and comprehensive basic obstetric care and comprehensive emergency obstetric care.
A pilot study carried out in 2008, in rural Sindh (in 315 villages with a total population of 138,600), found that simple interventions like training of lady health workers and linking them up with the traditional birth attendants significantly reduced the stillbirth rate from 66 to 43 per 1,000.
The silver lining in this scenario is that there is enough evidence available to reduce the risk of stillbirth. Good quality antenatal care and identification of high-risk pregnancies and easy access to emergency obstetric care would greatly improve life chances for mothers and babies in Pakistan.
Malnutrition and infection — are also a precursor to stillbirths and which can be overcome through low-cost antenatal care by the country’s 100,000 or so lady health workers.
These women, covering 60pc of the population, are part of the country’s family planning and primary health care.
Yet, Pakistan remains a maternal and infant hotspot.
The PDHS 2012-13 shows an infant mortality rate of 78 deaths per 1,000 live births.
It also shows a mortality rate of children under five years old of 89 deaths per 1,000 live births and the maternal mortality rate of 276 per 100,000 live births is also far too high.