We must train and provide skilled birth attendants, shift funding from curative Services to preventive programmes


Conference on Reproductive Health at CPSP

We must train and provide skilled birth attendants,
shift funding from curative Services
to preventive programmes

Each healthcare professional must train at least
ten birth attendants-Prof.Rashid Latif Khan

Pakistani Gynaecologists question maternal mortality
figures about Pakistan published in Lancet

KARACHI: At the time of independence in 1947; we had less then hundred doctors and only six specialists. Now we have over 150,000 doctors and over 24,000 specialists in 2013. But we have not improved healthcare with the same pace. Up to 1970s we were doing much better but since then we have not improved our parameters. We have not improved our Millennium Development Goals but now we see women in all fields. This was stated by Prof. Rashid Latif Khan while speaking at the conference on Reproductive Health which was a part of the CPSP Charter Day Celebrations on May 21st 2014.

Conference on Reproductive Health held on May 21st, 2014 was part of CPSP Charter Day celebrations.
Group photograph taken during the conference shows President CPSP Prof. Zafar Ullah Chaudhary
along with Prof. Tayyab, Prof. Yaseem Rashid, Prof. Sadiqa Jafary,
Prof. Rukshanda Rehman and others.

Continuing, Prof. Rashid Latif Khan was the Guest of Honour in the session said that we have made some progress, reduced child mortality and also improved maternal health. We are supposed to provide universal access to reproductive health but family planning has gone on the back burner. We have not focused on population control. Total government spending on health has remained between 2.2 to 3.3% this year. Almost 80% of healthcare is provided by private sector. Provision of free healthcare is not possible. We have over worked teaching hospitals but BHUs, Tehsil Hospitals and DHQ Hospitals were not functioning to their full capacity. There has been uneven progress. We must aim at providing skilled birth attendants, train them and redirect our funding from curative services to preventive programmes. He made a passionate appeal to all the specialists to train at least ten skilled birth attendants each which will make a big difference. Invite them to your facilities, train them. Transfer patients to facilities at the right time. It is all possible. He advised the gynaecologists to go for treatment of infertility. According to figures we have just eighteen IVF centers in Pakistan though we need at least one hundred fifty throughout the country, he remarked.

Prof. Nosahd Sheikh VC LUMHS Hyderabad who was the chief guest in his speech said that universities have to do capacity building of healthcare professionals in cities as well as rural areas. Unfortunately maternal mortality in Pakistan has not reduced much over the last two decades and we are also faced with other communicable and infectious diseases. We need to adopt holistic approach in which every one plays its role. We at LUMHS have started an online course for GPs which covers maternal and child health as well. He suggested that the CPSP should also start some online courses.

Dr. Sajjadur Rehman from Qatar was the first invited guest speaker who made a presentation on Global Burden of Disease Study 2013. His presentation was based on a study conducted in 187 countries based on Millennium Development Goals up to December 2013. Maternal mortality is defined as death during labour or within twenty four hours after delivery. Death after twenty four hours and within six weeks is considered as later maternal mortality. With the help of slides, he showed that between 2003 to 2012, there has been some reduction in maternal mortality globally. With the advance age of the mother, maternal mortality is high and is increasing. Figures reported about Pakistan in this study which was published in Lancet were quoted as 400/100,000 deliveries which was quite high as compared to other Muslim countries.

He further stated that in 1990, maternal mortality in countries like Bangladesh, Oman, Saudi Arabia, UAE, and Qatar was quite high as compared to Pakistan. But in 2013, all these countries have reported significant reduction in maternal mortality and done much better. Now the only country which has high maternal mortality in the region as compared to Pakistan was Afghanistan. As regards the global situation, Pakistan, Dr.Sajjadur Rahman opined was the only country in the region with maternal mortality between 400-500 and it is classified with countries like Somalia and Ethiopia. If we fail to make any interventions the situation in Pakistan in 2030, he alleged, will be the same as is seen in Ethiopia and Somalia. Speaking about the causes of maternal mortality he mentioned abortion, haemorrhage, advanced age of mothers, hypertension, obstructed labour, sepsis and these are all preventable and can be addressed. As regards infant mortality and childhood mortality, there has been tremendous reduction globally from 1970-2013 and greatest reduction has been witnessed in less than five years mortality. Saudi Arabia, Iran, Qatar have all reduced their infant mortality by making effective programmes thus have made significant progress. All countries located on Pakistan’s east and west have done much better but we still have the worst neonatal mortality rates in Pakistan. Increase in income and maternal education plays an important role in maternal mortality reduction. Qatar has maternal mortality figures of 9.85/100,000 in 2011-2012. He then pointed out that all the Gulf countries have been developed by Pakistani workforce. In the Gulf countries 100% pregnant mothers are delivered by trained birth attendants and the infants are examined by the paediatrician after birth. They have also ensured 100% immunization.


Maj. Gen. Salman Ali along with Prof. M. Asghar Butt presenting a memento
to Prof. Rubina Sohail at the session devoted to Neonatal Health during
CPSP Charter Day celebrations. Picture on extreme left shows Prof. Aisha Mehnaz.

During the discussion Prof. Mohammad Tayyab and Prof.Yasmeen Rashid from Lahore contested the figures of 400/100,000 of maternal mortality saying that both WHO and World Bank websites show the figures of 260/100,000 and the figures presented by the speaker published in Lancet were highly inflated. They further questioned that the figures are all dependent on what methodology is used in the study and what statistical test was used. All the figures reported are not 100% correct. It was also pointed out that Dr.Sajjadur Rehman has made a wonderful presentation but the real facts are different. UNICEF and World Bank figures come from Surveys. One has to look at the previous surveys and then decide as to what are the correct figures? What is the correct national figure for Pakistan? Prof. Rashid Latif pointed out that let us not talk about the figures for the time being but the message in the presentation is clear that we have to act. We should take active interest as there is lot of room for improvement. We should work up; survey figures will vary as it will depend on which areas are surveyed. We need to have correct national figures. It was also pointed out that China does not give any figures to UNICEF. We need to conduct our own studies, he remarked.

Prof. Sadiqa Jafary was the next speaker who gave details of the working of National Committee on Maternal and Neonatal Health (NCMNH). It is working in close collaboration with NGOs like MAP and AMAN. We have worked hard to get Misoprostol registered and ensure its availability, she added.

Prof. Yasmeen Rashid described her experience of In utero transfusions at her Center. It is a team work and selection of patients for this treatment was extremely important. The team members, she said, include obstetrician, ultrasonologist, hematologist, paediatrician and paediatric surgeon. So far we have had 498 in utero transfusions in 166 patients and achieved 112 live births. There were thirty intra uterine deaths and 24 neonatal deaths. Patients are delivered at 34 weeks plus mostly between 34-35 weeks of pregnancy. In patients with hydrops we had 48% live births with 19 IUD and 13 neonatal deaths and 79% live births in patients without hydrops with eleven IUD and eleven neonatal deaths. She further pointed out that after two in utero transfusions, most babies will not require transfusion. Commenting on this presentation Prof. Rashid Lateef remarked that Prof. Yasmeen Rashid’s presentation has showed that Islands of excellence are there in Pakistan and all is not so bad.

Prof. Mohammad Tayyab from AIMC was the next speaker who talked about choosing the contraceptive method best suited for women. He pointed out that China has 19%, India 17.4% and Pakistan 2.8% of the world population. He highlighted the importance of thorough physical evaluation of the patient, relative laboratory investigations and ultrasound, social education and empowerment profile. WHO guidelines suggest that one has to be careful in patients with blood pressure, DVT, IHD and migraine. As per WHO medical eligibility criteria for combined use of oral contraceptives, absolute risk of VTE is 5/100,000. In case of certain risks, one should avoid certain type of contraceptives. He also talked about benefits of combined oral contraceptives, role of institutions and having local guidelines and their application.

Prof. Rizwana Chaudhry from Rawalpindi- Islamabad talked about PPIUCD- Post Partum Intrauterine Contraceptive Device insertion which she felt was an answer to the unmet needs of Pakistani women. Pakistan, she said, has a population of 193 million with 1.59% growth rate. Our maternal mortality was 260/100,000 while infant mortality rate was 59/1000 as per World Bank Report. PPIUCD was ideal for contraception if deliveries take place in healthcare facilities. Pakistan has a fertility rate of 4.1%, Bangladesh 3.0% while India has 2.7%. PPIUCD can be inserted Tran’s cesarean or even post cesarean immediately after expulsion of placenta or within ten months. During 2012-2013 a total of 13,328 deliveries took place at their center which included 4359 cesarean section deliveries and we inserted 480 PPIUCD. 551 women were counseled of which 480 agreed and 292 were followed up. The satisfaction rate was found to be 85%, 3.8% had expulsion of the device while another 5.4% got it removed on request. PPIUCD, Prof. Rizwana Chaudhry remarked was safe and convenient.

Neonatal Health

The other session which was devoted to Neonatal Health was chaired by Prof. Maj. Gen. Salman Ali along with Prof. Asghar Butt and Prof. Aisha Mehnaz. Prof. Akbar Nizamani was the first speaker who talked about Labour room protocols based on PCPN guidelines. Prof. Rubina Sohail from Lahore highlighted the role of obstetricians and gynaecologists in reducing neonatal death. She highlighted the importance of infection control policies, monitoring of labour which can help reduce the neonatal mortality. Even these small interventions, she further stated, can go a long way in capacity building of healthcare professionals. Dr. Tahir Manzoor speaking on Newborn Action Plan and Pakistan opined that neonatal deaths in Pakistan were quite high. He also referred to critical newborn interventions in detail.

Dr. Naila Shahid from UNICEF made her presentation on Helping Babies Breath (HBB) Initiative. She pointed out that we have infant mortality rate of 74/1000 live births and hands on skills learning can reduce this death rate significantly. Doctors, she opined, are not trained how to use Ambu bag. We use mannequin for training. HBB initiative is being practiced in sixty countries including Pakistan. One million still births take place due to asphyxia. There are 830,000 neonatal deaths due to asphyxia worldwide. All infants need assessment at birth. We have trained LHVs and Midwives who are doing it. Midwives were trained in Tanzania and it helped them reduce their still births by 24% while their neonatal mortality also reduced by 47%.

Dr. Saida Ahsan Pal who represented Association for Mothers and Newborns (AMAN) was the next speaker in this session who talked about Continuing Medical Education with referenced to training for maternal and newborn health. She pointed out that postpartum haemorrhage was the leading cause of maternal mortality in Pakistan. It is because of bad obstetrics which can be prevented and sepsis can be avoided. She pointed out that most of our teaching hospitals were not providing clean safe deliveries. In some institutions, even water is not available to wash hands between operations. There is no proper infection control and sepsis control. Doctors do not know how to go for family planning, how to talk to the patients. We run two emergency obstetrics courses and one course at demand at any institution every year. Training in management of PPH, partograms, PPIUC has reduced the PPH rate significantly. Obstetricians and Gynaecologists, she alleged, were horrible women who are horrible to women. When I decided to take up this specialty, I had decided that I am going to be a bit different. Doctor, she further stated, need to change their attitude towards the patients. They must treat the nurses and paramedic with respect. In fact we all the healthcare professionals need to respect each other.

Continuing Dr. Sadia Ahsan Pal said that since 2009, they have organized twenty workshops; five hundred forty three doctors and nurses were trained. We in Pakistan do not have facilities of paediatricians in our labour rooms as we cannot have this luxury. She laid emphasis on training skilled birth attendants. We have also trained 675 healthcare professionals in the use of Misoprostol while 363 skilled birth attendants have been trained in intra uterine contraceptive devices, she added.