CHALLENGES IN ACCESS TO AND UTILIZATION OF REPRODUCTIVE

Background: Pakistan’s maternal mortality rate is high, and adequate and timely emergency services
could prevent most maternal deaths. A woman’s right to life-saving services of skilled health care
providers in childbirth is undeniable. This paper examines factors restricting women's access to
emergency obstetric care services in Pakistan. Method: This cross-sectional survey on emergency
obstetric care services collected information at the health facility level using UN process indicators. The
study enrolled 170 health facilities from nineteen randomly selected districts in Punjab and NWFP.
Results: Diverse factors limit women’s access to Emergency Obstetric Care (EmOC) services. EmOC
services were unavailable in most health facilities surveyed. Staff absenteeism, geographic remoteness,
delayed access, and ambulance shortages jeopardize the transferral of seriously ill patients to higher level
care facilities. Cultural norms dictate that women should be examined by women doctors, whose dearth
makes these services inaccessible. Conclusion: Many maternal deaths would be avoidable if EmOC
health services were accessible. The geographic obstacles to timely access, poor hospital infrastructure,
and high staff absenteeism rates require immediate attention. Health facilities' working hours were
inconsistent with the provision of around-the-clock essential services, depriving and endangering the
lives of many in need. It is imperative to increase skilled female workers capable of managing EmOC
problems through proper incentives. A focused approach at local levels through proper supervision,
motivation, and management would unquestionably save women's lives.
Keywords: Maternal health, social access, women mobility, referral hospitals; EmOC services.
INTRODUCTION
Women have a basic human right to be protected when
they undertake the risky enterprise of pregnancy and
childbirth.1 Every death in pregnancy and childbirth is a
multiple personal tragedy. It is a biological or medical
event. It is a health system malfunction. It may entail
family or community responsibilities.2 We cannot close
our eyes to the overwhelming figure of 600,000 maternal
deaths worldwide, every year, due to pregnancy-related
complications.3 Life threatening complications of
pregnancy are generally not preventable or predictable,
but when nothing is done to avert maternal death, natural
mortality is around 1,000 to 1,500 per 100,000 births.1
Such high maternal mortality is a denial of women's
human rights.4,5 The provision of quality services to
reduce maternal mortality is a human rights issue for
women and their children.6
The availability of services is generally
determined by the geographic distribution of fixed and
mobile health care facilities and their service hours.
The accessibility of services includes both their cost to
users in money and time and their social acceptability.
The physical accessibility of a primary health facility
where the necessary staff is posted and available is
defined as the proportion of the served population
living within 2 to 5 km or alternatively at 20 to 60
minutes walking distance. Social accessibility can be
understood in terms of religious, tribal, and cultural
barriers and accessibility of services. For example, in
Pakistani society, female health care providers are
essential for the provision of antenatal, natal and
postnatal care.7
Women's inability to travel alone as and
when they wish is viewed as an important barrier to
improving their health.8 The majority of Pakistani
women report they are unable to go to a health facility
unaccompanied; male family members must
accompany them.9,10 In such a conservative society,
women understandably feel uncomfortable discussing
reproductive health issues with male doctors and
prefer to be seen by women doctors for gynecological
and obstetric consultations.11–13 Thus the absence of
female doctors makes many otherwise accessible
health facilities unacceptable socially, hence
inaccessible, depriving these women of their human
rights to equality of treatment and dignity.
This paper examines the geographic,
temporal, and socio-cultural factors and circumstances
restricting or increasing women's access to emergency
obstetric care (EmOC) services in Pakistan.
Pakistan's population of approximately 153
million, two-thirds rural, is the world's sixth largest.
Almost one-third of the population lives below the
poverty line14 and two-thirds earn less than US$2 a day.15
In Pakistan an estimated 16,500 maternal
deaths occur annually16; the maternal mortality ratio is
estimated at 500 per 100,000 live births. One of every
38 women risks dying of childbirth related causes in
her lifetime.17,18
Female literacy, particularly among rural
women, is among the lowest in the world; girls rank
far below boys in educational attainment. A report
reveals that percentage of illiterate population
comprise of 38% males and 65% females.19
In Pakistan, despite the fact that every health
policy and program announced in the past two decades
has emphasized increasing the availability of female
health staff, facilities in rural areas are still
understaffed16, a situation partly attributable to security
and safety issues.20 Available evidence shows that
many women have no access to modern health services,
particularly during pregnancy and childbirth.21,22
Studies have concluded that family planning/
reproductive health clinics are accessible to only 10
percent of the population, with only 5 percent living
within easy walking distance.23 To increase access and
empower women, the Lady Health Workers (LHW)
program was introduced in the mid-1990s; it now
covers 60% of the population and uses the concept of
community services and referral systems delivered to
the doorstep to circumvent proscriptions against
woman's mobility. The employment of female
fieldworkers who visit women in their homes has
increased the uptake of services, especially family
planning and immunization, but little change has been
observed in antenatal visits or hospital deliveries.9,24
A recent report found that, while the
availability of female providers increased substantially
during the 1990s, the availability of skilled birth
attendants remains so low that only about half of
mothers received antenatal care during their last
pregnancy, and 80% of women in labour receive no
assistance from a skilled birth attendant during delivery
- and this trend is even stronger in rural areas.25–29
A study in Sindh province pointed out that
12% of facilities are open for only 6 hours daily;
24-hour coverage is provided only by the district
headquarters hospital. Transport for referral is
available at only 35% of facilities. Maternal mortality
records are available in 55% of facilities. Only 33% of
government hospitals are equipped to offer obstetric
care. Users consequently visit private hospitals for
such services.30
Once complications in pregnancy become
apparent, the mother's course, which may lead to her
death and the death of her infant, is determined by, inter
alia, whatever barriers prevent a woman in labour from
receiving the care that might save her life. The
‘three-delay’ model31 explains that a third delay may
occur at the facility before care is received. Better
staffing of peripheral health facilities and improved
access to obstetric services could reduce maternal
mortality.32 Reports also indicate that in Azad Jammu
and Kashmir33, Sindh34, NWFP and Punjab35, most
tertiary, secondary, and primary referral facilities do not
provide EmOC—the key to saving maternal lives—or
meet minimum acceptable levels set by WHO.

MATERIAL AND METHODS
This current study was conducted in conjunction with
a larger survey designed to collect EmOC information
at the health facility level. UN process indicators36
were used to identify the availability, use, and quality
of emergency obstetric care. For the purpose of the
study, two of Pakistan's four provinces; Punjab and
North West Frontier Province (NWFP) were selected,
where it was the first study on EmOC situation
analysis and also these two provinces account for
some 70% of Pakistan's population.
In Pakistan, provinces are further divided for
administrative purposes into districts. Depending on
population size, each district has four or more rural
health centres (RHC), two or three ‘Tehsil’ Hospitals
(THQ) and one district hospital (DHQ). The RHCs are
providing basic EmOC services. The Tehsil and
District hospitals provide comprehensive EmOC.36
Two teams undertook the study, one in each
province, both trained by the chief investigator. To
minimize bias, random sampling was done at both
area and health-facility levels. To better evaluate the
situation, in the first stage of sampling, 30% of
districts in both provinces (n=19 districts) were
randomly selected. In the second stage of sampling, all
public health facilities providing EmOC in 11 districts
in Punjab and 8 in NWFP were included (n=170; 120
hospitals from Punjab and 50 from NWFP). From
Punjab, districts were Jhelum, Sialkot, Mianwali,
Toba Tek Singh, Okara, Sahiwal, Khanewal, Multan,
Vehari, Lodhran and Bahawalpur districts. From
NWFP, they were Swat, Lower Dir, Charsadda, Swabi,
Haripur, Kohat, Karak and Bannu districts. Data
collection took place from July to September 2003.
The records reflect 12 months of facility data. Data
sources were the health facility's records, including
the registries of labour and birth, operating theatre,
antenatal care, and gynaecological ward records.
The needs assessment was conducted mainly
using pre-established tools36, a few questions were
added. The reliability and validity of information in the
hospital records were checked by repeating data
collection from a 10% sample of hospitals. Permission
was obtained from the ethics review committee at the
University of Tokyo, Japan, and from the Ministries of
Health in Punjab and NWFP, Pakistan. Data processing
and analysis were carried out using SPSS version 10
(SPSS Inc., Chicago, IL, USA) to produce frequencies
and percentages. Chi-square tests were used to observe
the strength of associations between variables.
Punjab Province: The average literacy rate
was 46% (female literacy 33%), the per capita income,
US$1752. The urban population was 26%, with an
unemployment rate of 21%. Access to TV, radio, and
newspaper was 71%, 38%, and 39% respectively.
Eighty-five percent had access to water in their homes;
24% had running water (pipe water). Electricity was
accessible to 71% of the population. In the NWFP
Province: The average literacy rate was 37% (female
literacy 19%), the per capita income, US$ 1627. The
urban population was 14%, with an unemployment
rate of 29%. Access to TV, radio, and newspaper was
44%, 43%, and 23% respectively. Fifty-seven percent
had access to water in their homes; 38% had running
water (pipe water). Electricity was accessible to 85%
of the population.37

RESULTS
Range of EmOC service availability
In our survey assessing the current status of
emergency obstetric care services in Pakistan, we
found that EmOC services were far from universally
available: only 60 (35%) of 170 public health facilities
in 19 randomly selected districts actually provided
EmOC services.35 Further, 14.7% provided only basic
services, and only 21.2% provided comprehensive
services. In NWFP 76% of hospitals did not provide
any EmOC services, while in Punjab (59%) it was
comparatively better (χ2: 3.5, p<0.040).
It was found that 75% of DHQ hospitals in
NWFP and 83% of DHQs in Punjab provided
comprehensive EmOC services. Similarly, in NWFP, at
the THQ level, 67% of facilities provided basic EmOC
services, where as in Punjab, at the THQ level, 14%
provided basic EmOC, 52% comprehensive, and in both
provinces 33% of THQs were providing no services.
At RHC level, in Punjab only 25% of health
facilities provided basic EmOC services; while none
of the RHC in NWFP were providing EmOC services.
Convenience of service hours
Our study sample consisted of 170 hospitals, i.e. 20
DHQs, 27 THQs, and 123 RHCs. All 20 DHQs were
providing services round-the-clock; 41% of THQs
provided services up to 6 hours (NWFP: 50%, Punjab:
38%); 59% claimed to provide services round-the-clock
(NWFP: 50%, Punjab: 62%). At the same time, 54% of
RHCs (NWFP: 62%, Punjab: 50%) were providing
services for up to 6 hours and others (46%) provided
services round-the-clock (NWFP: 38%, Punjab: 50%).
Availability of human resources
We found that 49% of all health facilities studied did
not have allocated staff as recommended by the
Ministry of Health. In Punjab, only 42.5%, in NWFP,
while 72% of the required staff per allocated vacancies
was present, this result was also found to be
statistically significant between the two provinces (χ2:
12.3, p<0.000). In Punjab province, however it was
also observed that the allocated staff presence was
better in higher-level health care facilities than in
RHCs (χ2: 6.5, p<0.037).
It was also noted that staff remained on duty
even at night in 69% of sampled hospitals where staff
were interviewed (DHQ: 95%, THQ: 89%, RHC:
60%). The vast majority of facilities (91%) also
claimed that they had female staff, though not
necessary skilled in EmOC services (DHQ: 100%,
THQ: 96%, and RHC: 88%).

Social accessibility: Availability of women doctors
Almost every public health facility providing EmOC
services is required to have at least one female doctor
on the medical staff. Findings however revealed that
women doctors were available in only 41.8% (n=170)
of facilities. In NWFP, 32% of the hospitals had
women doctors, in Punjab, 45%.
Nurses were present in 18% of NWFP and 2.5% of
Punjab hospitals; Lady Health Visitor(LHV) were
present in 46% of NWFP and 32.5% of Punjab
hospitals; Traditional Birth Attendants (TBA) were
present in 2% of NWFP and 9.2% of Punjab hospitals;
and 2% of NWFP and 10% of Punjab hospitals had no
female staff.
At the THQ level, on average 78% of
hospitals had a women doctor (NWFP: 50%, Punjab:
86%) compared to the 28% average at the RHC level
(NWFP: 21.6%, Punjab: 31%). In general, fewer
women doctors were present in rural health centres
than in higher-level hospitals. (χ2: 32.4, p<0.000)
It was also observed that the provision of
EmOC services was directly associated with presence
of women doctors in health care facilities (χ2: 48.6,
p<0.001). The data also pointed to the fact that a
number of facilities did not provide any EmOC
services at all, despite having two or more
(non-doctor) female health staff members,
emphasizing the need for having a women medical
doctor in health facilities, especially in rural areas.

Geographic accessibility: Distance and time to
higher referral hospital (i.e., district level)
It was noted that from the first-level of care to the higher
referral hospitals, 37% of were up to 30 km away, 39%
were from 31 to 60 km away, and 24% were more than
60 km away. In NWFP, only 40% of referral hospitals
were up to 30 km range, while in Punjab, 35%. Thus
highlighting the fact that almost 60 to 65% of the
hospitals in both provinces required patients to travel
minimally for more 30 km to more than 60 km.
It was found that, by whatever vehicular
means of transportation was available, the median time
required to reach a referral hospital providing
comprehensive EmOC from a hospital providing only
basic EmOC was 45 minutes (q1-q3: 20-60 minutes) in
NWFP and 60 minutes in Punjab (q1–q3: 30–90
minutes). Further details show that almost 30% to 40%
of hospital in NWFP and Punjab could be reached in
more than one hours range to get emergency treatment,
depending on the road conditions and more importantly
availability of vehicle.

Serviceability of ambulances
It was found that overall; ambulances in working order
were unavailable in 76 (45%) out of 170 health
facilities. Province wise, in NWFP, ambulances for
patient transportation were non-functional or
unavailable in 56% of facilities (THQs: 33%, RHCs:
73%), while in Punjab’s health facilities, the figures
were 40% (THQs: 29%, RHCs: 48%). Functional
ambulances were more likely to be present at
higher-level health facilities than at rural health
centers (χ2=24.2, p<0.000) and more available in
Punjab province than in NWFP (χ2=3.65, p<0.041).

DISCUSSION
The goals set and agreed at Alma Ata for the pursuit for
‘Health for all’ apply the concepts of universal coverage
with provision of accessible, affordable, and efficient
services. Besides meeting other primary health care
requirements, systems and services should be socially
and culturally acceptable. These principles and
associated requirements demand a creative practical
approach to health care delivery system development.
The fifth millennium development goals
include a focus on improving maternal health and
advocate the reduction by three-quarters of the
maternal mortality ratio between 1990 and 2015. To
address its high maternal mortality, Pakistan requires a
pragmatic approach, one that is culturally acceptable
with a wide base of support in local communities.
Gender is one of the organizing principles of
Pakistani society. Local traditions and culture embody
values predetermining gender values in society. There
is considerable diversity in the status of women across
classes, regions, and the rural/urban divide due to
uneven socioeconomic development and the impact of
tribal, feudal, and social formations on women's lives.
This has led to a low level of resource investment in
women by the family and the State.
Recently, emphasis of international maternal
health efforts has been shifted to the provision of
accessible, affordable, and quality EmOC services to
save mothers’ lives.
We found that the majority of hospitals in our
study were not providing EmOC services and that
most referral hospitals capable of providing EmOC
were geographically inaccessible to potential users.
Timely geographic access is especially
important in obstetric emergencies or complications at or
shortly after delivery. In many rural areas in Pakistan, the
transportation infrastructure is underdeveloped, hindering
the transfer of patients. During such transfers to higher
levels of care following in-hospital emergencies,
ambulances are extremely important. Half of hospitals in
our study did not have serviceable ambulances. Facilities’
working hours were inconsistent with the provision of
around-the-clock essential services, depriving and
endangering the lives of many in need. High staff
absenteeism in many health facilities brought to light other
issues needing attention. Only a focused approach at local
levels by proper supervision, motivating programs, and
skilled management can solve these problems.
Unquestionably, if implemented, measures will make a
difference by saving women’s lives.
In Pakistan, especially in rural areas where
the majority of the population resides, women's
mobility is restricted and most women are
uncomfortable discussing issues of pregnancy,
contraception, and reproductive tract infections with
male doctors, resulting in high unmet need. Many
endanger their lives by eventually approaching
unskilled health workers.7,11–13
However, the mere presence of a female care
provider at a hospital is only one part of the equation;
her presence is no guarantee that she or anyone else is
capable of managing complicated deliveries or trained
to recognize and treat complications of pregnancy.
Nurses, midwives, auxiliary midwives, and other
providers working in birthing centers may not have
the skills and competencies to perform all the six
signal functions that define a basic EmOC facility,
even if it was part of their original training.38 The
appropriate solution is to increase skilled workers
capable of managing EmOC problems.
In Pakistan as elsewhere, the vast majority of
the country’s doctors resides in and serves urbanized
areas, and this is especially true of women doctors. Rural
areas are underserved. The first step toward addressing
the issue of women doctors in underserved rural areas is
to recognize the underlying core issues: poor salary
packages, inadequate service structure for women
doctors willing to work in rural areas, and security issues.
The government of Pakistan should offer better salary
packages, improved and transparent service structures,
and scholarship programs to facilitate further
postgraduate studies to women doctors willing to work
in rural areas. Another issue of national level policy is
security for these women. Unless the security issue is
resolved or proper measures are taken to manage it, it is
unrealistic to expect women to serve in rural areas. But
one thing is certain: increasing the availability of women
doctors in these facilities will permit many lives to be
saved by prompt and skilled care.
Equally essential is community education.
Women's education and health must be emphasized
through a long-term comprehensive approach. Antenatal,
natal, and postnatal care can be stressed most effectively
by sensitizing and involving important people around her
(husband, mother-in-law) and highlighting the
importance of her role as chief caretaker of her offspring.
Otherwise, the decision to seek care at crucial times will
always be delayed and even service quality improvement
in hospitals will be ineffective.
It is important to strengthen and improve
existing first referral health care centers and ensure
provision of accessible and affordable emergency
obstetric care. Efforts to make them more accessible to
women should also focus on streamlining the referral
system to avoid overloading tertiary hospitals. The
gender sensitive dimensions of demographic and
social change need to be stressed further in all policies
and development plans. The narrowing of gender
disparities will increase women’s wellbeing.

REFERENCES
1. Fathalla MF. Human rights aspects of safe motherhood. Best
Practice Res 2006;20:409–19.
2. Freedman LP. Using human rights in maternal mortality
programs: from analysis to strategy. Int J Gynecol Obstet
2001;75:51–60.
3. Desai J. The cost of emergency obstetric care: concepts and
issues. Int J Gynecol Obstet 2003;81:74–82.
4. Fathalla MF, Guest editorial: Women have a right to safe
motherhood, Plan Parenthood Challenges 1998;1:1–2.
5. Cook RJ, Dickens BM, Fathalla MF. Reproductive Health and
Human Rights–Integrating Medicine, Ethics, and Law.
London: Oxford University 2003; p.393–401.
6. Cook R, Galli Bevilacqua BM. Invoking human rights to
reduce maternal deaths. Lancet 2004;363:73.
7. Kielmann AA, Siddiqi S, Mwadime RKN. District health
planning manual. Tool kit for health managers. Ministry of
Health, Pakistan. Multidonor Support Unit. Islamabad. 2002.
8. Cleland J, Kamal N, Sloggett A. Links between fertility
regulation and the schooling of and autonomy of women in
Bangladesh. New Delhi, India: Sage Publications, 1996;p.
205–17.
9. Mumtaz K, Salway S. I never go anywhere”: Extricating the
links between women's mobility and uptake of reproductive
health services in Pakistan. Social Sci Med 2005;60:1751–65.
10. Piet-Pelon NJ, Rob U, Khan ME. Men in Bangladesh, India
and Pakistan. Reproductive Health Issues. Dhaka: Karshaf
Publishers, 2000; p 26.
11. Green A, Rana M, Ross D, Thunhurst C. Health planning in
Pakistan: a case study. Int J Health Plann Manage
1997;12(3):187–205.
12. Winkvist A, Akhtar HZ. Images of health and health care
options among low income women in Punjab, Pakistan. Soc
Sci Med 1997;45:1483–91.
13. Khan A. Mobility of women and access to health and family
planning services in Pakistan. Reprod Health Matters
1999;7(4):39–48.
14. Pakistan Economic Survey 2003-04, Government of Pakistan,
Finance Division, Economic Advisers Wing, Islamabad.
2004.
15. National Institute of Population Studies. NIPS. Population
Growth and its Implications. Islamabad. 2005.
16. Siddiqi S, Haq IU, Ghaffar A, Akhtar T, Mahaini R. Pakistan's
maternal and child health policy: analysis, lessons and way
forward. Health Policy 2004;69:117–30.
17. Tinker AG. Improving women's health in Pakistan. Human
Development Network. HNP Series. Washington, DC: The
World Bank. 1998.
18. Court C. WHO claims maternal mortality has been
underestimated. BM J 1996;312(7028):398.
19. UNFPA. State of the World Population 2004, 2004.
20. Ali SS, Kaukab F, Ali A. Health management information
system in Punjab. Mother Child Health, 2000;38(1):32–6.
21. Population Council. The gap between reproductive intentions
and behavior: a study of Punjabi men and women. Population
Council, Islamabad. 1997.
22. Sultan M, Cleland J, Ali MM. Assessment of a new approach
to family planning services in rural Pakistan. Am J Public
Health. 2002; 92(7):1168–72.
23. Rosen JE, Shanti RC. Pakistan Population program: the
challenges ahead. Country Study Services No.3. Washington,
D.C.: Population Action international. 1997.
24. Ministry of Health, Pakistan. Progress on agenda for health
sector reforms. Islamabad. 2004.
25. Population Council. Adolescents and youth in Pakistan
2001-02: A nationally representative survey. Islamabad:
Population Council. 2003.
26. Ministry of Population Welfare/ Population Council. Pakistan
Contraceptive Prevalence Survey, 1994-95. Basic Findings.
1995.
27. Davies J, Agha S. 10 years of contraceptive social marketing
in Pakistan: an assessment of management, outputs, effects,
costs and cost efficiency 1987-96. PSI Research Division
Working Paper No.7. Washington D.C. Population Services
International, Research Division. 1997.
28. Pakistan Integrated Household Survey, 2001/2002. Islamabad.
Federal Bureau of Statistics. 2002.
29. UNFPA. State of the World Population 2005, 2005.
30. Siddiqui RI, Rizvi T, Jafarey S. Situation analysis of
emergency obstetric care in four districts of Sindh. J Col
Physicians Surg Pak 1999;9(4):187–9.
31. Thaddeus S, Maine D. Too far to walk: maternal mortality in
context. Soc Sci Med 1994; 38:1091–110.
32. Midhet F, Becker S, Berendes HW. Contextual determinants
of maternal mortality in rural Pakistan. Soc Sci Med
1998;46:1587–98.
33. MSU. Preparedness for emergency obstetrical care in Azad
Jammu and Kashmir. Islamabad. Multi Donor Support Unit,
Social Action Programme. 2000.
34. Bhutta Zulfiqar A. Maternal and child health in Pakistan.
Challenges and opportunities. Karachi Oxford University
Press; 2004.
35. Ali M, Hotta M, Kuroiwa C, Ushijima H. Emergency obstetric
care in Pakistan: Potential for reduced maternal mortality
through basic EmOC facilities, services and access. Int J
Gynecol Obstet 2005:91,105–12.
36. Maine D, Wardlaw TM, Ward VM, McCarthy J, Birnbaum A,
Akalin MZ, et al. Guidelines for monitoring the availability
and use of obstetric services. New York:
UNICEF/WHO/UNFPA; 1997.
37. NIPS. Pakistan population data sheet 2001.National Institute
of Population Studies. Islamabad, Pakistan. 2002.
38. Paxton A, Bailey P, Lobis S, Fry D. Global patterns in
availability of emergency obstetric care. Int J Gynecol Obstet
2006;93:300–7.

source:www.ayubmed.edu.pk