Not only does Pakistan have one of the highest population growth rates in the world, it also has the third highest burden of maternal, foetal and child mortality in rural areas where 60 per cent of its population lives.

In rural Pakistan, maternal mortality rate is nearly twice as that in the cities (319 women out of 100,000 die due to pregnancy related complications in rural areas in contrast to 175 in urban areas). These deaths occur despite the deployment of a very large number of Lady Health Workers (LHWs) trained by the government since the mid-1990s. The sad reality is that 80pc of maternal deaths are preventable. If rural women had improved access to maternal and neonatal healthcare, many lives could be saved.

To see if they could come up with a way to cover the gaps in rural areas, as more than 42pc of Pakistan’s rural population is not covered by the LHW programme, the Rural Support Programmes Network (RSPN) in collaboration with the Health and Nutrition Society and the Thardeep Rural Development Programme implemented a one year project in a non-LHW covered area of rural Sindh in district Dadu.

Families living in remote and rural areas often have the hardest time accessing the most basic health service. In these poor and deeply conservative areas, men have control over decision-making and women are usually unable to negotiate for better health services or to access services without their spouse’s consent. The project attempted to reduce the several delays in utilising emergency obstetric care, which are known to contribute towards pregnant mothers dying in these rural areas.

Community-based interventions go a long way in reducing maternal deaths

The RSPN, an NGO that is expert in community mobilisation, organised the community of Dadu up to district level and hence they were able to make the linkages with the relevant government departments. The main interventions made by the project in Dadu were first mobilised through Community Resource Persons (CRPs) to address the first delay at the household level, which is when families delay seeking medical care when a woman encounters complications during pregnancy or labour (male CRPs for men and female CRPs for women). The second step was the formation of Village Health Committees (VHC) and the establishment of a transport fund and arrangement of vehicular transport for complicated delivery cases to address the second delay of not having transportation to a healthcare facility. Thirdly, training and equipping of existing public sector health facilities to address the third delay, which is not receiving adequate and appropriate treatment once at a healthcare facility.

A detailed study was undertaken as part of the project to demonstrate the success of the community based intervention model implemented in just one union council of district Dadu called Khudabad (population of around 27,000). The study also selected the adjoining union council of Kamal Khan (population of around 32,000) where no intervention was done, in order to compare the effectiveness of the project.

The study revealed that counselling and information sessions with CRPs seemed to have improved risk awareness and health consciousness among the households in Khudabad. The CRPs, all from the local community, went from house-to-house visiting almost 90pc of the households in the project area. CRPs were found to be the most common source of information for women in Khudabad about complications during pregnancy and wives demonstrated an increase in their ability to recognise danger signs during and after pregnancy.

The project empowered pregnant women to take greater control of decision-making regarding their health and this could be seen in the considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad. The husbands became more supportive since the male CRPs would visit them as well and the hesitation to go to the doctor was gone.

According to Bashir Anjum, the project manager, “The CRPs were a good source of information and they created awareness about health issues … the government and donors can adopt the CRP model as a low cost (and makeshift) alternative to LHWs until they can be deployed to these areas.”

The Village Health Committees, if further empowered, could also contribute towards making the government’s failing healthcare system more accountable. According to Nazir Bhand, a member of the VHC from Khudabad, “We need time but we are getting there. We would like to see a permanent change — we now get after the health department to listen to our demands. It is our right to demand better healthcare.”

Developing a community mechanism to provide funds for transport was also a key intervention. Khudabad badly needed an ambulance service although it had an established Maternal and Child Healthcare centre. Its operational hours were also extended from 2pm to 8pm and the waiting time for patients was reduced to less than 30 minutes. The centre was also equipped with oxygen tanks and the labour room was made operational by the project, which helped reduce maternal care complications. The Dadu model has proven to be one of the most successful in resolving maternal healthcare issues at the community level.

“One of the key contributions of this project was to show how communities can partner with the government to improve services,” explains Shandana Khan, the head of the RSPN. “We are constantly trying to make linkages and RAF (the Research and Advocacy Fund which supported the project) has shown us that it can be done … Our ultimate goal is to make communities so strong that they make the government accountable.”

For this purpose a district level committee has been formed with the government and community representatives, which coordinates referrals and addresses glitches in the system. She would like to see the intervention done in Dadu scaled up into a bigger project that can be implemented in other rural districts to make healthcare available for the poor and marginalised communities of Pakistan.

Published in Dawn, Sunday Magazine, June 15th, 2014