August 6, 2020
By Ayaz Khan
Emergency calls to Habib Ullah Rind who runs the Saiban Welfare Trust have hit a dramatic rise in the blistering heat of Sibi. He is busy in giving first aid to a hermit (darvesh), who has been badly struck by a heatwave when his phone rings. It is yet another urgent call for his help, and it forces him to rush towards the location to ascertain the nature of the emergency.
But with difficult times thanks to the Coronavirus situation in Balochistan, his welfare work of taking critical patients to Sibi Civil Hospital, has had to inch through.
“My team and I have been instructed to follow Standard Operating Procedures (SOPs) issued by the government of Balochistan while carrying out our work,” he explains. “For instance, we have been strictly told not to aid patients who are experiencing flu-like symptoms. But by far the most difficult cases to deal with,” he says, “are the gynecological cases, especially if the patient has any flu-like symptoms.”
It is a situation of a quandary for him.
“We cannot let the patients suffer. If they (female patients) need to be hospitalized, we carry them to hospital but we have to drop the patients at the gates of the hospital because of the fear that our ambulance and entire team will have to be quarantined. We have to resort to asking the patients to say that they have come on their own.”
Following the pandemic outbreak, government-run hospitals have closed Outpatient Departments (OPDs) which has caused much trouble to the patients solely relying on these hospitals. The closure of OPDs amid the pandemic has left most of the patients vulnerable, particularly female patients, who need critical maternity healthcare.
Ibrar, a journalist hailing from Quetta, had been visiting the Combined Military Hospital (CMH) Quetta for the maternity care of his wife until the lockdown led to the closure of the CMH. Following the lockdown and closure of the hospital (CMH), he has been instead going to see her in Civil Hospital Quetta. It is the only option for him, even though the Civil Hospital does not even have basic facilities.
“My foremost concern is going to the civil hospital for my wife’s maternity healthcare was a lack of basic facilities along with the fear of the pandemic,” he says. “All the senior gynecologists have stopped attending patients since the start of the outbreak. Patients are left at the mercy of junior doctors. The patients cannot rely on private clinics wither because 80 percent of the clinics are closed in the city.”
Sakina*, a mother of six children, waits for her turn outside Bolan Medical Complex’s labor room. She has been diagnosed with a challenging pregnancy and it is her second visit to the hospital. BMC is one of the important government-run health facilities and its gynecological OPD usually remains flocked with patients. But the COVID-19 emergency has disrupted the general OPD which is quintessential in carrying out general gynecological procedures required for an early and efficient check up to tackle any complication during the birth of the child.
“The doctor told me to be here for my checkup today. She had also instructed us to arrange for blood for dealing with any emergency. But, at the eleventh hour, she has refused to treat Sakina*,” complains Sakina’s* mother.
“Because of the closure of the OPD, the due process, which is much necessary for making sure all essential tests are taken, is disrupted which is causing trouble in handling maternity cases properly,” says Dr. Sabiha.
Currently, patients do not get properly checked in OPD and must directly visit the labor room. The labor room is mostly full and only the obstetric cases, which need immediate care, are dealt with in an emergency. Most of the cases, owing to the closure of the OPD, reach the labor room at a crucial time; but at the same time their essential medication—necessary injections which need to be administered at the delay of many hours—can not be completed. This delay of proper medication is leading to pregnancy termination or self-abortions, as Dr. Sabiha explains further.
The total tally of Corona cases in Balochistan has reached 11,780. The pandemic has made its presence in most of the districts of the province and the cases in district Lasbela have rocketed while the official number of cases stands at 64. Lasbela is the home town of the incumbent Chief Minister (CM) of Balochistan. The entire district has only one designated hospital at Hub where Corona patients have been isolated.
Saima* and her one of the relatives are in the isolation wards of Jam Ghulam Qadir hospital in Hub. Saima*, 35 hailing from Lasbela, preferred to visit Civil Hospital Karachi for her delivery. She lost her child and has now been tested Corona positive after 15 days of her return to Bela. Closure of the OPDs has forced patients from Lasbela to take the route down to either Hub – or Karachi given the lack of facilities at Civil Hospital Hub.
“We have kept all female (gyne) patients in isolation,” says Dr. Hasan, Resident Medical Officer (RMO) Civil Hospital Hub. “The problem with the cases is that both types of patients are asymptomatic, so we have to keep them in isolation.”
Female paramedics at risk
The infectious disease has created a vicious cycle. On one hand, the negligence by female patients has been exposing the paramedics to danger; on the other hand, exposure of paramedics to the virus is itself causing a delay in the treatment of patients. Professor Najma’s team at the Balochistan Medical Complex (BMC) has suffered a similar fate.
“Initially, we started providing facilities to patients without having proper protective gear (PPE) which led to almost eight of my paramedics contract the virus,” she says. “Now we have received PPEs by the government. Few paramedics have recovered until now and this has caused staff deficiency because of which we have been facing difficulty in carrying out our duties.” Professor Najma is the head of the gynecology unit, BMC.
There are many other factors that are affecting the maternal healthcare system during the pandemic.
Closure of OPDs has led to the non-availability of antenatal facilities. The pandemic has affected maternal healthcare on the whole.
“We have observed an increase in miscarriages and the pH levels of pregnant women,” says Dr. Najma. “These cases might increase the risk of maternal mortality rate (MMR).”
A female paramedic working in the civil hospital of Quetta on condition of anonymity disclosed, “During treatment of a critical female patient, I myself contracted Coronavirus. Later my brother also got infected. Most of the patients are not screened for Coronavirus which has enhanced the risk for doctors.” She says they cannot send patients for Corona screening unless their obstetric and gynecological issues are addressed properly.
“The gynecology building of the hospital,” she says, “is not constructed in such a way where we (paramedics) can maintain social distancing. With overall six beds available in the labor room, we have to adjust two to three patients on each bed. Staff deficiency has led to more difficulties in carrying out our duties.”
Increasing risk of female mortality rate
The post 18th amendment benefits have not been generously availed by Balochistan in terms of improving the overall healthcare system. According to the National Health Account (NHA), 2013-14, out-of-pocket (OOP) expenditure in Pakistan is 75 percent. In Balochistan, however, the OOP expenditure continuously increased from 2009 to 2014. In 2009-10, the OOP expenditure was Rs14,405 million. It further increased in 2011-12 which was Rs16,168 million and it quadrupled in 2013-14 rising to Rs24,253 million. Similarly, the report reveals that OOP expenditure remains the highest in Balochistan (79.41 percent).
According to some estimation by the Balochistan Institute of Research and Development (BIRD), a think tank based in Balochistan, approximately 780 women die annually owing to a dearth of maternity healthcare facilities in the province. As per the report, the province has 28 public hospitals, 550 basic health units, and 90 childcare and maternity health clinics. However, it also estimates that 90 percent of these facilities lack female doctors.
A recent estimation by UNICEF reveals that 116 million babies will be born worldwide. Out of the 116 million babies, more or less 29 million babies will open their eyes to South Asia. As per UNICEF’s estimation, five million babies are expected to take birth in Pakistan in the forthcoming nine months. Flattening the curve of maternal mortality (MMR), however, has been one of the gravest health issues in Pakistan and particularly in Balochistan.
“The prevalent sorry state of the maternity healthcare system in Balochistan is appalling,” says Javaria Tareen, CEO of Balochistan Institute of Research and Development (BIRD). “Women are already affected by malnutrition and gynecological departments are at risk during the pandemic outbreak. The World Health Organization (WHO) says that healthcare and education fall under the umbrella of Human Resource Development (HRD) which is an investment. Sadly both sectors are treated as expenditures rather than being given foremost priority in the budget allocation. Due to a lack of maternity health facilities,” Ms. Javaria adds, “the figure of annually dying women might increase to 1000 during this Corona emergency.”
Dr. Amir Baksh Baloch, director of technical People’s Primary Health Initiative Balochistan (PPHI-B), also believes that maternity healthcare has already been an emergency in Balochistan and the current pandemic will exacerbate the situation.
“During any pandemic, three sections of the society are declared vulnerable: those aged above 60 years, those who have a compromised immune system – these people fall in the bracket of co-morbidity. And the third most vulnerable section is that of pregnant women,” Dr. Amir Baksh explains.
“If we are compelled to live with the pandemic, we will have to do two things to prevent mortality rate. Firstly, we have to make sure that all of the three vulnerable sections are isolated properly with the required treatment. Secondly, it’s quintessential to continue antenatal care for pregnant women. The closure of the OPDs is leading to a lack of antenatal care which is necessary to diagnose pregnancy related dangers beforehand.”
Dr. Amir says that two alarming factors are exceeding female mortality in Balochistan – the first and foremost factor is that of Postpartum Hemorrhage (PPH) and the other is anaemia. “The former causes 25 percent of deaths during deliveries and the latter is also responsible for a high death rate. If 25 percent of deaths are decreased by adopting effective family planning, the mortality rate will decline effectively,” he concludes.
Healthcare experts continue to give their input over what is needed by the province which is lagging behind the others in terms of basic facilities. The government however does not seem to be acting upon their advice. But in the meantime, it is the women who continue to suffer the lack of health services.