Comparing the Burden of and Approaches to Maternal Mortality in Pakistan and Iran

Maternal mortality, or maternal deaths, are defined as any deaths that are caused as a result of complications during pregnancy or childbirth, or any death occurring within 42 days of a pregnancy being terminated, regardless of the duration of the pregnancy.^1,2 As women are the bearers of life and most often the primary carers of all her children, especially in developing countries, maternal health is especially important.

Across the world, a pregnant woman dies every 2 minutes due to complications with pregnancy or childbirth; In other words, attributed to maternal mortality.³ The maternal mortality ratio (MMR) is often hard to measure due to poor data and the various causes that can lead to maternal mortality, however, globally, it is the key indicator of maternal health.² The global MMR has decreased globally from being 342 deaths per 100,000 live births in 2000 to 223 deaths per 100,000 live births in 2020.⁴ Despite this progress, there has been stagnation of the MMR recorded between 2016 and 2020, and there is still a substantial way to go before the global MMR reaches the 2030 Sustainable Development Goal of 70 maternal deaths per 100,00 live births.⁴

Almost 95% of all maternal mortality deaths are accounted for in low- and middle-income countries, and major complications account for about 75% of these deaths.² Major complications that cause maternal mortality include severe bleeding, infections, pre-eclampsia and eclampsia, complications during childbirth, and unsafe abortions.²

This essay will use Pakistan and Iran as case studies to compare and contrast the burden of maternal mortality in each country, and the effectiveness of approaches used to address maternal mortality. 

Burden of Mortality

Pakistan and Iran are both in the World Health Organisation Regional Office for the Eastern Mediterranean (WHO EMRO) region and share a land border,⁵ however the difference between their MMR’s is dramatic considering their close geographic range. Pakistan’s MMR has decreased from 387 per 100,000 live births in 2000 to 154 per 100,000 live births in 2020.⁴ In contrast, Iran has made progress to decrease it’s MMR from 44 per 100,000 live births in 2000 to 22 per 100,000 live births now in 2023.⁴ Although both countries have approximately halved their MMR, Pakistan is still one of 10 countries that contributes to over 60% of the world’s maternal deaths.⁶ 

Maternal mortality poses a significant burden on Pakistan’s public health system, however the burden is not evenly distributed across regions. The Khyber Pakhtunkhwa (KPK) province in north-western Pakistan has an MMR of 269 per 100,000 live births, compared to the Punjab province in central-eastern Pakistan has an MMR of 157 per 100,000 live births.^7,8 The main reasons why the KPK region has a higher MMR than Punjab is due to the remote and mountainous terrain, availability of health infrastructure, and conservative culture surrounding woman accessing health care.⁹

The primary causes of maternal mortality in Pakistan are haemorrhage (27%), hypertensive disorders (16%), sepsis (11%), unsafe abortions (9%), and obstructed labour (7%).^10,11 Lack of skilled maternal health care workers is another contributing factor to maternal mortality in Pakistan.¹⁰ In comparison, the primary causes of maternal mortality in Iran are excessive bleeding (43.7%), infection (21.3%), hypertensive disorders (13.9%), and other causes (21.1%).¹² However, common across both countries is the lack of access to adequate maternal health services, especially in rural areas, cultural and social barriers to accessing maternal health care, and delays in seeking care, which all contribute to the MMR.^11,12

There are also a range of demographic factors that contribute to the MMR. In Pakistan, these include a high number of teen pregnancies where 10% of girls give birth before they turn 18, a high rural population with 63% of the population living in rural areas, and limited health care access, especially in rural areas.¹¹ Additional demographic factors were shared among Pakistan and Iran including, lower levels of education (40% illiteracy in Pakistan compared to 6.4% in Iran), and socioeconomic status (24.3% of people in Pakistan and 0.1% in Iran live on less than $1.90 a day).^11,13

Although the primary causes and demographic factors that contribute to Pakistan and Iran’s MMR are similar, Iran has a significantly lower MMR because it has focussed on improving rural access to maternal health services since 1990.¹³ Whilst Iran has made significant progress in reducing its MMR, further progress is needed to reach the WHO target which encourages Iran to reduce its MMR to less than 10 maternal deaths per 100,000 live births by 2030.¹³ In contrast, Pakistan needs to focus on improving access to maternal health care in rural areas to reduce its MMR. 

Figure 1. Chart demonstrating the progress of MMRs in Iran and Pakistan from the years 2000 to 2020.⁴

Current Approaches to Reduce Maternal Mortality

Pakistan and Iran have both used a variety of approaches to reduce maternal mortality in their countries, however some of the most notable approaches taken that address one or more main causes of maternal mortality in both countries are the Lady Health Worker (LHW) programs, Skilled Birth Attendants (SBA’s) programs, and Emergency Obstetric and Newborn Care (EmONC) interventions.  

In 1994 Pakistan launched the LHW program to improve the MMR and child health outcomes.¹⁴ As a community-based initiative, it is focussed on employing and training local women as healthcare workers to serve their respective communities. LHW’s are extensively trained and are able to provide basic maternal and child health services, including family planning services, postnatal care, counselling on infant care and breastfeeding, and immunisations.¹⁴ As LHW’s are selected from the community, they are uniquely placed to communicate effectively with the households they visit, provide education on health-related matters, and identify and refer any potential high-risk pregnancies to equipped healthcare facilities.¹⁵ However, the program has been criticised for not supporting LHW’s enough to allow for proper implementation and effect to take place.¹⁵

In contrast, Iran has used LHW’s in a more comprehensive manner, increasing their training to include prenatal care, birth delivery services, and postpartum care.¹⁶ Additionally, Iran implemented a complimentary national health insurance program that is aimed to reduce the financial barriers that women may face when accessing maternal care by covering maternal health services for free.¹⁷ Similar to LHW’s, Iran also uses the Behvarz program to empower rural women and provide them with employment opportunities and increase community engagement.¹⁸ The Bahvarz are trained similarly to LHW’s, but men can also be part of the program if they wish, although their numbers are relatively small.¹⁸

Whilst both countries have implemented the basic foundations of LHW programs, Iran has gone further to train LHW’s in higher-risk scenarios such as delivery and postpartum, has removed financial barriers to access care, and has additional health support services such as the Behvarz.^17,18

In addition to LHW’s, both countries have also increased the number of SBA’s to try and reduce their MMR’s. SBA’s differ from LHW’s in that LHW’s are community based, usually in rural areas, and are trained in a variety of health services, whereas SBA’s are typically midwives, nurses, or doctors who receive specialised training on maternal and newborn health during pregnancy, childbirth, and the newborn period, and work in hospitals or health facilities.¹⁹ Pakistan first started trying to increase the number of SBA’s in 1995 as part of the National Maternal and Child Health (MCH) Program, which included deploying Community Midwives (CMWs) to improve rates of skilled birth attendance in rural areas of the country.¹¹ In 2010, the National Program for Family Planning was launched by the government to train and deploy over 10,000 midwives across the country.²⁰ These initiatives and programs provide financial incentives, career growth opportunities, and training opportunities for rural healthcare workers in order to incentivise them to work in rural areas where maternal mortality is the highest, although it is unclear whether SBA training is free in Pakistan.^19,20 Additionally, the programs have included community awareness campaigns to raise awareness about the importance of SBA’s and educate women on the importance of care during pregnancy and the postpartum period.¹⁹ Despite these efforts, the programs to increase SBA’s have only been moderately effective for reasons that will be elaborated on below. 

In comparison, Iran implemented the SBA program in the 1990’s under the Ministry of Health and Medical Education (MOHME) which is responsible for training and deploying SBA’s.²¹ The SBA program in Iran includes a 6-month training course that is offered to selected midwives and nurses for free and is available through universities and medical schools.²¹ The purposes and outcomes of the SBA programs in Iran and Pakistan are the same, however, Iran has made the course more accessible for its population should they wish to become SBA’s.²² 

The EmONC program has also been implemented in both Pakistan and Iran as per WHO guidelines.²³ The EmONC program focusses on training formal healthcare workers to identify and manage obstetric emergencies and provides essential drugs, supplies and equipment to healthcare facilities, thereby improving the quality of obstetric healthcare available to women.²³ The EmONC program was initiated in Pakistan in 2005 as a collaboration between the Government of Pakistan and the United Nations Population Fund (UNFPA).²⁴ The program includes regular monitoring and supervision to facilities that are part of the program to ensure quality obstetric care is upheld. Additionally, the EmONC program in Pakistan has a referral system in place for women who require further specialised care.²⁴ Whilst the program undoubtedly addresses some of the major causes of maternal mortality by improving the quality of care, the program is only free at government run facilities and some services and supplies incur additional out-of-pocket costs.²⁵

The EmONC program in Iran also includes a proactive referral system for high-risk pregnancies and supports its members to manage obstetric emergencies as seen in Pakistan.²⁶ However, the EmONC program in Iran has evaluated the major causes of maternal mortality and has focussed specifically on early detection and management of these primary causes of maternal mortality.²⁷ For this reason, Iran has achieved greater success in providing antenatal coverage and improving maternal health than Pakistan has with the same program.

Effectiveness of the Approaches to Reduce Maternal Mortality

LHW’s workers in Pakistan have been shown to reduce maternal mortality by 29% in areas where they are implemented compared to areas where they are not.¹¹ LHW’s have also been demonstrated to increase utilisation of maternal health services such as antenatal visits, skilled birth attendants, and postnatal care.²⁷However, the effectiveness of the LHW program in Pakistan in somewhat inhibited because it has not focussed on addressing the primary causes of maternal mortality, the program is more reactive in nature.²⁸ In contrast, Iran’s LHW program has been one of the most successful in the world contributing to a 73% reduction in maternal mortality between 1990 and 2013.⁴ More specifically, another study reported that due to Iran prioritising its LHW program to focus on the major causes of maternal mortality, maternal mortality due to haemorrhage reduced by 54% and sepsis by 76% between 1995 and 2012.²⁹

Similarly to the LHW program in Iran, Iran’s SBA program has also been specifically focussed on addressing the major causes of maternal mortality in the country, thereby increasing its effectiveness.²¹ The exact contribution to the reduction of Iran’s MMR is hard to calculate for SBA’s because they are so closely linked with LHW’s and other maternal health programs through referrals and awareness campaigns, some studies have estimated that the introduction of SBA’s in Iran is associated with a 43-72% reduction in MMR.³⁰ Reports from Pakistan have also demonstrated that SBA’s have been effective in improving Pakistan’s MMR. The proportion of deliveries attended by an SBA increased from 17.8% to 47.6% from 2006-2012 and found that women who were under the care of an SBA were significantly less likely to experience complications during birth, indicating the role of SBA’s in reducing Pakistan’s MMR.¹¹

The EmONC program in Iran has also strategically targeted the main causes of maternal mortality in Iran. Its effectiveness is primarily as a result of the impact on improving rates of antenatal visits and identifying hypertensive disorders. Before the introduction of the EmONC program in Iran, only 62% of pregnant women had received at least one antenatal visit, however those rates increased to 96% in 2016.³¹ Increasing antenatal care coverage in Iran has enabled the country to implement early detection systems for high risk maternal health factors, hence it is able to directly address some of the primary causes of maternal mortality.³¹Although Pakistan has not been able to expand their EmONC program as much as Iran, where EmONC is available in Pakistan it has made a direct impact to the MMR. As 35% of maternal deaths in Pakistan are attributed to obstetric causes such as haemorrhage, sepsis, and obstructed labour, Pakistan has been able to provide emergency services and early detection analyses to women who access EmONC.¹¹ Furthermore, another study estimated that the Pakistan EmONC program had directly contributed to a 20% reduction in the country’s MMR.³²

Critical Appraisal of Approaches to Maternal Mortality

Building on the effectiveness of the abovementioned initiatives that Iran and Pakistan have used to address maternal mortality, this section will analyse the feasibility, strengths, and weaknesses of each initiative. 

The LHW program in Pakistan is technically feasible as it relies on local women from rural areas who can be trained and employed to deliver basic health services.¹⁴ The LHW program has indeed increased the coverage of health services in rural areas and is a more acceptable form of health delivery since it is community led.¹⁵ However, its weaknesses surround lack of support, resources, funding, low salaries, and limited career progression opportunities.¹⁵ There is also a shortage of LHW’s in some areas,¹⁵ and the aforementioned weaknesses have the potential to discourage any potential future women becoming LHW’s if other careers are available. Regardless, the strengths of the LHW program in Pakistan focus solely on the impact that LHW’s have on reducing the country’s MMR through increased utilisation of maternal and child health services.²⁷ Whilst a commendable strength, if the weaknesses are not addressed, there is limited potential for the expansion of the LHW program in the future. In comparison, Iran’s LHW is highly feasible due to strong infrastructure that supports the development, training, and deployment of LHW’s, which is underpinned by a well-established primary healthcare network.¹⁶ However, similar to Pakistan, the program has been criticised for providing limited support and supervision for LHW’s once deployed.¹⁷ Another reported weakness of the LHW program in Iran stems from gender bias discrimination in some communities which hinders their ability to provide health services to women and girls.³¹ Although this only occurs in some communities, and an overall key strength of Iran’s LHW program is its high rates of community acceptance, which fosters greater community engagement and education, and acceptance of maternal health services.¹⁷Furthermore, the feasibility and strength of the program is attributed to Iran’s ability to provide comprehensive health services including pre- and post-natal care, family planning services, and health education.¹⁶

The SBA program in Pakistan is also technically feasible due to a large pool of potential doctors, nurses, midwives, and CHW’s, who are financially incentivised to complete the relatively short training course.¹¹ The main strengths of the program relate to Pakistan’s effort to increase the number of deployed SBA’s across the country, however this is overshadowed by the main criticism that reports the quality and skills of SBA’s are varied and unreliable, and inadequate infrastructure and supplies further inhibits the quality of care that can be provided by an SBA.²⁰ In comparison, Iran’s SBA program has high feasibility as it is builds upon existing healthcare infrastructure and training and deployment of SBA’s are financially and logistically supported.²¹Whilst the program has faced challenges in retaining SBA’s and ensure quality of training and care is consistent across regions, the program has been successful due to its decentralised manner, where SBA’s are deployed at the community and health facility level and it’s cohesion with other health services such as the Behvarz, which has increased the availability of and accessibility to maternal health services in Iran.^18,22

The EmONC progam in Pakistan is technically feasible with obstetric emergency training available to be implemented across healthcare facilities in the country, however there is a shortage of healthcare workers in some areas of Pakistan which limits the feasibility of implementation.²⁰ The key weakness of the program is its high investment requirements for infrastructure and equipment, which is compounded in rural areas of Pakistan that won’t have health facilities capable of accommodating this equipment should investment and personnel be available.²³ However, the program has improved the quality of obstetric care received by women, thereby improving their health outcomes, and the referral system is well established for women who are identified as needing specialised care.²⁴ In comparison, Iran’s EmONC program has high feasibility for similar reasons to the LHW and SBA programs, i.e., Iran has leveraged the existing health infrastructure available.^17,26 Its key strengths are its focus on building capacity and strengthening the referral system, and high focus on antenatal care, including hypertensive disorders, which is a primary cause of maternal mortality in the country.²⁷ However, one of the weaknesses of the EmONC program in Iran is the difficulty in expanding the services into rural areas of the country that don’t have existing health infrastructure to build upon.²⁷

Recommendations to Improve Approaches to Maternal Mortality in Pakistan

The LHW, SBA, and EmONC programs in Pakistan all suffer from similar limitations, including limited support and infrastructure, varied quality of care levels, and workforce shortages. Therefore, the below recommendations aim to target the primary causes that inhibit the success of maternal mortality approaches, and simultaneously target the primary causes of maternal mortality. 

Firstly, Pakistan needs to strengthen their primary healthcare system to ensure that healthcare facilities are equipped and well-resourced, accessible, and affordable. As this approach primarily relies upon funding, it is recommended that Pakistan increase government funding by allocating and investing more money into primary healthcare facilities and healthcare training. This should be supported by health insurance schemes that provide financial protection to rural areas to increase the affordability of maternal health services, and public-private partnerships that can contribute to the sustainability of the approach through additional funding and technical assistance. Increased funding would also contribute to the retention of LHW’s and SBA’s and improve the ability to monitor and evaluate quality of care, as the primary weaknesses of those programs was limited support, low salaries, and varied quality of care. 

Secondly, to ensure the uptake of maternal health services, Pakistan needs to engage and involve women during the program design and implementation phases. This can be achieved through focus groups and community meetings and will assist Pakistan in building community support by including mothers from the onset and ensuring programs are culturally sensitive and tailored to meet mother’s needs. Improving community engagement will have the additional benefit of increasing health communication and education in communities, as women are inherently sought after and included in programs, and messages can be tailored to meet women’s needs and preferences.

Lastly, Pakistan could benefit from employing mobile health technology. LHW’s, SBA’s, and EmONC workers can use telemedicine and mobile clinics to provide basic maternal health consultations, diagnoses, and treatments to communities that do not have the appropriate health infrastructure available. Not only is this a cost-effective solution, it requires minimal additional infrastructure, and can reach rural communities faster and more effectively than other methods, as shown in Iran.³³

Final Note

This essay has analysed the burden and primary causes of maternal mortality in Pakistan and Iran. While both countries have made significant progress in reducing maternal mortality since the late 1990’s, further progress is needed. In particular, Pakistan needs to implement a multifaceted approach to maternal mortality that focussed on increasing basic infrastructure, community engagement, and workforce capacity, and become proactive in addressing the primary causes of maternal mortality in the country. 

References

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