Although, the traditional concept of “Early Childhood Development” largely focuses on ages 0 – 8 years, some researchers and scientists have started to include the prenatal development as part of ECD. A recent meeting of the “Society for the Study of Reproduction” proposed that mother’s health at the time of conception influenced significant epigenetic (inherited) changes in developing fetus that could later manifest as birth defects, obesity, insulin resistance, hypertension and cardiovascular disease to name a few.

Growing research in this direction has resulted in many health professionals to practice and promote prenatal care as essential for pregnant women. ‘Improving Maternal Health’ is an avenue of focus internationally as well and is ranked as goal # 5 in the United Nations Millennium Development Goals. The Government of Pakistan, too, has tried to address issues related to maternal/prenatal health by extending support through developing rural community health centers, training lady health workers and dissemination of health related material for pregnant women. However, despite this movement, there are wide gaps in the population regarding who has access to services and who actually utilizes them.

Factors influencing utilization of antenatal care

Mother's health, nutritional status and the quality of care she receives during pregnancy are the key determinants of a newborn's survival and healthy start in life. Pakistan has one of the highest infant mortality rates in Asia because women largely do not receive timely and proper antenatal care. Not to mention the high prevalence of anemia and unassisted deliveries at home which add to high infant mortality and morbidity associated with pregnancy-related condition.

A number of factors that influence utilization of prenatal care are summarized as follows:

Poor Provision of Services
In Pakistan, one of the major reasons cited for high maternal mortality rate has been attributed to service delivery, with only 28 percent of the population having access to prenatal care.  A survey conducted in 2006-2007 indicated that 39 percent of births were assisted by skilled birth attendant (SBA), while 68 percent of births were reported to occur in the rural areas where women had lower (by 31 percentage points than their urban counterparts) access to skilled care delivery. This limited access could be another reason why the same survey showed that 34 percent births took place in health facility, highlighting majority of births taking place at home.

Many countries like Malaysia, Thailand, Sri Lanka, Jamaica and Tunisia reduced maternal mortality by half in a decade by improving access to emergency obstetric care; family planning services and skilled birth attendants i.e. midwives, nurses and doctors. (Source: USAID Report) The same report proposed a two-pronged strategy to address the existing condition in Pakistan by strengthening health systems and providing continuum care to pregnant women.

Socio-Economic Conditions
It is no secret that a large percentage of pregnant women in Pakistan cannot afford care, resulting in severely limited access to prenatal care. As a result prenatal health is largely characterized by poor hygiene, lack of water, limited knowledge and limited access to health services. According to a survey conducted in 2006-07, women’s wealth status was found to be one of the determinants of receiving skilled care. Women at the poorest situation had approximately 5 times less access to skilled care compared to their richest counterparts and 38 percent responded that costing was the barrier in accessing health facility. Caesarean section is one life saving emergency obstetric care when complications occur during pregnancy and childbirth. According to the WHO survey a large gap in accessing Caesarean section was reported among different income groups.

Women in the poorest socioeconomic group had 11 times less access to caesarean section than their richest counterparts.

Nutrition, an important factor during prenatal child development, is poor as well and many mothers are malnourished during the length of their pregnancy.  Studies prove the importance of maternal nutrition in preventing pre-term and low birth weight babies and thus further improving the nutrition of children. Anaemia is one of the important factors that hampers the daily activities in almost every woman and multiple pregnancies even makes it worse. Low maternal hemoglobin levels are associated with increased risk of pre-term delivery, low birth weight babies, and fetal death.

Lack of Education
Since female education is a challenge in Pakistan, most women have fewer years of formal education, which sparks a large domino effect of consequences related to prenatal care. A lack of formal education results in less knowledge about pregnancy and appropriate prenatal healthcare as a whole.

In areas where antenatal clinics are accessible, advice to mothers focuses on provision of iron and folic acid supplements, care of newborn, breastfeeding, nutrition of child and family planning. However, there is little discussion or counseling provided on change of state from woman to a mother, the importance of her keeping healthy, and the decision to become pregnant. Antenatal visits can prove to be a platform for advising women on the physical, physiological and psychological changes during pregnancy; nutrition and immunization of the newborn and mothers; proper birth spacing; and prevention of malnutrition. Postpartum depression is also one of the major morbidity affecting maternal health, which could be, addressed in the prenatal period.

Lack of Trust and Comfort with Healthcare Industry
Having limited experience with the healthcare industry, people generally have a lower level of trust with physicians, nurses, and the entire healthcare regimen. Many women who are distrustful of biomedicine will decline certain prenatal tests, citing their own bodily knowledge as more trustworthy than their doctor’s high-tech interpretations. In addition to this, Pakistan’s socio-cultural framework and patriarchal set up does not provide the space where women can exercise choice of utilizing existing services. Male members or “elder” women in the family play the role of decision makers and it becomes difficult to challenge their positions of authority. Therefore, some women may opt to avoid the distress and discomfort of the medical industry and refuse prenatal care entirely. According to the WHO survey 2006-07, of those women who did not deliver their most recent birth in a health facility, 57 percent responded that institutional delivery was not necessary.

Steps to improve antenatal care

Given these challenges and issues, some steps have been taken by the Government of Pakistan and international development organizations to improve antenatal/prenatal services. For example in December 2007, USAID/Pakistan embarked on a project called the Strengthening Health Systems project, (TACMIL Health Project). The main purpose of this two year activity was to improve technical assistance to the public and private health sector and strengthen health systems for improving service delivery with a focus on maternal and child health. The program has been implemented in all provinces of Pakistan. The impact of the program has not been disseminated.

While there are many challenges existing in a developing country like Pakistan, prenatal health can no longer be marginalized and needs to reprioritize. There is an increasing need for dedicated programs to ensure universal access to reproductive health care and family planning services across the country and provision of affordable maternity care by skilled personnel. Areas in Pakistan where poverty, conflict, distances and overloaded health systems obstruct access to adequate healthcare demand special attention. Moreover, community mobilization and awareness can become key tools for involving men in wider reproductive health and for encouraging health counseling for adolescents as well as for highlighting ill-effects of child marriages and domestic violence. 

Collective efforts at societal and government levels will help ensure the health of our future generations.

About the Writer:
Ms. Mahira Chishty holds a Masters degree in Social Work from Columbia University, New York and has an experience of working in the development sector. She is currently working as a Senior Coordinator in the Program Support and Development Unit at the Sindh Education