Dr. Musarrat Zahoor is a gynecologist currently working at the Burhani Hospital, which is a charitable institution. She graduated with an MBBS degree from Dow University of Health Sciences and did her post-graduation (MCPS) in Gynecology and Obstetrics from College of Physicians and Surgeons of Pakistan (CPSP). She has over 13 years of work experience as a civilian gynecologist, in both clinical and surgical fields. Her interests include attending various national and international conferences related to her field, attending gynecology and obstetrics workshops and keeping herself up to date with the latest research.

What factors impact maternal health in our society? How can these be addressed to ensure safe motherhood?

Women’s health care in our society is hardly a priority, even in the minds of women themselves. Social and cultural issues and lack of accessible health care result in overall poor physical well being of women. It is generally observed at the household level, that there exists a large disparity where spending on nutrition for females is concerned. Added to that is the onus of child bearing especially in cases where women bear children one after another. Most of the time, in these cases, miscarriages, low birth weight, and premature births are likely to happen affecting mother’s health owing to high demands and pressures of raising a second child when the first one is also in infancy..Then there are also those instances where consistent miscarriages or the pressure to produce a male child are common and result in maternal stress and psychological problems like depression. Unsafe abortions or unhygienic child birth practices quite often lead to maternal deaths and poverty and lack of awareness worsen the situation manifold.

Having said this, ignorance I feel is by far the biggest of all challenges in our country. It also paves way for many myths and doubts. For example there is a general misconception that taking polio drops or mineral water will result in birth control. You can only counter uncertainty through education and awareness at a mass level. There is also no concept of pre-pregnancy check-ups and taboos are associated with discussing a medical condition with doctors, friends, family or acquaintances. This can be very harmful for example in instances where both the partners are Thalassemia Minor (which is not harmful to any one), the child can develop a more severe form of illness by inheriting the bad gene from both parents. So pre-pregnancy testing is important to rule out any complications.

In the developed world, pregnancies are pre-planned – so a female’s health is taken care of before she even gets pregnant. There are pre-conception medical examinations and tests such as diabetic profiling, thyroid profiling, and venereal disease profiling, etc. that a female is required to clear in order to ensure safe and healthy pregnancy and child birth. Such practice should be enforced in Pakistan as well and couples should be encouraged to visit the doctor as soon as they start to plan a baby. Intensive awareness campaigns are needed and it may take years of consistent counseling and advocacy to spread the message and bring about a behavioral change.

In addition, minimum services required to abate risk of maternal death or disability include not only the ante-natal services but also minimally skilled assistance for proper delivery arrangement (both traditional birth attendants and midwives), and available and accessible facilities for post-partum care for the assessment of mother and child health. Medical practitioners should extend counseling to patients during these critical stages of motherhood. Other services such as family planning can be integrated as well. People have been spacing childbirths for thousands of years through natural methods such as withdrawal, abstinence, and breastfeeding. Preferably, injections are given for spacing rather than pills, besides other methods. At least a two year period of spacing is recommended between children. Birth spacing ensures health and well being of both the mother and child. 

What economical food choices are available to meet the nutritional requirements of females during pregnancy?

The food in a woman’s diet is the main source of energy for the baby. Expectant mothers are often unable to meet the nourishment requirements during pregnancy. This can only be partially linked to affordability since many a times unhealthy eating habits and wrong food choices lead to deficiencies.

A number of readily available food items can fulfill the nutrition requirements of a pregnant mother and not all are expensive options. For instance it is not necessary to buy expensive fruits like strawberries and leechees to meet the vitamin and mineral requirements of the body during pregnancy. More affordable options such as bananas, apricots, etc. can be consumed. A lot of affordable supplements are also widely available. Pulses are a very good source of protein and can be used as replacement for eggs or meat if affordability is an issue. Similarly, carbohydrates can be obtained from flour which is a staple food in our households generally. As for calcium, two cups of milk is a standard bodily requirement during pregnancy and other dairy products such as butter and yogurt should be frequently consumed. For affordability, calcium supplements prescribed by doctors can also meet the requirements of the mother and the growing fetus. Any leafy vegetable can be taken for a healthy intake of iron as iron plays a major role in the growth and development of cells, as well as tissue formation. Overcooking of vegetables must be avoided as it burns all the nutrients.

I have also observed that anemia (iron deficiency) is quite common in pregnant women, not because of eating less but mostly because of ill eating habits like overcooking of food, not eating the right food and/or at the right time, etc. Iron supplements, as digestible by the patient, such as folic acid are also advised by doctors. It is important to note that there has to be a gap of at least 3-4 hours between the intake of calcium and iron as the absorption of iron would be affected by the combined consumption. It is better that iron supplement is taken at night after meals because it helps in avoiding heartburn. Pregnant mother or the unborn child do not require Vitamin D and therefore it is only prescribed in case of proven deficiency or while breastfeeding.

Can the extra nutritional needs of pregnant mothers be met through supplements alone?

Expectant mothers have a higher need for some vitamins and minerals. However supplements cannot replace a healthy diet. While taking a prenatal vitamin and mineral supplement ensures that both the mother and the baby get enough vital nutrients like folic acid and iron, taking extra can be harmful. It is important therefore to consult the doctor. A healthy diet needs to be maintained throughout pregnancy comprising foods that have vitamins and minerals that the body needs. A typical plan may include 3 servings of proteins, 4 servings of dairy products, 4-5 servings of vegetables, and 4-5 servings of carbohydrates. It is important to mention here that during pregnancy 300 extra calories are required while during breastfeeding the requirement is 500 calories so the care doesn’t end at child birth.

What are the basic types of prenatal tests that every expectant mother should undergo? Does it help us to know or worry about what is coming?

Prenatal tests are meant to determine if a mother is healthy and that the baby is developing normally. A combination of fetal ultrasound and maternal blood testing help determine the risk of the fetus having certain birth defects. During the first trimester a mother is usually tested for blood group (in case transfusion is needed at the time of giving birth); the RH factor (complications arise if the mother is RH negative and the baby RH positive); HIV status; and Hepatitis B & C testing so that vaccine treatments are offered to the mother and the baby after birth. Complete Blood Count (CBC) is also done to check any symptoms such as weakness, fatigue, or bruising a mother-to-be may have as well as for diagnosing conditions such as anemia, infection, and many other disorders. Hemoglobin type (CVS) is assessed in expectant mothers as well and if Thelisimia (severe anemia) is detected, the mother is prescribed high iron doses to avoid miscarriages or fetal death.

Expectant mothers of older age group (35 years plus) are often tested for Down syndrome (amniocentesis) during the second trimester to check for any genetic disease that could result in congenital abnormalities. During the third trimester ultrasound is done as well to study fetal heart rate and biophysical profiling (if it is suspected that the to-be-born child is suffering from restricted growth); accordingly induction or cesarean section may be advised. Mothers may also be tested for glucose tolerance to check for any fetal abnormalities.

These tests are vital in prenatal care because the results provide the doctor with necessary information to ensure that the pregnancy is healthy. Maternal anxiety around testing is not surprising but what is important is to understand that undetected conditions can result in greater complications for the mother and the child both.

The trend of mid-wives delivering babies at home is incessant in our culture. Although it is unrealistic to expect a turn-around in the norm, what are some of the precautions that mid-wives must take to ensure a healthy delivery for the baby as well as the mother?

Across Pakistan, about two-thirds of women deliver children outside of a hospital or clinic with community mid-wives playing an important role in pre-natal care and child birth. It is extremely important that mid-wives are properly trained and provided necessary equipments. Various organizations are providing training as well as delivery kits that include sterilized equipment, baby bath, baby gown, baby sheet, hand-washing material, etc. at the cheapest possible rates. It is important that local mid-wives are encouraged to acquire these and the community made aware to demand the use of sterile equipment at the time of delivery.

Mid-wives learn from experience the complications that may arise during home births. It is important that they refer the case to a doctor before complications become too grave. Most of the maternal deaths occur because mid-wives deal with the complicated pregnancy cases with delaying tactics and refer to the doctor at a very later stage or may not refer at all. Midwives can't perform C-sections and some can't administer drugs or anesthesia. Timely referrals can ensure the patient gets secondary/tertiary care and the baby be saved before the case complications increase beyond repair.