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The Social and Cultural Factors of Maternal Mortality in the Context of Three Delays: The perspective of Lady Health Workers of South Punjab, Pakistan.

Byline: Sonia Omer


Maternal mortality is a pressing issue and high maternal deaths is the matter of concern for many nations of the world. Globally, nearly 303000 maternal deaths cases are reported and among these almost 99 percent are found in developing countries (Organization 2015). While defining maternal mortality " It is a death of women while pregnant within 42 days of termination of pregnancy irrespective of duration and the site of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from incidental or any accidental causes,"(Organization 2004b)

In developing world, the mothers have high death ratios during pregnancy due to number of reasons like hemorrhage, hypertensive disorder of pregnancy anemia, unsafe abortions or obstructed labor. The significant fact is all these complications are preventable and can be treated at health care centers in an effective manner (Aftab Mazhar Tabassum, Bhutta, and Tajjamul 2014). It is maternal mortality that can portray the true picture of status of women in any country as it is a complex indicator of status of women everywhere (Liljestrand and Sambath 2012). What really bothers policy makers that deaths of women in pregnancy or its related issues are due to certain causes which are highly preventable (Backman et al 2008).

According to latest data received from world CIA fact book, Pakistan stands at 53 out of 181 counties in highest maternal mortality rate after Afghanistan in South Asian region. The maternal mortality rate in Pakistan is 178 deaths/100,000 live births (CIA 2018). The health care system in Pakistan does not reveal a very positive picture. Efforts have been made to address health issues by introducing different policies in the past including the lady health worker program. This program aimed to train women to serve as health providers at community level across the country. The lady health worker render services to communities, most specifically related to mother and child survival. This eventually help women, particularly of rural side to obtain vital information about maternal care and to make plans on their reproductive life as per their wish and desire. (Kabeer 2001).

The present study designed to know the views of lady health workers on socio and cultural factors of maternal mortality in the light of three delays model. The researcher intended to know of those factors which are the actual barriers for rural women in seeking a maternal care, reaching to health care and receiving an adequate service from health centers. The three delay model of maternal mortality by Maine and Thaddeus (1994) has been of great significance to understand maternal deaths beyond the visible biomedical reasons (Maine and Thaddeus 1994). These delay emphasizes that maternal mortality is not only because lack of economic and human resource but significant social, economic and cultural factors, accessibility and approach to quality of care are numerous interwoven factors.


The present study has used the qualitative design to investigate the social phenomenon of maternal deaths. The researcher selected Dera ghazi khan division on the basis of low socio economic and maternal health indicators revealed in multiple indicator cluster survey report of Punjab 2017-18. Focus group discussion (FGD) was used as a tool of data collection and four (FGDs) were conducted from all four districts of Dera Ghazi khan division including Tonsa ,Layyah , Rajunpur and Dera Ghazi Khan itself. For selection of LHWs, the list of LHWs working in each district was obtained from the health department of each district and seven lady health workers were randomly selected for each district of South Punjab. All The focus group discussions were conducted at the each district hospital with the facilitation of in charge District head quarter hospital (DHQ).

After analyzing each of the contribution received from the focus group discussion participant, the researcher proceeded towards the themes emerged from FGD, according to the reality expressed by the focus group discussion participant. The data was analyzed through thematic analysis. Thematic analysis allows the researcher flexibility with a well-defined explanation of what is it and how it is carried out. The author in this paper had tried to incorporate individual experiences, however influence of broader social context was also considered. (Braun and Clarke 2006).


Delay One: Seeking Care

This delay is about seeking maternal care. Studies from developing countries revealed that that 70 to 80 percent of the maternal deaths are taking place because of this first delay (Win VapattanawongandVong, 2015; YunusKauserand Ali 2013). The large number of respondents of the study were of the view that this first delay had been the main cause of maternal deaths in the study area. Regarding this delay of seeking care, the data revealed about the poor social and economic status of the rural community of the selected districts.

A LHW revealed:

The whole area is poverty ridden and people are living a centuries old life style. The employment opportunities are extremely limited and men are forced to work outside their area, away from their families which further complicate the woman life and prevent the families to spend on maternal care of women.

It was found in the current research that majority of the people of study area were illiterate and percentage of even middle and primary pass was very low. This resulted into great unawareness and lack of knowledge on women's health. Furthermore, women own low status and less empowerment in villages had been effecting their health significantly.

One of the LHWs stated:

Look, Girl child is always exposed to terrible practices and they are more expected to face discriminations in several matters which includes less provision of food, less or no education and disparities in health care. Parents take girl child as burden. Girls have economic dependency on men and his family. The early marriage is the only way out to get rid of girls. One of the reason of early marriage is waata satta (simultaneous marriage of brother sister pair from two households).

Asking further questions on first delay, the respondents reported that women of the area were found highly dependent on husbands and mother in laws. Both were found involved in making significant decisions taken for pregnant mother. The antenatal visits were also very low in rural side.

One of the respondents said:

Mother in law role is crucial and she leads in many decision as large number of men are employed outside the village. Mother in law usually starts comparing and says she herself has delivered 12 children without any special care.

Another respondent added:

See, this is my job to convince family for antenatal care but very few listen to us. As long as medicines are free they take it. They hardly make both end meet so it is out of question for the family to pay extra attention on pregnant woman. Even the mobility of women in village to health center without men or elderly women of house is next to impossible and veil (pardah) is strictly observed.

While probing further on other factors in seeking care, the majority of the respondents agreed and informed that large family size and unhealthy spacing between births were the contributory factors of the poor maternal care and maternal deaths in villages. In addition to that, certain religious practices and beliefs were found as influencing factors in this regard.

Talking of the reasons, one of the respondents stated:

Religion is most of the time dragged in the matter whenever we convince women on having reasonable spacing on children. Pregnant women herself is not the decision maker on family size and spacing. The sons are preached that spacing is a sin. This has caused into poor health of rural women and prevent them to seek care.

Another respondent added:

People in the village think that following family planning methods can result into influencing men and women capability of having children (banjh pun).They believe it is a conspiracy of foreign countries who want to stop birth of Muslim children.

Besides that it is a well-known fact that the safety and wellbeing of pregnant women profoundly depends upon place of birth and birth attendants (Armstrong 2007). The respondents reported of preference of families on traditional birth attendants. Such decisions were hurdles in seeking right maternal care during pregnancy .The LHW argued: Look, I come across families where pregnant woman is educated, though there are rare, but despite of their wish of going to safe birth place, the decision regarding birth place is taken by mother in law or husband himself. The family members prefer Dai (traditional birth attendant) and they have crucial part in high maternal mortality in the villages of south Punjab.

The unhygienic conditions during delivery and other significant factors including loss of blood and infections lead to death especially in home deliveries.

One LHW added:

We have seen these Dai (traditional birth attendant) cutting the umbilical cord of mother from the knife they use to cut vegetables.

Furthermore, the respondents also informed of presence of fake private clinics in villages and rural people had been found preferring those private clinic.

One of the LHWs added

The private hospitals are a mafia, playing with the lives of people and Dai (traditional birth attendant), in many cases is playing a role of agent by refereeing families to those private clinics for medical consultation for mother during pregnancy. Most of the clinics are reportedly shops of quacks.

The respondents further explained that faith and trust of families on certain rituals and cultural practices contributed towards maternal deaths. The beliefs of people on so called spiritual healers of villages and use of medicines prescribed by these spiritual healers were bringing dreadful results on the health of pregnant mother. One of the respondents informed People here in villages have very weak religious beliefs and many still consult peer sb (referring to spiritual healer) for maternal health care. I have witnessed mother in law and husbands giving certain medicines to pregnant women as per advice of (peer sb). In fact they act upon the instruction of these so called spiritual healers from intake of diet, medicines to place of birth. Families believe in making mother drink so called holy water given by the peer sb if mother makes any complain during pregnancy.

Delay two: Reaching to Right Medical Facility

This delay is about reaching to medical facility at the time of need. The respondents informed of multiple factor as hurdles for pregnant mother to reach to right medical care at times of obstetric complication.

A lady health worker informed:

When the mother starts leaving signs of life only than the family rush to a proper medical facility and company of men of house is so compulsory regardless of situation of poor mother, otherwise they keep waiting of the arrival of men of house.

The distance of health care where an emergency can be treated like Tehsil or District head quarter hospitals is one of the major delay in reaching maternal care in case of emergency. As per information provided by the respondents, an average household of the area has to travel 40 to 50 kilometers to reach to the nearest governmental health facility where emergency can be treated for One of the respondent said:

Distance further creates problem for pregnant women as most of the time they are treated by traditional birth attendants or by the private clinics in village. when women is about to die of any complication during pregnancy or delivery than the family moves towards Basic health unit which is closest facility but that is useless as people have no knowledge that basic health units are not established to deal with emergencies.

The respondents reported that refereeing patient from basic health unit to Tehsil headquarter hospital to District head quarter hospital takes not hours but sometimes days and these referral system are the delays which eventually become reason of maternal mortality. Beside that poor economic status and poor means of communication were the reason which complicate cases especially when families were unable to arrange transportation. One stated:

Families carry their pregnant women like luggage in carts, motor cycle or motor cycle rickshaws in case of emergency. The irony is ambulance service by government is there but number of ambulances are not sufficient to deal with the pressure of emergency calls. The bad conditions of road further aggravate the situation.

Delay Three: Receiving Medical Care

This delay of maternal mortality was about receiving an appropriate health care facility. This delay was also influenced by numerous factors which are connected to social, economic and cultural patterns of rural societies.

One of the respondents informed:

Families do not take responsibility of bringing a mother at last stage to these health care facilities and once they reach, they really expect these doctors are God who can save the lives instantly. I have seen families becoming violent and misbehave with doctor if situation of mother deteriorates On the other hand, the majority of the respondents also revealed of absence of major facilities in these public sector hospital and attitude of doctors toward the families.

One of the respondents revealed:

It is a matter of great concern that few of these Tehsil and District hospitals do not have even blood banks, well equipped intensive care units and other major facilities. In the absence of these facilities what families of patient receive is referral to other hospital and that takes life of innocent mother.

Another LHW added:

If at one hand the families are ignorant and poor, on the other hand the medical staff is not always cooperative rather rude towards families. The reason I understands may be the pressures of thousands of patient these hospital receive every day and this fact cannot be ignored. Once I saw a doctor asking mother in severe labor pains to go out of ward and change her dress as it was dirty and producing bad odor and I have also seen the husband dragging the para medical staff from his office to provide him a bottle of blood immediately.

Another lady health worker made a revelation:

I won't blame doctors. What they could do if they are insisted by families to save a baby boy if life of mother and infant is in danger. These doctor hear of second marriage of their son in the corridors of hospital if daughter in law is dying.


The present research exposed that number of social cultural and economic factors exist in all the three delays of maternal mortality. In first delay of seeking care, poverty and unemployment along with other factors were the key factors which played an essential role in maternal deaths. It was also evident from other researches too that people belonging to low income groups usually have less approach to health care facilities in comparison to those of living in developed countries with reasonable income (PeterGarg Bloom Walker BriegerandRahma 2008). The study also found that the low status of women and women less autonomy had aggravated the situation in rural. This situation exist because of number of factors including low level of education among females, the gender inequalities, less control on available resources, lack of decision making , restrictions on women mobility, economic dependency of women, domination of mother in law and husbands.

Besides that, some visible factors which were obstacles in seeking maternal care were the certain rituals, beliefs and cultures including preferring traditional birth attendant and quacks not only for delivery but throughout the assistance in pregnancy. The other prime delay in seeking care was the low antenatal care visits of mothers which is prime determinant of maternal health care.

Furthermore, the study found majority of the rural people had not been using family planning methods. The huge family sizes and son preference were other factors that truly deteriorated women health. This was also revealed in several studies that the Patriarchal erections and low status of women results into high fertility rates and fertility reduction becomes more different in such circumstances (Chen XieandLiu 2007).The study found that the religious card was often played in such areas where teachings of Islam had been interpreted in a manner that restrict women to seek care including issue of their mobility. The data of the study indicated that majority of the women with obstetric complications were brought to health facility in state of emergency. Poor infrastructure of roads, means of communication and low resources of family added troubles for pregnant women. The distance of health facility and referral systems were resulting into deaths of women.

Evidences from other studies conducted in developing countries prove that inadequate health care system including poor infrastructure, distance to health care and improper and misplaced priorities backs maternal mortalities (Sundari 1992). In third delay of maternal mortality, the data of the current research received important influential factors that caused maternal deaths including ignorance and lack of understanding of families to deal with obstetric emergencies and cooperate with doctors, lack of facilities including shortage of lifesaving equipment's in public sector hospitals and display of certain behaviors of doctors with the families.


The study concluded that numerous socio-economic and cultures factors had profound effect on the prevalence of maternal mortality in rural side of South Punjab. The present study concluded that maternal mortality is the consequence of substantial socio cultural factors existed in all the three delays and deaths could be avoided if measures were taken to combat and deal with these factors. Poor status of rural people, lack of employment opportunities, illiteracy, weak status of women, religious and cultural beliefs were the prominent contributory factors that prevented pregnant women to seek maternal care. This first delay was concluded as a chief delay among other two delays of maternal mortalities. The lack of capacity of families to each to health care in emergencies, weak infrastructure, and poor means of transportation and restrictions on mobility of women to reach to right medical care were some of the factor concluded in the second delay.

In addition to the certain behaviors of families in medical facility care, unequal doctor patient relationship, lack of medical facilities especially at THQs and DHQs were the prime factors concluded in the in third delay.

Notes and References

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Peters, David H., AnuGarg, Gerry Bloom, Damian G. Walker, William R. Brieger, and M. Hafizur Rahman. "Poverty and access to health care in developing countries." Annals of the New York Academy of Sciences 1136, no. 1 (2008): 161-171.

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Publication:Journal of Pakistan Vision
Geographic Code:9PAKI
Date:Jun 20, 2019
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