摘要：Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May 2010–February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan. Complications of pregnancy and childbirth remain the leading cause of death and disability for childbearing women in Pakistan. With a maternal mortality ratio of 297 per 100 000 live births, 1 Pakistan is 1 of 6 countries contributing to more than 50% of all maternal deaths worldwide. 2 The widely endorsed strategies for promoting safe childbirth 3,4 —skilled birth attendance, with timely referral for emergency care in a well-functioning health care system—are reflected in Pakistan’s formal maternal health policy. 5 Significant attempts to implement this policy have occurred, first under the Safe Motherhood and later the Millennium Development Goal (MDG) initiatives, with a degree of success in improving services. 6 Yet despite these efforts, Pakistan is unlikely to meet the targets of the fifth MDG, which includes the reduction of maternal mortality and universal access to reproductive health care by 2015. 2,7 We suggest one reason for this failure is that the maternal health strategies used to date have failed to understand and address the factors that restrict access to care for women living at the economic and social margins of society. The most recent national level data show the persistence of large socioeconomic inequalities in access to maternal health care services across every indicator. Although 92% of women in the highest wealth quintile report antenatal care use, this percentage is 37% among women in the lowest quintile. Similarly, 74% of women in the highest wealth quintile deliver in a health facility compared with 12% of women in the lowest quintile. 1 The current Pakistani National Maternal Newborn and Child Health Program (2013–2016) acknowledges these inequities and aims to provide care to the disadvantaged and vulnerable groups. 5 To date, policy and practice interventions remain predominantly “more of the same,” with most effort focused on strengthening district health systems through improvements in technical and managerial capacities, and the introduction of a new cadre of community-based skilled birth attendants. Nevertheless, there has been some effort to increase demand for maternal health services through state-run targeted, socially acceptable communication strategies. 5 This reflects the growing recognition that a simple, supply side, technical approach is insufficient to address inequalities in access to maternal health care services or to impact on levels of maternal mortality. 7,8 Furthermore, recognizing that maternal health-seeking behavior is constrained by a range of cultural and structural factors, particularly gendered norms that devalue women’s well-being and also poverty, a number of small-scale interventional approaches have tried to reduce the demand-side obstacles. Bhutta et al. 9 have described a community-based cluster randomized controlled trial in Sind that included promotion of health care seeking (including facility birth) and maternal health education, through group sessions delivered by trained women health workers. The 10 district Pakistan Initiative for Mothers and Newborns (PAIMAN) intervention between 2005 and 2010 combined upgrading of health facilities with behavior change and community mobilization interventions, including a particular focus on “birth preparedness” and “complication readiness.” 6 An intervention in 2009 provided women in the Jhang district of Punjab who met poverty selection criteria with highly subsidized antenatal, delivery, and postnatal care through a low-cost voucher scheme and reimbursement of travel costs. 10 The effects of these interventions on levels and disparities in maternal health care use has been variable. Bhutta et al. 9 reported a 10% increase in facility births (54% vs 44%; P = .07), but these authors did not explore variations by socioeconomic status; this was a surprising omission given that their intervention was based on geographic clusters rather than targeted to particularly poor women, and therefore, introduced the possibility of differential benefits between social groups. The PAIMAN intervention was found to increase levels of skilled birth attendance and postpartum care across all wealth quintiles, but did not decrease the differential between the rich and the poor. In terms of institutional delivery, no increase was seen among the poorest wealth quintile, and there was an increased disparity between the poorest and all other wealth groups (17% vs 74% in the richest quintile postintervention). 6 The voucher scheme, 10 which specifically targeted poorer women, appeared to have more success in tackling inequalities, with a significant increase in institutional delivery among the poorest quintile (31%–47%) and a reduction in the disparity between this group and the richest group (33%–16% points). Nevertheless, even after the introduction of the scheme, more than 60% of the poorest quintile of women reported not receiving adequate antenatal care, and more than 50% did not deliver in a health care facility. Importantly, Agha 10 reported that selling the vouchers to women was a difficult and time-consuming task, but that utilization of the vouchers for antenatal care and delivery care was very high (approximately 97% in the latter case). The limited impact therefore related primarily to enrollment in the intervention and raised questions about who remained outside of the scheme and why. The partial success of these demand-side interventions in tackling inequalities raises doubts as to their ability to effectively identify the poorest women and address the obstacles to care that they face. It also questions whether they are adequately informed by an understanding of the factors that restrict access. Although research in Pakistan has consistently documented large socioeconomic inequalities in maternal health service access, 1,11 there has been little investigation to date beyond descriptive analyses of correlates (e.g., wealth and education) that could provide insight into the underlying causes and potential remedies of these persistent disparities. There have been sustained calls for greater attention to the “causes of the causes” of poor maternal health outcomes and a return to framing health improvement within a political context. 12 Although the relationship between economic poverty and uptake of maternal health services is well documented, a growing body of research elsewhere in South Asia suggests the importance of understanding the role of nonmaterial aspects of poverty. Such research indicates that economic poverty alone does not explain the large disparities in access to maternal health care between the rich and poor and highlights the ways in which sociocultural hierarchies operating along the lines of gender, caste, religion, and ethnicity act to systematically exclude and marginalize particular groups of women. 13,14 A number of Indian studies draw attention to the large variations in maternal health care use between castes, even after controlling for income and education. 15,16 While currently overlooked in work on maternal health in Pakistan, the importance of understanding the multidimensional nature of poverty is also suggested by recent social development research. At the macrolevel, Pakistan has been found to show poor progress on human development and poverty reduction compared with countries with similar levels of per capita gross national product—a situation that has been attributed in part to its “high degree of ethnic and class polarization.” 17 (p30) Microlevel studies demonstrate how hierarchical social relationships based on caste and extended family ( biradari ) position some groups as subordinate to others, leading to economic exploitation, social exclusion, and political marginalization. 18,19 Currently, despite the stated commitment to provide care to disadvantaged groups, 5 neither national-level projects nor community-based interventions in Pakistan have been informed by a detailed understanding of how long-term economic and social marginalization operate to constrain poor women’s access to maternal health services. Understanding these structures and processes and being able to effectively identify the poor and socially excluded is crucial to developing interventions that can tackle the persistent inequalities. We report a detailed, qualitative study that begins to address these questions. Our findings paint a clearer picture of the realities of marginalized rural Pakistani women’s lives and suggest a number of key factors that must be addressed in the design and implementation of policies and interventions if they are to be more successful in tackling inequalities in maternal health.
