Beyond Infrastructure: Unpacking Maternal Mortality in Punjab
Mahru Hasan Syed is a third-year BA-LL.B student at the Lahore University of Management Sciences (LUMS), with a keen interest in issues related to human rights and public international law. She has also recently interned with law firms such as Kazmi & Kazmi and Lexium.
Despite arguably being Pakistan’s most developed province, Punjab continues to lose hundreds of women each year to preventable pregnancy-related causes — a human rights crisis hiding in plain sight. With a maternal mortality ratio (MMR) of 300 deaths per 100,000 live births, the province reflects both progress and persistent challenges. While infrastructural and healthcare reforms have contributed to improvements, a deeper examination reveals that socio-cultural factors continue to play a decisive role in maternal outcomes. Deeply entrenched norms and practices, often overlooked in mainstream policy discussions, significantly affect women's access to and experience of maternal healthcare.
This analysis delves into how socio-cultural norms, gender dynamics, stigma, and health literacy shapes maternal mortality in Punjab. Applying an intersectional lens, it highlights how factors such as age, marital status, geographic location, and entrenched patriarchal structures have a compounded impact on the vulnerability of women, especially adolescent and unmarried mothers.
The Knowledge Gap: Health Illiteracy, Misinformation, and Risk
Health literacy rates in Punjab show sharp disparities between urban and rural populations. In many rural communities, women have limited or no formal education, significantly limiting their understanding of pregnancy-related risks and their rights to medical care. Moreover, superstitions and misinformation often replace science and evidence-based health practices. There are also several myths around medical interventions, such as the belief that cesarean sections are unnatural or inherently harmful, while some believe that taking certain medications can harm the baby. These deeply rooted myths can result in dangerous delays in seeking hospital-based care or disregarding medical advice, particularly during obstetric emergencies.
Cultural Silence and Dangerous Traditions
Cultural taboos further exacerbate these risks. In certain rural areas of Punjab, discussing pregnancy, especially in early stages, is considered inappropriate or even unlucky. This culture of secrecy can delay the disclosure of complications of symptoms, preventing timely access to antenatal care. Consequently, many families still prefer home births conducted by dais (traditional birth attendants) due to both cultural preference and lack of trust in public health institutions. While dais may have general experience, they typically lack the formal training necessary to handle life-threatening complications like postpartum hemorrhage, obstructed labor or breech presentations.
This distrust in the healthcare system is not entirely misplaced. Rural health facilities in Punjab frequently suffer from systemic issues such as chronic staff shortages, poor infrastructure and lack of essential equipment. Women often report experiences of neglect, lack of privacy, verbal abuse and an acute shortage of female healthcare professionals. These systemic failings perpetuate a cycle of dependence on informal providers, reinforcing misinformation and placing both mothers and newborns at continued risk.
Patriarchy and Power: Gender Norms that Cost Lives
Traditional gender roles heavily influence women's autonomy, especially regarding health decisions. Despite urbanisation and educational advancement in the province, patriarchal norms often dictate that women must seek permission from male family members, fathers, husbands, or in-laws, before accessing healthcare services. This dependency causes delays in seeking timely care during pregnancy or in the event of complications. The National Report on Status of Women in Pakistan 2024 found that “Pakistan’s women are largely dependent on male family members such as fathers, brothers, or husbands to make important life decisions related to education, health” and do not consider it appropriate to visit a doctor alone.
Catherine MacKinnon offers a useful lens for understanding these dynamics. In her work, she argues that male dominance is not incidental, rather a systemic issue, deeply embedded in the structures and institutions in a society. Applying this view to Punjab’s maternal health crisis reveals how deeply embedded gender norms translate into institutional neglect. Women’s restricted mobility, economic dependence, and the need for male permission are not just cultural practices, they are forms of structural control that deprioritize women’s health and autonomy.
Academic literature also underscores these patterns. A 2022 BMC Women’s Health study reported that Pakistani women are "restricted to household and child rearing responsibilities" and "men are viewed as dominant figures… who usually make all family decisions," resulting in systematic exclusion from crucial health decisions. As a result, several health concerns may go unnoticed until it is too late. Even when complications arise, women may be told to wait for a male guardian's approval or for cultural rituals to be completed, leading to life-threatening delays. This undermines a woman’s fundamental right to health and autonomy and calls for urgent rights-based interventions to empower women in health decision-making.
The Rural-Urban Divide: When Geography Decides Survival
While Punjab’s overall MMR is better than some other provinces, the rural-urban divide is significant. Rural women face a 26% higher risk of maternal death compared to their urban counterparts. This discrepancy is due not only to fewer healthcare facilities but is deeply rooted in socio-cultural norms that constrain women’s autonomy and mobility. In many rural communities, women are less likely to have access to antenatal care, institutional deliveries, or be attended by skilled health professionals. Cultural expectations often require male accompaniment for travel, while restrictive gender roles limit their access to education and exposure to mass media. These constraints not only isolate women from health systems but also prevent them from recognising danger signs in pregnancy or seeking timely care.
Private Clinics and Invisible Realities
Though Punjab has seen a rise in private maternity clinics, especially in urban areas, these facilities remain largely unregulated and financially inaccessible to the poor. Even those who can afford private care may be vulnerable to exploitation or substandard services. Alarmingly, there is a significant gap in research on the role of private facilities in either perpetuating or addressing maternal mortality. This lack of data, coupled with the absence of a real-time maternal health surveillance system, undermines evidence-based policymaking and hampers efforts to respond to emerging trends effectively.
Intersecting Vulnerabilities: Adolescents, Unmarried Mothers, and Hidden Pregnancies
The aforementioned issues intersect when it comes to child marriage and adolescent motherhood. In Punjab, early marriage remains common in rural areas despite legal restrictions under the Child Marriage Restraint Act, 1929. While the legal age of marriage for girls is 16 years in Punjab, enforcement remains inconsistent. Adolescent girls are socially and biologically more vulnerable to pregnancy-related complications such as eclampsia, obstructed labour, and postpartum hemorrhage. They are also more likely to suffer from nutritional deficiencies. Their limited knowledge of reproductive health and their bodies, combined with the social pressure to prove their fertility, increases risks. The absence of adolescent-friendly sexual and reproductive health services further exacerbates this crisis.
One of the most neglected yet critical socio-cultural factors affecting maternal mortality is the stigma attached to unmarried pregnancies including those resulting from sexual violence, coercion or the lack of access to health-related education. In Punjab's conservative social framework, pregnancy outside marriage is often met with ostracism, shame, and even violence. Unmarried pregnant women may also avoid seeking medical help altogether to escape social scrutiny or legal repercussions. In extreme cases, families may hide the pregnancy, leading to a complete lack of prenatal care. This not only increases the risk of maternal death but also contributes to underreporting in official statistics, resulting in deficiencies when it comes to policy-making.
Private clinics, by contrast, offer relatively discrete and sometimes anonymous services. For unmarried adolescents, these clinics can become critical spaces, albeit not without complications. While some operate with a degree of medical professionalism and confidentiality, the unregulated nature of many such clinics raises serious concerns. In rural areas, where health literacy is low and public facilities are understaffed or absent, these clinics often operate in secrecy. Additionally, the fear of legal or familial repercussions leads to underreporting of abortion-related complications, which further distorts maternal mortality data and undermines public health responses. The absence of adolescent-friendly reproductive health education also means that many young girls do not understand their legal rights, the risks associated with unsafe abortions, or where to find qualified and ethical medical assistance.
The Mental Health Crisis in Maternal Care
Another deeply neglected yet critical area within maternal healthcare is the mental health of women. Pregnancy is often portrayed as a time of joy and anticipation, but for many women, it is also a period marked by psychological vulnerability and emotional upheaval. The mental health of pregnant women is just as crucial as their physical health, yet it remains one of the most overlooked aspects of maternal care, particularly in resource-constrained and socio-culturally restrictive settings like Pakistan. Biologically, pregnancy triggers substantial hormonal changes that can influence mood and emotional stability. Psychologically, women may grapple with anxiety about childbirth, parenting, financial pressures, and relationship dynamics. These stress factors are further intensified by socio-cultural expectations that idealise motherhood while simultaneously silencing any expression of emotional distress, yet mental health is rarely integrated into maternal care frameworks.
Considering the massive gaps in the provision for physical health, one can only imagine the precarious position of mental health support for women in Punjab. A rights-based maternal health strategy must therefore account for both physical and mental healthcare needs. The consequences of untreated mental health issues in pregnancy are far-reaching. They can lead to poor self-care, missed antenatal appointments, substance misuse, or inadequate nutrition, all of which pose risks to both maternal and fetal health.
Pandemics and Preparedness: Lessons from COVID-19
Additionally, the COVID-19 pandemic highlighted and intensified pre-existing vulnerabilities in Punjab’s maternal health system. While exact Punjab-specific numbers vary, one study in Khanewal (Punjab) observed a significant decline in maternal service use during lockdowns due to drug stockouts, staff shortages, law enforcement harassment, and transport difficulties. This aligns with the reported overall nationwide dip in facility-based births of about 19 percent in 2020. The delays in seeking, reaching, and receiving adequate care, became more pronounced in a qualitative study that highlighted women reporting stockouts and reductions in service hours and staffing, with many shifting from public to private providers, due to stigma, fear, and lack of access to protective equipment. Midwives working in rural areas of Punjab and Sindh documented compromised antenatal care and a turn to telemedicine efforts that could not fully offset the disruptions These setbacks highlight the fragility of maternal health systems in the face of emergencies and the importance of socio-cultural preparedness alongside infrastructural readiness.
Recommendations: Building a Rights-Based, Culturally Sensitive Response
Reducing maternal mortality in Punjab requires more than simply increasing the number of hospitals or midwives. It demands a rights-based approach that recognises the socio-cultural landscape in which women live and make decisions. Policy efforts must prioritise empowering women to make autonomous health decisions by destigmatising access to care for unmarried women and educating communities to dispel harmful myths.
One of the most promising avenues is investing in culturally sensitive, community-embedded female healthcare providers, such as Pakistan’s Lady Health Workers (LHWs). Trained from within the communities they serve, LHWs are uniquely positioned to bridge the gap between formal healthcare and traditional norms. Their familiarity with local customs enables them to build trust, counter misinformation, and provide essential antenatal, postnatal, and family planning services, particularly to women who might otherwise be excluded from institutional care. Strengthening and expanding the LHW programme with a focus on basic rights, respectful care can play a vital role in reducing maternal deaths across Punjab.
Additionally, the current data on the issue itself is incredibly outdated. Punjab needs a robust maternal health surveillance system that captures data disaggregated by age, marital status, location, and socioeconomic status to inform evidence-based interventions. Enforcing laws on child marriage, integrating mental health into maternal services, regulating private clinics, and designing adolescent-friendly reproductive health education are all essential components of a comprehensive response.
Conclusion: Maternal Mortality as a Justice Issue
Maternal mortality in Punjab is a reflection of deeply entrenched socio-cultural inequalities. From restrictive gender norms and health illiteracy to mental health neglect and legal invisibility, the barriers women face are structural and systematic. Each maternal death represents not just a health crisis, but a collapse of social support, policy attention, and moral accountability. To move forward, Punjab must reframe maternal health as a matter of social justice and gender equity, not just medical provision. This means prioritising comprehensive, intersectional, and community-rooted reforms that centre the voices and rights of women, and invest in systems of care that are respectful, responsive, and accountable.
Disclaimer: Any and all opinions and views represented in this blog are personal and belong solely to the author(s) of the blog and do not represent the opinions or views of the Centre for Human Rights.
Mahru Hasan Syed is a third-year BA-LL.B student at the Lahore University of Management Sciences (LUMS), with a keen interest in issues related to human rights and public international law. She has also recently interned with law firms such as Kazmi & Kazmi and Lexium.
Despite arguably being Pakistan’s most developed province, Punjab continues to lose hundreds of women each year to preventable pregnancy-related causes — a human rights crisis hiding in plain sight. With a maternal mortality ratio (MMR) of 300 deaths per 100,000 live births, the province reflects both progress and persistent challenges. While infrastructural and healthcare reforms have contributed to improvements, a deeper examination reveals that socio-cultural factors continue to play a decisive role in maternal outcomes. Deeply entrenched norms and practices, often overlooked in mainstream policy discussions, significantly affect women's access to and experience of maternal healthcare.
This analysis delves into how socio-cultural norms, gender dynamics, stigma, and health literacy shapes maternal mortality in Punjab. Applying an intersectional lens, it highlights how factors such as age, marital status, geographic location, and entrenched patriarchal structures have a compounded impact on the vulnerability of women, especially adolescent and unmarried mothers.
The Knowledge Gap: Health Illiteracy, Misinformation, and Risk
Health literacy rates in Punjab show sharp disparities between urban and rural populations. In many rural communities, women have limited or no formal education, significantly limiting their understanding of pregnancy-related risks and their rights to medical care. Moreover, superstitions and misinformation often replace science and evidence-based health practices. There are also several myths around medical interventions, such as the belief that cesarean sections are unnatural or inherently harmful, while some believe that taking certain medications can harm the baby. These deeply rooted myths can result in dangerous delays in seeking hospital-based care or disregarding medical advice, particularly during obstetric emergencies.
Cultural Silence and Dangerous Traditions
Cultural taboos further exacerbate these risks. In certain rural areas of Punjab, discussing pregnancy, especially in early stages, is considered inappropriate or even unlucky. This culture of secrecy can delay the disclosure of complications of symptoms, preventing timely access to antenatal care. Consequently, many families still prefer home births conducted by dais (traditional birth attendants) due to both cultural preference and lack of trust in public health institutions. While dais may have general experience, they typically lack the formal training necessary to handle life-threatening complications like postpartum hemorrhage, obstructed labor or breech presentations.
This distrust in the healthcare system is not entirely misplaced. Rural health facilities in Punjab frequently suffer from systemic issues such as chronic staff shortages, poor infrastructure and lack of essential equipment. Women often report experiences of neglect, lack of privacy, verbal abuse and an acute shortage of female healthcare professionals. These systemic failings perpetuate a cycle of dependence on informal providers, reinforcing misinformation and placing both mothers and newborns at continued risk.
Patriarchy and Power: Gender Norms that Cost Lives
Traditional gender roles heavily influence women's autonomy, especially regarding health decisions. Despite urbanisation and educational advancement in the province, patriarchal norms often dictate that women must seek permission from male family members, fathers, husbands, or in-laws, before accessing healthcare services. This dependency causes delays in seeking timely care during pregnancy or in the event of complications. The National Report on Status of Women in Pakistan 2024 found that “Pakistan’s women are largely dependent on male family members such as fathers, brothers, or husbands to make important life decisions related to education, health” and do not consider it appropriate to visit a doctor alone.
Catherine MacKinnon offers a useful lens for understanding these dynamics. In her work, she argues that male dominance is not incidental, rather a systemic issue, deeply embedded in the structures and institutions in a society. Applying this view to Punjab’s maternal health crisis reveals how deeply embedded gender norms translate into institutional neglect. Women’s restricted mobility, economic dependence, and the need for male permission are not just cultural practices, they are forms of structural control that deprioritize women’s health and autonomy.
Academic literature also underscores these patterns. A 2022 BMC Women’s Health study reported that Pakistani women are "restricted to household and child rearing responsibilities" and "men are viewed as dominant figures… who usually make all family decisions," resulting in systematic exclusion from crucial health decisions. As a result, several health concerns may go unnoticed until it is too late. Even when complications arise, women may be told to wait for a male guardian's approval or for cultural rituals to be completed, leading to life-threatening delays. This undermines a woman’s fundamental right to health and autonomy and calls for urgent rights-based interventions to empower women in health decision-making.
The Rural-Urban Divide: When Geography Decides Survival
While Punjab’s overall MMR is better than some other provinces, the rural-urban divide is significant. Rural women face a 26% higher risk of maternal death compared to their urban counterparts. This discrepancy is due not only to fewer healthcare facilities but is deeply rooted in socio-cultural norms that constrain women’s autonomy and mobility. In many rural communities, women are less likely to have access to antenatal care, institutional deliveries, or be attended by skilled health professionals. Cultural expectations often require male accompaniment for travel, while restrictive gender roles limit their access to education and exposure to mass media. These constraints not only isolate women from health systems but also prevent them from recognising danger signs in pregnancy or seeking timely care.
Private Clinics and Invisible Realities
Though Punjab has seen a rise in private maternity clinics, especially in urban areas, these facilities remain largely unregulated and financially inaccessible to the poor. Even those who can afford private care may be vulnerable to exploitation or substandard services. Alarmingly, there is a significant gap in research on the role of private facilities in either perpetuating or addressing maternal mortality. This lack of data, coupled with the absence of a real-time maternal health surveillance system, undermines evidence-based policymaking and hampers efforts to respond to emerging trends effectively.
Intersecting Vulnerabilities: Adolescents, Unmarried Mothers, and Hidden Pregnancies
The aforementioned issues intersect when it comes to child marriage and adolescent motherhood. In Punjab, early marriage remains common in rural areas despite legal restrictions under the Child Marriage Restraint Act, 1929. While the legal age of marriage for girls is 16 years in Punjab, enforcement remains inconsistent. Adolescent girls are socially and biologically more vulnerable to pregnancy-related complications such as eclampsia, obstructed labour, and postpartum hemorrhage. They are also more likely to suffer from nutritional deficiencies. Their limited knowledge of reproductive health and their bodies, combined with the social pressure to prove their fertility, increases risks. The absence of adolescent-friendly sexual and reproductive health services further exacerbates this crisis.
One of the most neglected yet critical socio-cultural factors affecting maternal mortality is the stigma attached to unmarried pregnancies including those resulting from sexual violence, coercion or the lack of access to health-related education. In Punjab's conservative social framework, pregnancy outside marriage is often met with ostracism, shame, and even violence. Unmarried pregnant women may also avoid seeking medical help altogether to escape social scrutiny or legal repercussions. In extreme cases, families may hide the pregnancy, leading to a complete lack of prenatal care. This not only increases the risk of maternal death but also contributes to underreporting in official statistics, resulting in deficiencies when it comes to policy-making.
Private clinics, by contrast, offer relatively discrete and sometimes anonymous services. For unmarried adolescents, these clinics can become critical spaces, albeit not without complications. While some operate with a degree of medical professionalism and confidentiality, the unregulated nature of many such clinics raises serious concerns. In rural areas, where health literacy is low and public facilities are understaffed or absent, these clinics often operate in secrecy. Additionally, the fear of legal or familial repercussions leads to underreporting of abortion-related complications, which further distorts maternal mortality data and undermines public health responses. The absence of adolescent-friendly reproductive health education also means that many young girls do not understand their legal rights, the risks associated with unsafe abortions, or where to find qualified and ethical medical assistance.
The Mental Health Crisis in Maternal Care
Another deeply neglected yet critical area within maternal healthcare is the mental health of women. Pregnancy is often portrayed as a time of joy and anticipation, but for many women, it is also a period marked by psychological vulnerability and emotional upheaval. The mental health of pregnant women is just as crucial as their physical health, yet it remains one of the most overlooked aspects of maternal care, particularly in resource-constrained and socio-culturally restrictive settings like Pakistan. Biologically, pregnancy triggers substantial hormonal changes that can influence mood and emotional stability. Psychologically, women may grapple with anxiety about childbirth, parenting, financial pressures, and relationship dynamics. These stress factors are further intensified by socio-cultural expectations that idealise motherhood while simultaneously silencing any expression of emotional distress, yet mental health is rarely integrated into maternal care frameworks.
Considering the massive gaps in the provision for physical health, one can only imagine the precarious position of mental health support for women in Punjab. A rights-based maternal health strategy must therefore account for both physical and mental healthcare needs. The consequences of untreated mental health issues in pregnancy are far-reaching. They can lead to poor self-care, missed antenatal appointments, substance misuse, or inadequate nutrition, all of which pose risks to both maternal and fetal health.
Pandemics and Preparedness: Lessons from COVID-19
Additionally, the COVID-19 pandemic highlighted and intensified pre-existing vulnerabilities in Punjab’s maternal health system. While exact Punjab-specific numbers vary, one study in Khanewal (Punjab) observed a significant decline in maternal service use during lockdowns due to drug stockouts, staff shortages, law enforcement harassment, and transport difficulties. This aligns with the reported overall nationwide dip in facility-based births of about 19 percent in 2020. The delays in seeking, reaching, and receiving adequate care, became more pronounced in a qualitative study that highlighted women reporting stockouts and reductions in service hours and staffing, with many shifting from public to private providers, due to stigma, fear, and lack of access to protective equipment. Midwives working in rural areas of Punjab and Sindh documented compromised antenatal care and a turn to telemedicine efforts that could not fully offset the disruptions These setbacks highlight the fragility of maternal health systems in the face of emergencies and the importance of socio-cultural preparedness alongside infrastructural readiness.
Recommendations: Building a Rights-Based, Culturally Sensitive Response
Reducing maternal mortality in Punjab requires more than simply increasing the number of hospitals or midwives. It demands a rights-based approach that recognises the socio-cultural landscape in which women live and make decisions. Policy efforts must prioritise empowering women to make autonomous health decisions by destigmatising access to care for unmarried women and educating communities to dispel harmful myths.
One of the most promising avenues is investing in culturally sensitive, community-embedded female healthcare providers, such as Pakistan’s Lady Health Workers (LHWs). Trained from within the communities they serve, LHWs are uniquely positioned to bridge the gap between formal healthcare and traditional norms. Their familiarity with local customs enables them to build trust, counter misinformation, and provide essential antenatal, postnatal, and family planning services, particularly to women who might otherwise be excluded from institutional care. Strengthening and expanding the LHW programme with a focus on basic rights, respectful care can play a vital role in reducing maternal deaths across Punjab.
Additionally, the current data on the issue itself is incredibly outdated. Punjab needs a robust maternal health surveillance system that captures data disaggregated by age, marital status, location, and socioeconomic status to inform evidence-based interventions. Enforcing laws on child marriage, integrating mental health into maternal services, regulating private clinics, and designing adolescent-friendly reproductive health education are all essential components of a comprehensive response.
Conclusion: Maternal Mortality as a Justice Issue
Maternal mortality in Punjab is a reflection of deeply entrenched socio-cultural inequalities. From restrictive gender norms and health illiteracy to mental health neglect and legal invisibility, the barriers women face are structural and systematic. Each maternal death represents not just a health crisis, but a collapse of social support, policy attention, and moral accountability. To move forward, Punjab must reframe maternal health as a matter of social justice and gender equity, not just medical provision. This means prioritising comprehensive, intersectional, and community-rooted reforms that centre the voices and rights of women, and invest in systems of care that are respectful, responsive, and accountable.
Disclaimer: Any and all opinions and views represented in this blog are personal and belong solely to the author(s) of the blog and do not represent the opinions or views of the Centre for Human Rights.
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