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Reproductive, Maternal, Newborn, and Child Health in Pakistan: Challenges and Opportunities

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Reproductive, Maternal, Newborn, and Child Health in Pakistan: Challenges and Opportunities Series Health Transitions in Pakistan 2 Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities Zulfi qar A Bhutta, Assad Hafeez, Arjumand Rizvi, Nabeela Ali, Amanullah Khan, Faatehuddin Ahmad, Shereen Bhutta, Tabish Hazir, Anita Zaidi, Sadequa N Jafarey Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in Lancet 2013; 381: 2207–18 achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of Published Online health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We May 17, 2013 undertook an in-depth analysis of Pakistan’s progress towards MDGs 4 and 5 and the principal determinants of http://dx.doi.org/10.1016/ S0140-6736(12)61999-0 health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in See Comment page 2137 relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. This is the second in a Series of Notwithstanding the urgent need to tackle social determinants such as girls’ education, empowerment, and nutrition four papers about health in Pakistan, we assessed the eff ect of systematically increasing coverage of various evidence-based interventions on transitions in Pakistan populations at risk (by residence or poverty indices). We specifi cally focused on scaling up interventions using delivery Department of Paediatrics and platforms to reach poor and rural populations through community-based strategies. Our model indicates that with Child Health, Division of successful implementation of these strategies, 58% of an estimated 367 900 deaths (15 900 maternal, 169 000 newborn, Women and Child Health, 183 000 child deaths) and 49% of an estimated 180 000 stillbirths could be prevented in 2015. Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta PhD, A Rizvi MSc, Prof A Zaidi FAAP); Introduction Pakistan is assessed at an aggregate level, the country has Health Services Academy, More than 90% of 7 million deaths globally in children a vast and diverse landscape of almost 800 000 km2 and Islamabad, Pakistan (Prof A Hafeez FCPS); John younger than 5 years occur in only 40 countries, with huge diff erences between its six provinces and the Snow, Islamabad, Pakistan most deaths occurring in just a few countries in south Federally Administered Tribal Areas in resources, access, (N Ali MPH); Save the Children, Asia and sub-Saharan Africa.1 Pakistan is at the centre of and development. The disbandment in June, 2011, of the Islamabad, Pakistan a very volatile geopolitical region with several decades of federal Ministry of Health and the constitutional devolu- (A Khan MPH); 5 National Institute of confl ict within the country and in the bordering areas. It tion of health to the provinces have placed a huge Population Studies, is a fairly young but populous nation; the population has impetus on provinces for planning and action in relation Islamabad, Pakistan grown from 27 million at the time of independence in to public health, especially reproductive, maternal, new- (F Ahmad MSc); Jinnah 1947 to an estimated 185 million people in 2012, and born, and child health (RMNCH). Postgraduate Medical 36·7% of the population are younger than 14 years. Globally, the country has the third and second highest rates of newborn mortality and stillbirths;2,3 its rate of Key messages progress in achieving the targets for the Millennium • Despite periods of stable economy and the dividends of a young population, Pakistan’s 4 Development Goals (MDGs) 4 and 5 have been slow. progress in achieving Millennium Development Goals (MDG) 4 and 5 for reproductive Although much of the health-related information from health and maternal and child survival, respectively, remains unsatisfactory. • Progress in addressing key social determinants such as poverty, female education and Search strategy and selection criteria empowerment, and undernutrition has been slow, and unfettered population growth eliminates economic and health gains. We searched all electronic databases for information that was • For health and development indicators, huge disparities exist between and within relevant to reproductive health and maternal and child health provinces, indicating the need for targeting and proactive strategies to reach poor and in Pakistan since Jan 1, 1960. We used a comprehensive marginalised communities. search strategy with extensive hand searches and cross • Existing programmes such as the Lady Health Worker Programme, if improved and tabulation of reports and references to access grey literature. linked to functional primary care and secondary care facilities, are important strategies There were no language restrictions. to achieve change in the short term but need to be coupled with improvements in The search strategy was iterative and the fi nal version included quality of care in the health system. core terms (“maternal and child health” OR “maternal” OR • In the long term, Pakistan needs the political will to prioritise pro-poor and integrated “wom*” OR “mother*” OR “pregnan*” OR “infant*” OR reproductive, maternal, newborn, and child health services after devolution of health “newborn*” OR “neonate*” OR ”child*” OR “reproduct*” OR services to the provinces. “family planning” OR “nutrit*” OR “maternal survival” OR • Many gains are possible. A restricted repertoire of evidence-based interventions “child survival”) AND (“Pakistan” OR “Punjab” OR “Sindh” OR packaged to address reproductive, maternal, newborn, and child health issues have “North West Frontier Province” or “NWFP” OR “Khyber the potential to reduce the burden of maternal and child deaths by 57%, but need to Pakhtunkhwa” OR “Baluchistan” OR “Pakistan province”). be scaled up with strategies to overcome poverty and barriers to access. www.thelancet.com Vol 381 June 22, 2013 2207 Series Centre, Karachi, Pakistan We undertook an in-depth analysis of available infor ma- from Pakistan of relevance to RMNCH and nutrition (Prof S Bhutta FRCOG); Pakistan tion to assess Pakistan’s progress towards MDGs 4 and 5 and also searched the grey literature representing Institute of Medical Sciences, and the principal determinants of health in relation to national and provincial level information of relevance. Islamabad, Pakistan (Prof T Hazir FCPS); and RMNCH and nutrition. We also assessed the feasibility of Additionally, we obtained original data from several Ziauddin Medical University, delivering health and nutrition interventions to address sources for secondary analysis of time trends in coverage Karachi,Pakistan RMNCH and survival, with the aim of accelerating pro- of interventions. We analysed the National Nutrition (Prof S N Jafarey FRCOG) gress and making recommendations for change. Surveys for 1987,11 2001,12 and 2011 separately.13 For Correspondence to: subnational analysis of district-based trends, we used all Prof Zulfi qar A Bhutta, Centre of Excellence in Women and Child Data sources and analytical methods available recent Multiple Indicator Cluster Surveys (MICS) Health, Aga Khan University, We undertook a systematic review of available infor- from Khyber Pakhtunkhwa,14,15 Punjab,16,17 Baluchistan,18 Stadium Road, Karachi 74 800, mation pertaining to the state of maternal and child and Sindh;19 the data were pooled to make a district-level Pakistan health in Pakistan since its independence. Our starting dataset of more than 168 000 households. Because methods zulfi [email protected] point was an in-depth review of recent situational of house hold poverty assessment diff ered between the analyses,2,3,6–9 relevant policy documents, and offi cial MICS, a composite socioeconomic status index for each reports about progress towards the MDGs.10 We under- district was estimated using several variables, including a took an electronic search of all published materials weighted average of household assets, education, net primary school enrolment, construction material for A house holds, source of drinking water, sanitation facilities, Unclassified 2·5% Abortion related 5·6% and household utilities (source of cooking and lighting). Indirect maternal 13·0% Eclampsia 10·4% Using standard methods, we extracted information about Other direct 4·3% verbal and social autopsies from the Pakistan Demo- 20 21 Placental Obstetric embolism graphic and Health Survey (PDHS) 2001 and 2007, and disorders 1·2% 6·0% associated information from the 2007 survey. PDHS 2007 Iatrogenic causes was undertaken and analysed by teams of experts led by Puerperal 8·1% SNJ for maternal deaths and ZAB for deaths in children sepsis 13·7% 21 Antepartum younger than 5 years and stillbirths. The verbal autopsy haemorrhage 5·5% information was further analysed to assess the underlying Postpartum haemorrhage 27·2% Obstructed labour 2·5% factors and delays associated with stillbirths, and maternal and child deaths. We specifi cally analysed the reported B place of death and factors associated with delays in Congenital abnormalities 4·0% recognition, care-seeking, and care provision. We Unclassified 1·0% Antepartum probable fetal problems 0·8% estimated the distribution of deaths by cause for each Intrapartum Antepartum maternal province and various asset quintiles from the weighted unexplained disorders 18·7% PDHS data using standard principal component analysis 20·9% and the reported data for maternal, newborn, and postneonatal child deaths, and stillbirths
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