Reproductive Health in Pakistan.docx

7/26/2019 Reproductive Health in Pakistan.docx

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Reproductive Health in Pakistan: Evidence and Future DirectionsF. F. Fikree (The Population Council, One Dag Hammarskold Pla!a, "th Floor, #e$ %ork,#% &''&(, )*+. )http:pma.org.pk-ullarticlete/t.php0articleid1&"23

Introduction

Reproductive Health 4RH5 and speci-icall6 $omen7s reproductive health has 8een elevated in the

consciousness and action agenda o- governments and donor agencies throughout the $orld in part

through the 9nternational Con-erence on Population and Development resource allocation, program

priorities, service provision, utili!ation and, o- course, research.+t the start o- the ne$ millennium,

in-ormation availa8le regarding the reproductive health o- Pakistani $omen and men portra6 an

unsatis-actor6 picture. Pakistan is the second largest uslim state and the seventh most populated

countr6 o- the $orld $ith a gro$th rate o- 3.;


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consideration 86 polic6 makers, program managers, donor agencies and advocac6 groups 4Ta8le &5.


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+ suggested pro/6 indicator -or maternal mortalit6 is perinatal mortalit6, as the main underl6ing -a

tors -or 8oth 4nonnal pregnanc6 and a clean and sa-e deliver65 are essentiall6 the same. The data -or pe

rinatal mortalit6 is scantier than that -or maternal mortalit6. + recentl6 concluded multiAcenter hospital

stud6 reported a perinatal mortalit6 rate o "3 per &, '' 8irths 4a8out (3< still8irths5". *ma

llAscale communit6 8ased studies -rom arachi&' and ahore&& report much lo$er rates var6ing -rom >@.&

to ;( per &,''' 8irths respectivel6. Ho$ever, $hat is most distur8ing is that despite the lack o-

in-ormation on ne$8orn health, data -rom PC illustrates that, -or the past 3> 6ears, there has 8een

no change in the perinatal mortalit6 rate A at'" per &,'

' 8irths A reminiscent o- the stagnant maternal mortalit6 ratio mentioned earlier&3,&= 4Ta8le &5.For

e/ample, the coverage o- antenatal care is ='


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The maternal health indicators so -ar discussed do not e/amine the social and communit6

paradigms surrounding emergenc6 o8stetric complications and death. Communit6 and hospital

8ased studies highlighted dela6ed re-errals as a ke6 risk -actor -or maternal mortalit6 in ur8an

arachi&(,&2. Dela6s resulting -rom inappropriate maternal services 43 &< men5 though less than @. This in-ormation on level and mortalit6 and mor8idit6 conse?uences o- opting -or an

induced a8ortion to terminate an un$antedundesired pregnanc6, though unrepresentative -or

Pakistan, nevertheless merits serious deli8erations, as it is indicative not onl6 o- the contri8ution o-

unsa-e a8ortions to a Pakistani $oman7s ?ualit6 o- li-e and pu8lic health e/penditures 8ut more


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pertinentl6 to Pakistan7s -amil6 planning program 4Ta8le >5.


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The in-ormation $e have on other aspects o- reproductive health is sparse and generall6 8ased on hos

pital records though recentl6 there has 8een a concerted e--ort to setAup a cancer registr6 in a distri

ct in arachi. There is no national level data -or reproductive tract in-ections or cancer among

others. Even reports -rom multiAcenter, nationall6 representative hospital 8ased surve6s, as

has 8een mentioned -or maternal and perinatal mortalit6, are lacking. Ho$ever $hat $e do kno$ is indicati

e that the levels, especiall6 o- se/uall6 transmitted in-ections 4*T9s5 and H9K+9Ds, are lo$

at the moment. For e/ample, in a communit6 8ased surve6 conducted in arachi, the preval

ence o- gonorrhea or chiam6dia $a under one percent though trichomonas and candidiasis $as much

higher 4>< a nd;< respectivel653; $hile among commercial se/ $orkers the prevalence o- all *

T9s $as a8out 3>


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ith regards to reproductive tract cancers, the most common -emale cancer is 8reast cancer 4peak

incidence around =' A =" 6ears5 $ith ovarian cancer 8eing the third most common3",='. +lthough lung

cancer is the most common male cancer reported, prostate cancer has 8een reported as the -ourth


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leading male cancer 8ut onl6 -or #orthern Pakistan3",=&. Ho$ever, most seek care late suggesting that

communit6 a$areness o- signs and s6mptoms o- reproductive tract cancers is lo$.

There are several communit6A8ased studies regarding other reproductive health illnesses, 8ased on

$omen7s reports o- perceived mor8idit6. Kalidation o- the relationships 8et$een sel-Areported

s6mptoms and signs and clinicall6 veri-ia8le conditions are poor. Ho$ever, regardless o- the

imprecise correspondence 8et$een the reported signs and s6mptoms and medicall6 veri-ia8le

conditions, $omen7s perception o- g6necological mor8idit6 is signi-icant in its o$n right, 8ecause it

determines health seeking 8ehavior. Reproductive health services are the most costAe--ective health

intervention -or adults as, especiall6 -or $omen, nearl6 one ?uarter o- the disease 8urden is

reproductive health. For e/ample, in-ertilit6 4primar6 =.>< and secondar6 & 2.@


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en and $omen do seek care, -rom pu8lic and private -acilities and concerns regarding ?ualit6 o-

care o--ered 86 health pro-essionals have 8een raised in several -ora. 9n a small stud6 4n3'=5

conducted among clients visiting pu8lic and private -acilities, ?ualit6 o- care $as investigated interms o- unsa-e needle practices=>. The maorit6 o- adult $omen and men sought care -or minor

s6mptoms 8ut largel6 un$arranted a8out 2&< o- them received an inection -or that clinic visit, most

o-ten using an unsterili!ed needle and s6ringe. This is not surprising 8ut $hat $as most relevant and

needs to 8e highlighted is that the prevalence o- Hepatitis C and among those $ho agreed to a

8lood test 4n1&=>5 $as @@< and &"< respectivel6=>. The mor8idit6 and mortalit6 associated $ith

Hepatitis C and $ill, o- course, impinge on the ?ualit6 o- li-e o- those alread6 in-ected 8ut $hat is


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more essential is recogni!ing that preventing unsa-e needle practices $ill prevent the transmission

o- other 8lood 8orne pathogens especiall6 H9K and Hepatitis C among adult men and $omen 4Ta8le


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25.


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Domestic violence is recogni!ed internationall6 as a signi-icant social and pu8lic health concer

n as $ell as a human rights issue. For Pakistan, despite the sensitivit6 surrounding discussing

such issues, there is no$ emerging a gro$ing a$areness o- the enormit6 o- violence against $omenand

its e-- ec on the health and social -a8ric o- $omen and their -amilies. Data -rom rural Puna8=; and

arachi=( indicate that the prevalence o- domestic violence, as reported 86 $omen, is a

ppro/imatel6 =>


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Ph6siological changes though none -or the introduction o- se/ education in schools -or the && A &;


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6ear olds 4n1&== 8o6s and &(( girls5="4Ta8le &'5.


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oreover, -ears o- detrimental health e--ects conse?uent to mastur8ation a8ound among 6oung

men 4&2 A3& 6ears5 4n1@;5 var6 -rom erectile d6s-unction 4='.@


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oreover, 8o6s and girls 4n&== and &(( respectivel65 report not onl6 high prevalence -or ph6sical


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a8use 4;;< and 32< respectivel65 8ut also se/ual a8use 4&@< and &"< respectivel65="4Ta8le &'5.

Though these data re-lect smallAscale unrepresentative studies, 8ut nevertheless signi-ies the urgent

need -or due attention 8eing paid to adolescents.

DiscussionThe evidence presented on the reproductive health status o- Pakistani men and $omen, although

limited in scope and ?ualit6, nevertheless highlights the inade?uate progress made in improving the

health o- Pakistani men and $omen in the past -i-t6 6ears.

Recogni!ing insu--icient nationall6 representative data on the elements o- reproductive health, the

?uestion $e need to ask ourselves as pu8lic health specialists, scientists,

o8stetriciansg6necologists, neonatologists, polic6 makers, donor communit6 and program managers

is Ihere should $e go -rom here0J 9nvest our scarce resources in esta8lishing a 8enchmark -or the

current status o- reproductive health and then move ahead or de8ate on $hat our current priorities in

reproductive health are and move ahead right no$.

The realit6 is that per-ect data A in scope and ?ualit6 A are unattaina8le and the need to utili!e thein-ormation currentl6 availa8le is o8vious. The realit6 is also that actions to improve outcomes along

the reproductive health continuum must go ahead even i- the data are inade?uate. hat must

ho$ever accompan6 these realities is a continuing push -or more representative data and

a$areness among data users o- the signi-icant uncertainties in data ?ualit6. Hence, evidence to

improve our understanding o- the reproductive health status 4scope and ?ualit65 need not dela6

sensi8le and reasona8le decisions on polic6 and program priorities.

The ne/t set o- ?uestions to discuss is $hether our programmatic interventions at a

provincialnational level is evidenceA8ased $ith small scale districtAlevel operations research to

demonstrate the reproductive health impact o- culturall6 relevant innovative strategies or move

ahead $ith provincialnational level strategies 8ased on popular, Igood ideasJ interventions such as

continuing training o- traditional 8irth attendants -or reducing maternal mortalit6. There is no eas6

ans$er to challenging the perceived $isdom o- the Igood ideasJ strateg6 8ut choices need to 8e

made. hile there are usti-ia8le, scienti-ic reasons -or $anting to kno$ the impact o- interventions,

the realit6 is that these operations research intervention studies take time and the outcome ma6 not

8e $hat $e had anticipated. Ho$ever, the evidence -rom other countries ma6 8e su--icient to

deli8erate programmatic choices. Thus, resource reAallocation can proceedG services can 8e

modi-ied, e/tended and improved simultaneousl6 $ith innovative operations research intervention

strategies 8eing implemented.

AcknowledgementThe author $ishes to thank Dr. *adi?ua #. a-are6 -or her help-ul comments in the earlier version o-

this paper.

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Reproductive Health in Pakistan.docx