Reproductive Health Scenario of Pakistan:

Where We Are and What Should We Be Doing?

Dr Ali Mohammad Mir February 14, 2013

Pakistan’s Scorecard– A brief overview

Among married women of reproductive age (MWRA) approximately 1 out of 3 of births are spaced <2 years apart

Women average 4 births during their reproductive life (the second highest fertility rate in South Asia after Afghanistan)

Low contraceptive use (only 30% of married couples use contraception)

The fourth highest under-five child deaths (after India, Nigeria and Congo)

Serious malnutrition with 38% of children under five (9 million) underweight.

Poor access to water and sanitation. Diarrhoea is the main killer of children.

World’s third highest burden of deaths due to neonatal tetanus

250,000-300,000 new cases of TB every year.

HIV prevalence high rates in populations most-at-risk especially injecting drug users and male sex workers.

Pakistan’s Scorecard– A brief overview

Challenges and Opportunities

Challenges: • Inadequate resource allocation to the health sector • Inequitable services allocation, tertiary vs primary; rural

vs urban

The Opportunity:• Devolution: A short-term challenge – a long term

opportunity

Signed by 147 heads of states and governments

Adopted by 189 nations

Pledged to “spare no effort to free our fellow men, women and children from abject and dehumanizing conditions of extreme poverty”

Goals relating health sector (4,5&6) 4 Targets and 16 Indicators

What is our current agenda: Achieving the MDGs

Goal 4: Reduce Child Mortality

Reducing Maternal Mortality

Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

2006-07 2009-10 MDG Target0

102030405060708090

10094

87

52

7572

40

76 78

90

Under-five mortality Infant Mortality Rate

Proportion of fully immunized children

Why are we lagging behind?

Major Causes of Newborn Deaths

40%

28%

17%

10%5%

Asphyxia

Pre-maturity

Congenital abnormality and others

Infectious Diseases

Unexplained

Malnutrition among < 5 Children by Province

Pakistan Balochistan KP Sindh Punjab AJK0

10

20

30

40

50

60

44

5248

50

39

32

15 16 17 1814

18

32

40

24

41

3026

Stunted Wasted Underweight

Maternal Tetanus Toxoid Coverage

BackgroundCharacteristic

PercentageReceiving two or more injections during last pregnancy

Percentage whose last birth was protected against neonatal tetanus

Number ofmothers

Punjab 59 65.1 3182

Sindh 51.2 58.3 1404

KP 43.2 51.2 827

Balochistan 29.7 30.9 264

Source: PDHS 2006-07

Measles Immunization Coverage

Measles Immunization Coverage 2010-11

Pakistan 82

Punjab 86

Sindh 77

KP 78

Balochistan 58

Source: Pakistan Social and Living Standard Measurement Survey 2010-11

What should we be doing about it?

Source: PDHS 2006-07

Longer Birth Intervals Reduce Child Mortality

<24 months 24 months 36 months 48 +months0

20

40

60

80

100

120

140

122

69 6761

101

54 52 51

Simple Interventions can save lives

Reduce Asphyxia- LHW/TBA Resuscitation Training (baby sucker)

Avoid Hypothermia: Immediate drying, skin to skin contact

Help the dyad: Initiate early Breastfeeding

2:223

Goal 5: Improve Maternal Health

Maternal Mortality Trend, 1990-2015

Reducing Maternal Mortality

Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

2006-07 2010-11 MDG Target0

50

100

150

200

250

300276

260

140

3755

90

Maternal Mortality RatioProportion of births attended by SBAs

Why are we lagging behind?

Maternal Mortality Ratio by Province: Disparity and Inequity

Punjab Sindh KP Balochistan0

100

200

300

400

500

600

700

800

900

227

314275

785

Causes of Maternal Deaths in Pakistan

Source: Pakistan demographic and health survey, 2006-07

6%

10%

8%

6%

3%

27%

14%

27%

Abortion related

High blood pressure during pregnancy

Iatrogenic causes/ resulting from med-ical treatment

Bleeding during pregnancy

Obstructed labour

Bleeding after delivery

Infection after delivery

Others

Trend in TFR and CPR

CPR 1991 1994 1997 2001 2007 2009 MDG Target

11.9 17.8 23.9 27.6 29.6 30.8* 55

*Source: MDGs Report Pakistan 2010

TFR 1991 2007 2008 2009 MDG Target

5.4 4.1 3.85 3.75* 2.1

*Source: MDGs Report Pakistan 2010

Placement of Services Basic Emergency Obstetric and Newborn Care

ServicesJhelum District

Jhelum District

Placement of Services Comprehensive Emergency Obstetric and Newborn Care

Services

Non Functional Services Due to Shortage of Staff

Female ward locked Blood Bank non functional due to

absence of B.T.O

Tertiary Care Crunch

Tertiary care facility with doubling of patients

THQ Hospital with vacant female beds

Vacant Positions By Province

Gynecologists Peadiatrician SMO/MO SWMO/WMO LHV0

10

20

30

40

50

60

70

80

90

Punjab Sindh KP GB AJK FATA/FANA

So What Should We Doing About it? Provide skilled care – CMW- Proper placement and

supervision and ownership;

Interim Strategy- train TBAs in RSR;

Promote post-natal care- breastfeeding; postpartum contraception;

Prevent and treat maternal infections ; tetanus toxoid, prevent malaria and treat STIs

Improve maternal nutrition; Vitamin A, Zinc, Iron and Folic Acid and Iodine;

Improve family planning- access by improving quality of care.

Increasing SBA to 50%

Increasing fertility by

1 childIncreasing

SBA + lowering fertility

276

Current Scenario

237

Scenario 1

182

Scenario 2

156

Scenario 3

GFR = 135Skill birth attendance39%

GFR = 135Skill birth attendance50%

GFR = 100Skill birth attendance35%

GFR = 100Skill birth attendance50%

35% Reduction in Fertility (alone) will Reduce Maternal Mortality by at Least One Thirds

One of the most cost effective ways of reaching MDGs 4 and 5 is raising contraceptive

prevalence

Using Evidence and Scale up Best Practices

Training TBAs help in lowering perinatal mortality

Birth spacing- reaching out to people with information and quality services raises CPR in rural areas

Goal 6:Combat HIV/AIDS, Malaria and TB

In Conclusion: What is Required ?

• Use devolution to increase funding to the health sector• Focus on service for the poor and rural 67 percent population• Develop a functional referral system • Strengthen role of LHWs • Upgrade skills of existing staff through trainings and add

responsibilities • Improve staff motivation through incentives and facilities• Performance based audit and improved monitoring and

accountability• Female staff recruitment and retention by providing lucrative

facilities• Provide proactive family planning/birth spacing services-

develop synergies

THANKS!