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Why are the Pakistani maternal, fetal and newborn outcomes so poor compared to other low and middle-income countries?


The United Nations’ establishment of Millennium Development Goals (MDGs) 4 and 5 – to improve child and maternal health, respectively, brought high maternal and neonatal mortality to the forefront of the global stage. These goals included a three-quarters reduction in the 1990 maternal mortality ratio (MMR) and a two-thirds reduction in the 1990 under-5 mortality rate, both to be achieved by 2015. Knowledge about rates and trends in maternal and neonatal mortality, as well as for stillbirths, can identify particular sub-populations that may be at higher risk for death, and inspire strategies to reduce this risk.

While Pakistan has shown a decrease in its MMR and neonatal mortality rate (NMR) since 1990, there has been less improvement in these outcomes as compared to other south Asian countries. Stillbirth rates have rarely been addressed and remain under-reported in Pakistan, but are approximately equal in number to the neonatal deaths. In 2015, there were about 5,500,000 births in Pakistan. The MMR in 2015 in Pakistan was reported as 178 deaths/100,000 live births, decreased by 58.7% since 1990, when the rate was 431 deaths/100,000 live births. However, in rural areas of Pakistan, the MMR in 2007 was reported as almost twice that figure, at 319 deaths/100,000 live births, with wide variation between provinces—227 in Punjab vs. 785 in Baluchistan. Because these data are derived from a poorly functioning vital statistics system or estimates based on sampling, they likely under-report deaths.

Pakistan’s overall NMR in 2015 was reported as 44 deaths per 1000 live births. However, in rural areas, the NMR was reported to be 62 deaths per 1,000 live births, while for the richest households, the NMR was reported as 34 deaths per 1000 live births. The stillbirth rate in 2015 was reported at 43 per 1000 total births. In the Pakistan 2017–2018 Demographic Health Survey (PDHS), the NMR for the five years preceding the survey was 42 deaths per 1000 live births. Again, because of the lack of a functioning vital statistics system, these numbers are at best estimates and the number of deaths are likely to be underreported.

Pakistan consistently lagged in achieving the health-related MDGs 4 and 5 for reducing maternal and child mortality. This led the government to launch the National Maternal, Neonatal, and Child Health (MNCH) Programme in 2007, to improve maternal and child health outcomes. This program concentrated on two main areas: (1) providing emergency obstetric services and community midwives, and (2) promoting institutional deliveries and skilled birth attendance. Lady health workers (LHWs) provided obstetric and newborn services, including primary health care through home visits in rural areas. Unfortunately, despite these efforts, the MDG targets were not achieved. As a signatory of the newer Sustainable Development Goals (SDGs) 2015–2030, the government of Pakistan developed a monitoring and evaluation mechanism for the National Health Vision 2016–2025. The resulting framework is coordinated with the Planning Commission of Pakistan for SDG reporting, as well as with other stakeholders to ensure an inclusive and wide reach. The SDG 3—to ensure healthy lives and promote well-being at all ages—includes bringing the global NMR to as low as 12 deaths per 1000 live births and the MMR to less than 70 deaths per 100,000 live births by 2030.

Countries such as Rwanda, Iran, Bhutan, Cambodia, the Lao People’s Democratic Republic, Mongolia, and Timor-Leste are categorized as having “achieved MDG 5A” based on MMR reduction estimates indicating a downward trend of at least 75% between 1990 and 2015. On the other hand, in Pakistan, the overall MMR decrease did not achieve that goal. Furthermore, in a recent report by UNICEF in 2018, Pakistan was listed as the riskiest place in the world to be born as measured by its NMR in 2016—higher than that of Central African Republic, Afghanistan, and Somalia. One in 22 babies born in Pakistan in 2016 died before the end of the first month of life.

The Global Network (GN) for Women’s and Children’s Health Research’s Maternal Newborn Health Registry (MNHR) provides a unique opportunity to compare pregnancy outcomes and putative explanatory factors for adverse outcomes at a surveillance site in Pakistan with sites in six other countries. The purpose of this paper is to compare the MMR, rates of stillbirth, and NMR as well as factors that might help to explain the differences between the site in Pakistan and six other sites in the MNHR, including two sites in India, as well as sites in Kenya, Zambia, the Democratic Republic of the Congo (DRC), and Guatemala.

By: Aziz A, Saleem S, Nolen T, Pradhan NA, Hibberd PL, Patel AB et al.

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