Reproductive Health Scenario of Pakistan Where We Are

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 v Among married women of reproductive age (MWRA) approximately 1 out of 3 of births are spaced <2 years apart v Women average 4 births during their reproductive life (the second highest fertility rate in South Asia after Afghanistan) v Low contraceptive use (only 30% of married couples use contraception) v The fourth highest under-five child deaths (after India, Nigeria and Congo)

Pakistan’s Scorecard– A brief overview v Serious malnutrition with 38% of children under five (9 million) underweight. v Poor access to water and sanitation. Diarrhoea is the main killer of children. v World’s third highest burden of deaths due to neonatal tetanus v 250, 000 -300, 000 new cases of TB every year. v HIV prevalence high rates in populations most-at-risk especially injecting drug users and male sex workers.

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

What is our current agenda: Achieving the MDGs v Signed by 147 heads of states and governments v Adopted by 189 nations v Pledged to “spare no effort to free our fellow men, women and children from abject and dehumanizing conditions of extreme poverty” v Goals relating health sector (4, 5&6) 4 Targets and 16 Indicators

Goal 4: Reduce Child Mortality

Reducing Maternal Mortality 100 90 80 70 60 50 40 30 20 10 0 94 76 75 90 87 78 72 52 40 2006 -07 2009 -10 MDG Target Under-five mortality Infant Mortality Rate Proportion of fully immunized children Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

Why are we lagging behind?

Major Causes of Newborn Deaths 5% Congenital abnormality and others 10% Unexplained Asphyxia Pre-maturity 17% Infectious Diseases 28% 40%

Malnutrition among < 5 Children by Province 60 52 50 50 48 44 41 40 40 39 32 30 30 20 32 26 24 15 16 17 18 18 Pakistan Balochistan KP Sindh Wasted Underweight 14 10 0 Stunted Punjab AJK

Maternal Tetanus Toxoid Coverage Background Characteristic Percentage Receiving two or more injections during last pregnancy Percentage whose last birth was protected against neonatal tetanus Number of mothers 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 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?

Longer Birth Intervals Reduce Child Mortality 140 122 120 101 80 69 60 67 54 52 24 months 36 months 61 51 40 20 0 <24 months Source: PDHS 2006 -07 48 +months

Simple Interventions can save lives v Reduce Asphyxia- LHW/TBA Resuscitation Training (baby sucker) v Avoid Hypothermia: Immediate drying, skin to skin contact v Help the dyad: Initiate early Breastfeeding

2: 223

Goal 5: Improve Maternal Health

Maternal Mortality Trend, 19902015

Reducing Maternal Mortality 300 276 250 260 200 150 140 100 50 90 37 55 0 2006 -07 2010 -11 MDG Target Maternal Mortality Ratio Proportion of births attended by SBAs Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

Why are we lagging behind?

Maternal Mortality Ratio by Province: Disparity and Inequity 900 785 800 700 600 500 400 314 227 275 200 100 0 Punjab Sindh KP Balochistan

Causes of Maternal Deaths in Pakistan Abortion related 6% 27% High blood pressure during pregnancy 10% Iatrogenic causes/ resulting from medical treatment 8% Bleeding during pregnancy 5% 14% Obstructed labour 3% Bleeding after delivery Infection after delivery 27% Others Source: Pakistan demographic and health survey, 2006 -07

Trend in TFR and 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 Services Jhelum District

Placement of Services Comprehensive Emergency Obstetric and Newborn Care Services Jhelum District

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 90 80 70 60 50 40 30 20 10 0 Gynecologists Peadiatrician Punjab Sindh SMO/MO KP GB AJK SWMO/WMO FATA/FANA LHV

So What Should We Doing About it? v Provide skilled care – CMW- Proper placement and supervision and ownership; v Interim Strategy- train TBAs in RSR; v Promote post-natal care- breastfeeding; postpartum contraception; v Prevent and treat maternal infections ; tetanus toxoid, prevent malaria and treat STIs v Improve maternal nutrition; Vitamin A, Zinc, Iron and Folic Acid and Iodine; v Improve family planning- access by improving quality of care.

One of the most cost effective ways of reaching MDGs 4 and 5 is raising contraceptive prevalence 35% Reduction in Fertility (alone) will Reduce Maternal Mortality by at Least One Thirds Current Scenario 276 Increasing SBA to 50% Scenario 1 237 Increasing fertility by 1 child Scenario 2 182 GFR = 135 Skill birth attendance 39% GFR = 135 Skill birth attendance 50% GFR = 100 Skill birth attendance 35% Increasing SBA + lowering fertility Scenario 3 156 GFR = 100 Skill birth attendance 50%

Using Evidence and Scale up Best Practices v Training TBAs help in lowering perinatal mortality v 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 servicesdevelop synergies

THANKS!