Elsevier

The Lancet

Volume 381, Issue 9884, 22–28 June 2013, Pages 2207-2218
The Lancet

Series
Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities

https://doi.org/10.1016/S0140-6736(12)61999-0Get rights and content

Summary

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367 900 deaths (15 900 maternal, 169 000 newborn, 183 000 child deaths) and 49% of an estimated 180 000 stillbirths could be prevented in 2015.

Introduction

More than 90% of 7 million deaths globally in children younger than 5 years occur in only 40 countries, with most deaths occurring in just a few countries in south Asia and sub-Saharan Africa.1 Pakistan is at the centre of a very volatile geopolitical region with several decades of conflict within the country and in the bordering areas. It is a fairly young but populous nation; the population has grown from 27 million at the time of independence in 1947 to an estimated 185 million people in 2012, and 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 progress in achieving the targets for the Millennium Development Goals (MDGs) 4 and 5 have been slow.4 Although much of the health-related information from Pakistan is assessed at an aggregate level, the country has a vast and diverse landscape of almost 800 000 km2 and huge differences between its six provinces and the Federally Administered Tribal Areas in resources, access, and development. The disbandment in June, 2011, of the federal Ministry of Health and the constitutional devolution of health to the provinces5 have placed a huge impetus on provinces for planning and action in relation to public health, especially reproductive, maternal, newborn, and child health (RMNCH).

Key messages

  • Despite periods of stable economy and the dividends of a young population, Pakistan's progress in achieving Millennium Development Goals (MDG) 4 and 5 for reproductive health and maternal and child survival, respectively, remains unsatisfactory.

  • Progress in addressing key social determinants such as poverty, female education and empowerment, and undernutrition has been slow, and unfettered population growth eliminates economic and health gains.

  • For health and development indicators, huge disparities exist between and within provinces, indicating the need for targeting and proactive strategies to reach poor and marginalised communities.

  • Existing programmes such as the Lady Health Worker Programme, if improved and linked to functional primary care and secondary care facilities, are important strategies to achieve change in the short term but need to be coupled with improvements in quality of care in the health system.

  • In the long term, Pakistan needs the political will to prioritise pro-poor and integrated reproductive, maternal, newborn, and child health services after devolution of health services to the provinces.

  • Many gains are possible. A restricted repertoire of evidence-based interventions packaged to address reproductive, maternal, newborn, and child health issues have the potential to reduce the burden of maternal and child deaths by 57%, but need to be scaled up with strategies to overcome poverty and barriers to access.

We undertook an in-depth analysis of available information to assess Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to RMNCH and nutrition. We also assessed the feasibility of delivering health and nutrition interventions to address RMNCH and survival, with the aim of accelerating progress and making recommendations for change.

Section snippets

Data sources and analytical methods

We undertook a systematic review of available information pertaining to the state of maternal and child health in Pakistan since its independence. Our starting point was an in-depth review of recent situational analyses,2, 3, 6, 7, 8, 9 relevant policy documents, and official reports about progress towards the MDGs.10 We undertook an electronic search of all published materials from Pakistan of relevance to RMNCH and nutrition and also searched the grey literature representing national and

Maternal and child mortality

Although there has been progress in terms of reduction in child mortality rates, trends indicate that Pakistan has begun to lag behind many regional countries in south Asia (appendix p 1). These data have been corroborated with the findings from PDHS 2007,21 which indicate that although there has been some reduction in postneonatal infant and child mortality rates, newborn death rates have remained largely unaltered. 57% of all neonatal deaths occurred within the first 72 h after birth, most

Why has so little changed?

The status of RMNCH in Pakistan relates to the mismatch between progress between economic development, investments, and RMNCH and nutrition indicators compared with many other countries in the region or elsewhere with worse economies and development indicators. Even during periods of economic growth, the trajectory of gains in RMNCH has been slower than in many regional Asian countries and regions with similar or fewer resources—eg, Nepal,43 Bangladesh,44 and Asia Pacific;45 even India despite

Way forward for RMNCH

Despite all the difficulties, Pakistan has the potential to improve RMNCH by scaling up key interventions, particularly, after devolution, when there are enhanced opportunities for tailoring packages of interventions to specific contexts and scenarios. We assessed the effect of systematically increasing coverage of various evidence-based interventions on reducing the burden of maternal, fetal, newborn, and child deaths using the Lives Saved Tool (LiST). This software58, 59 is used to assess the

Search strategy and selection criteria

We searched all electronic databases for information that was relevant to reproductive health and maternal and child health in Pakistan since Jan 1, 1960. We used a comprehensive search strategy with extensive hand searches and cross tabulation of reports and references to access grey literature. There were no language restrictions.

The search strategy was iterative and the final version included core terms (“maternal and child health” OR “maternal” OR “wom*” OR “mother*” OR “pregnan*” OR

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