1. Reproductive Health Scenario of Pakistan: Where We Are and What Should We Be Doing? Dr Ali Mohammad Mir February 14, 2013

2. 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)

3.  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

4. 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

5.  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

6. Goal 4: Reduce Child Mortality

7. Reducing Maternal Mortality Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

8. Why are we lagging behind?

9. Major Causes of Newborn Deaths

10. Malnutrition among < 5 Children by Province

11. 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 Punjab5965.13182 Sindh51.258.31404 KP43.251.2827 Balochistan29.730.9264 Source: PDHS 2006-07

12. Measles Immunization Coverage Measles Immunization Coverage 2010-11 Pakistan82 Punjab86 Sindh77 KP78 Balochistan58 Source: Pakistan Social and Living Standard Measurement Survey 2010-11

13. What should we be doing about it?

14. Source: PDHS 2006-07 Longer Birth Intervals Reduce Child Mortality

15. 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

16. 2:223

17. Goal 5: Improve Maternal Health

18. Maternal Mortality Trend, 1990- 2015

19. Reducing Maternal Mortality Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

20. Why are we lagging behind?

21. Maternal Mortality Ratio by Province: Disparity and Inequity

22. Causes of Maternal Deaths in Pakistan Source: Pakistan demographic and health survey, 2006-07

23. Trend in TFR and CPR CPR199119941997200120072009MDG Target 11.917.823.927.629.630.8*55 *Source: MDGs Report Pakistan 2010 TFR1991200720082009MDG Target 5.44.13.853.75*2.1 *Source: MDGs Report Pakistan 2010

24. Placement of Services Basic Emergency Obstetric and Newborn Care Services Jhelum District

25. Placement of Services Comprehensive Emergency Obstetric and Newborn Care Services

26. Non Functional Services Due to Shortage of Staff Female ward locked Blood Bank non functional due to absence of B.T.O

27. Tertiary Care Crunch Tertiary care facility with doubling of patients THQ Hospital with vacant female beds

28. Vacant Positions By Province

29. 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.

30. Increasing SBA to 50% Increasing fertility by 1 child Increasing SBA + lowering fertility 276 Current Scenario 237 Scenario 1 182 Scenario 2 156 Scenario 3 GFR = 135 Skill birth attendance 39% GFR = 135 Skill birth attendance 50% GFR = 100 Skill birth attendance 35% GFR = 100 Skill birth attendance 50% 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

31. 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

32. Goal 6:Combat HIV/AIDS, Malaria and TB

33. 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

34. THANKS!