Maternal Health Situation in Pakistan Where do we stand in South Asia? Prof .Tasneem Ashraf President SOGP Head of Gynae Unit-II BMCH Quetta

Women health situation in PAKISTAN It’s been 68 years since independence but our majority of population is still deprived of basic necessities of life like food ,education, health and clean drinking water. Our literacy rate is only 58% and 21% population is living below poverty line. We are struggling to keep our mothers alive during the process of child birth. In 2010 ,12000 maternal deaths occurred (world Bank report). Balochistan province being largest in terms of area and scattered population has the highest MMR, 778/100,000 live births and it is still increasing.

BASIC HEALTH INDICATORS OF PAKISTAN Total population 184.35 million Total Fertility Rate 3.07 Children born/woman Crude Birth Rate 27.28/1000/yr Population Growth Rate 1.80% Infant Mortality Rate 78/1000 Under Five Mortality Rate 94 Maternal Mortality Ratio 260/100,000 Contraceptive Prevalence Ratio 38% Source: World Bank Report 2012

BASIC HEALTH INDICATORS OF BALOCHISTAN Total Population 7.8million Fertility Rate 5.4 Child/Woman Infant Mortality Rate 105/1000 Under Five Mortality Rate 110/1000 Maternal Mortality Ratio 530-830/100,000 Contraceptive Prevalence Rate 1.8% Source: BRSP Annual Report 2007-2008

Millennium Development Goals The  MDGs are eight international development goals, were established following the Millennium Summit of the United Nations in 2000. Pakistan is a signatory to the UN mandate of MDGs. All 189 UN member states committed to achieve the following MDGs by 2015: Goal 1: Eradicate Extreme Hunger and Poverty. Goal 2: Achieve Universal Primary Education Goal 3: Promote Gender Equality and Women Empowerment. Goal 4: Reduce Child Mortality Goal 5: Improve Maternal Health   Goal 6: Combat HIV/AIDS, Malaria and other diseases Goal 7: Ensure Environmental Sustainability   Goal 8: Develop a Global Partnership for Development

MDG5. Improve Maternal Health Target 5.A: To reduce MMR by 3/4, by 2015. 5.1 To decrease Maternal mortality ratio. 5.2: To increase Proportion of births attended by skilled birth attendants. Target 5.B: Universal access to reproductive health. 5.3 Contraceptive prevalence rate increased. 5.4 Antenatal care coverage (at least one visit and at least four visits) increased. 5.5 Adolescent birth rate to be lowered. 5.6 Unmet need for family planning lowered.

Pakistan’s MDGs report There have been successes in some areas but the country is not doing well in health-related goals i.e. 4&5. Currently, it has the highest MMR (260/100,000) & IMR(78/1000) in South Asia. For Pakistan to meet the MDGs, the infant mortality rate should decline to 40 deaths /1000 live births and the under- five mortality rate should not be more than 52 deaths / 1000 live births. Maternal mortality should decline by almost 50 percent of its current level (140 / 100,000) by 2015.

What IS THE SITUATION IN DEVELOPING WORLD? WHO REPORT 2014 Almost 300,000 women died globally in 2013 from causes related to pregnancy and childbirth. The proportion of deliveries in developing regions attended by skilled health personnel rose from 56 to 68 per cent between 1990 and 2012. 40 million births in developing regions were not attended by any skilled health attendants, and over 32 million of those births occurred in rural areas. Antenatal visits ( 4 or more) increased from 37% to 52% from 1990 to 2012.

MMR : Source: The Millennium Development Goals Report 2014

Health indicators for South Asia Pakistan Bangladesh India Sri Lanka Nepal 1990 2012 Infant Mortality rate/1000 live births 95 60 97 39 81 49 24 11 94 41 MMR/100,000 live births 490 260 800 240 600 200 85 35 770 170 Under five mortality rate / 1000 live births 122 74 139 114 63 29 13 135 50 Total Fertility rate - 3.4 2.2 2.6 2.3 2.7 Life expectancy at birth (Years) 65.2 68.6 65.1 74.7 68.4

MMR in South Asian Countries (April 23, 2013)

Pakistan Vs Rest of the world (Fertility Rate)

Challenges Effecting Health Services Non availability of health services or insufficient services especially EmOC services at primary and secondary health centres. Poor quality health care . Lack of awareness and under utilization. Lack of human resource especially female staff, and inadequate capacity and skills. Inadequate Family planning services especially access and coverage.

Factors Effecting health services Lack of integration of all the health related programmes i.e. PPHI, MNCH, RH. Lack of accountability. Poor planning. Corruption and political interference. Inadequate financial resources.

Challenges influencing Health Services in Balochistan In Baluchistan tribal influence, feudal system and low illiteracy rate, poor road network (75000 villages are without proper road network). Law and order situation is poor, doctors and rich persons are kidnapped for ransom so people are afraid of working in far flung areas. Women health suffers more because of unavailability of female health care providers; gynaecologist, LHWS, FMT, etc. in the remote areas. Non- functional heath centers and lack of equipment for EmOC services.

STATUS OF WOMEN Limited facilities for education and employment. Violence against women is a national phenomenon. Domestic violence is common and no help is available. Men are killing women in the name of honor and tradition. Men treat the women just like their servants or animals. Inequalities in food intake relative to men

FAMILIAL FACTOR The women suffering is great because of their subordinate position in the family. No say at the time of marriage and trends of early marriages. Can not use health facility without the permission of in laws. Lack of decision power about family planning. Unequal work burden for productive as well as reproductive responsibility, Restricted mobility.

Women Health Status in Pakistan 30,000 women suffer from pregnancy related complications i.e. VVF, RVF, depression, chronic pelvic pain and PID. An estimate states that more than 5000 women suffer from Fistula every year. Anemia is very common in pregnancy and associated with high maternal morbidity and mortality. Unsafe abortion is a major cause of women suffering in Pakistan. Estimated abortions rate (spontaneous &induced) per year is 1 million.

Women Health Status in Pakistan Breast ,cervical ,ovarian and colon cancers are the leading causes of women death. No screening program. Very few gynecological oncology surgeons. Chemotherapy is very expensive. Radiotherapy is available in Govt. hospitals but over burdened staff is unable to provide quality treatment. Majority of the menopausal women have no access to health facility

Issues Malnutrition, poverty, illiteracy. Teenage Marriages High population growth rate Malnutrition, poverty, illiteracy. Teenage Marriages Poor communication and road network. Low skilled birth attendance rate Lack of awareness Poor primary health care services Insufficient maternal health care services especially EmOC .

What has worked in the world? In countries like Malaysia, Sri Lanka, Thailand, Jamaica and Tunisia there has been a significant decline in maternal mortality due to three factors: Access to skilled birth attendance (community midwives/midwives, nurses and doctors)   Access to emergency obstetric care (basic and comprehensive) Access to family planning services.

What's need to be done? Safe motherhood and post abortion care Ensuring availability of reproductive health services and EmOC services at all secondary and primary care centers. Involvement of senior doctors and teaching staff to provide tertiary EmOC services Production of competent midwives and skilled birth attendants. Activation of BHU and RHCs. Safe motherhood and post abortion care Evidence-based Interventions for Major Causes of Maternal Mortality.

What's need to be done? Infant health care & neonatal heath services. Comprehensive family planning facilities and care in collaboration with doctors. Infant health care & neonatal heath services. Good road network in urban and rural areas. Helpline and Flying squad to save maternal life. Free availability of iron and folic acid tablets in remote areas. Adolescents R.H. problems coverage. STDs/ HIV/ AIDS/ HBV/ HCV prevention, early detection and management. Cancer screening programs.

Message Women are the main building blocks of our society. Their efforts are hardly recognized and appreciated. They are still striving for their basic rights i.e. food, health, education, equality in rights & power and facing domestic violence. Lets join hands to help woman in seeking her rights.

Message SOGP strongly believes that the health of a citizen is the responsibility of Govt. Basic health and EmOC services should be available to them with out any cost at their door steps. We request Govt. and all political parties to unite together to provide good health services to our poor women. High maternal mortality should be declared an emergency and managed on priority bases.