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  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)

 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 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

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

 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

Goal 4: Reduce Child Mortality

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

Why are we lagging behind?

Major Causes of Newborn Deaths

Malnutrition among < 5 Children by Province

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 Sindh KP Balochistan Source: PDHS

Measles Immunization Coverage Measles Immunization Coverage Pakistan82 Punjab86 Sindh77 KP78 Balochistan58 Source: Pakistan Social and Living Standard Measurement Survey

What should we be doing about it?

Source: PDHS Longer Birth Intervals Reduce Child Mortality

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

2:223

Goal 5: Improve Maternal Health

Maternal Mortality Trend,

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

Why are we lagging behind?

Maternal Mortality Ratio by Province: Disparity and Inequity

Causes of Maternal Deaths in Pakistan Source: Pakistan demographic and health survey,

Trend in TFR and CPR CPR MDG Target *55 *Source: MDGs Report Pakistan 2010 TFR MDG Target *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

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

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.

Increasing SBA to 50% Increasing fertility by 1 child Increasing SBA + lowering fertility 276 Current Scenario 237 Scenario Scenario 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

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

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 services- develop synergies

THANKS!