Situation of Maternal Health: Pakistan Dr. Nabeela Ali Chief of Party PAIMAN

 Population 164 Million  Population Rural 67%  Growth Rate 1.9%  Total fertility rate 4.1 births  Contraceptive use 30% Demographic Profile

 Public sector hospitals 906  Basic Health Units 5,290  Population/Bed  1,536  Doctors 122,798  Nurses 57,646  Midwives 25,000  Lady health Workers 96,000

Issues in National Perspective  Every hour in Pakistan:  Three women die due to maternal causes  Thirty newborn babies die in first month of life  Interventions needed to reduce maternal and newborn mortality:  Skilled Birth Attendance  Referral and transportation systems  Health facilities providing emergency obstetric and newborn care (EmONC)  Awareness of community on key health messages and behaviors.

Maternal Health Indicators Pregnant women receiving prenatal care 61% Births attended by skilled personnel 39% Women receiving postpartum care 22% Source: PDHS 2007

Key Women’s Health Indicators  There are almost 29 million women of reproductive age  More than 5 million women become pregnant each year  Three delays (in decision making, in transportation, and in receiving care) contribute towards high MMR of about per 100,000 live births

 A large proportion of deliveries are conducted by unqualified personnel (62%)  Contraceptive Prevalence Rate is 30%-34%  Unmet need for FP is 33% Women’s Health Trends in Pregnancy & Delivery

Where do we stand ? Country Life Expectancy Infant Mortality Rate Under 5 Mortality Rate Population Growth Rate Pakistan Bangladesh India Source: Pakistan Economic Survey

MMR by District, 1993

Urban Rural Gap – “One” Antenatal Visits Source: PSLSM Recommended Four Antenatal Visits !! There is wide Gap between urban-rural for one antenatal visit There is wide Gap between urban-rural for one antenatal visit Further, it is required to have at least 4 antenatal Further, it is required to have at least 4 antenatal From 40% we have to reach 100% rural women seeking at least one antenatal visit From 40% we have to reach 100% rural women seeking at least one antenatal visit

Health – Human Resource Development Status Quo in the number of LHV, Midwives and Nurses

Correlation between neonatal mortality rate and SBA

We Pledged in September 2000  The Millennium Development Goals Goal 4 Reduce child mortality by two third between Goal 5 Reducing maternal mortality by three quarters between

Status of MDG - Maternal Health (Goal 5) MMR – per 100,000 live births /42015 GAP Target 2015: 140 per 100,000 live births Current rate: 350 per 100,000 live births At current pace MMR in 2015: 230 per 100,000 live births

years for achieving MDGs Opportunity Window 10 years Can Pakistan Achieve MDG Goal 4 & 5 ??  Is our progress since 2000 on track ? Slow  Will business as usual work ? No  Are extraordinary measures warranted? Yes

The triangle of death…… Lack of awareness Unskilled birth attendants Poor access to EmONC Traditional culture of birthing

Continuum of Care Scenarios Family TBA Skilled Attendant Nursing Care Obstetrician Poorly developed Intermediate Well developed

Rationale: Linking High Priority to SBA  More than 75% of deliveries take place at home in rural communities  The postpartum period is one of the most vulnerable for both mother and newborn, yet neither health programs nor mothers and families recognize this vulnerability.  For mothers, death at delivery, immediately thereafter, and during the first week of the baby’s life account for more than 60%  For newborns 50% of deaths are within 72 hours after delivery (The World Health Report 2005).  Add to this mounting death toll the stillbirths that alone total nearly 3.3 million annually.

Government’s Response To Achieve MDGs  MNCH Cell created in the Ministry  National MNCH Policy and Strategic Framework developed  Prime Minister endorsed the National MNCH Program in April 2005  Islamabad Declaration unanimously adopted by Federal, Provincial, District Governments and development partners  PC-1 implementation started as of June 2007  12,000 Community Midwives (CMWs) to be trained in next five years.

Priority Areas  Community Midwives trained and placed in rural communities  Provision of Basic and Comprehensive EmONC services  Comprehensive family planning services  Nutrition interventions  National Program for FP & PHC  Creating awareness and demand for services

LHW TBA Village CEmOc DHQ/ THQ Obstetric Emergencies (bypass RHC) BEmOC BHU/RHC IEEC 1 Training2 3 Upgrade, Train 5 Transport 4 Upgrade, Train 6 From Home to Hospital CMW

A Shared Responsibility Mother The woman prepares for birth and values and seeks skilled care during pregnancy, childbirth and postpartum period Family The family supports the pregnant woman’s plans during pregnancy, birth and postpartum period. Community The community advocates and facilitates preparedness and readiness to carry out the required actions. Provider The provider is responsible for providing skilled care during normal and complicated pregnancies, birth, and postpartum period in accordance with the standards specified in the protocols. Facility The facility must be adequately equipped, staffed, and managed in accordance with the QA service standards to assure that skilled care is provided for the pregnant woman and the newborn. Policymakers Policymaker creates an environment that supports the survival of the pregnant woman and the newborn.

Challenges at Hand

CBI……. The Rationale … Low & Inequitable Distribution of Health Resources Tertiary Hospital Secondary Health Care PHC 1% 9% 90% Population Served 40% 45% 15% Health Expenditure (Source: P&D Division 1994) PHC Wing,Ministry of Health

Health–Human Resource Development Status Quo in the number of LHV, Midwives and Nurses

Confidence in Public Sector Facilities? Source: PSLSM Quality issue lead to lack of confidence in Public sector which is resulting in high out of pocket expenditure for the poor

Communication Challenges  Information gaps regarding MNH behaviors  Wide spectrum of population  Cultural barriers  Mass media penetration  Reaching out to women behind walls

Media Support Increasing awareness and demand for MNH services through communication strategies that empower individuals and communities to seek and expect quality MNH services Advocacy for positioning Safe Motherhood as a key human and development issue.

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has. Margaret Mead