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

3. 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.

4. BASIC HEALTH INDICATORS OF PAKISTAN
Total population
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

5. 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
/100,000
Contraceptive Prevalence Rate
1.8%
Source: BRSP Annual Report

6. Millennium Development Goals
The  MDGs are eight international development goals, were established following the Millennium Summit of the United Nations in 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

7. 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.

8. 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 / live births.
Maternal mortality should decline by almost 50 percent of its current level (140 / 100,000) by 2015.

9. 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

10. MMR : Source: The Millennium Development Goals Report 2014

11. 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

12. MMR in South Asian Countries (April 23, 2013)

13. Pakistan Vs Rest of the world (Fertility Rate)

15. 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.

16. 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.

17. 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.

18. 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

19. 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.

20. 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.

21. 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

22. 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 .

23. 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.

25. 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.

26. 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.

27. 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.

28. 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.