reproductive health scenario of pakistan: where we are and what should we be doing?
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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 spacedTRANSCRIPT
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
250,000-300,000 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
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
2006-07 2009-10 MDG Target0
102030405060708090
100 9487
52
7572
40
76 7890
Under-five mortality Infant Mortality RateProportion of fully immunized children
Why are we lagging behind?
Major Causes of Newborn Deaths
40%
28%
17%
10%5%
Asphyxia
Pre-maturity
Congenital abnormality and others
Infectious Diseases
Unexplained
Malnutrition among < 5 Children by Province
Pakistan Balochistan KP Sindh Punjab AJK0
10
20
30
40
50
60
44
5248 50
39
32
15 16 17 1814
18
32
40
24
41
3026
Stunted Wasted Underweight
Maternal Tetanus Toxoid Coverage
BackgroundCharacteristic
PercentageReceiving two or more injections during last pregnancy
Percentage whose last birth was protected against neonatal tetanus
Number ofmothers
Punjab 59 65.1 3182Sindh 51.2 58.3 1404KP 43.2 51.2 827Balochistan 29.7 30.9 264
Source: PDHS 2006-07
Measles Immunization Coverage
Measles Immunization Coverage 2010-11
Pakistan 82Punjab 86Sindh 77KP 78Balochistan 58
Source: Pakistan Social and Living Standard Measurement Survey 2010-11
What should we be doing about it?
Source: PDHS 2006-07
Longer Birth Intervals Reduce Child Mortality
<24 months 24 months 36 months 48 +months0
20
40
60
80
100
120
140122
69 67 61
101
54 52 51
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, 1990-2015
Reducing Maternal Mortality
Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan
2006-07 2010-11 MDG Target0
50
100
150
200
250
300276
260
140
3755
90
Maternal Mortality RatioProportion of births attended by SBAs
Why are we lagging behind?
Maternal Mortality Ratio by Province: Disparity and Inequity
Punjab Sindh KP Balochistan0
100
200
300
400
500
600
700
800
900
227314 275
785
Causes of Maternal Deaths in Pakistan
Source: Pakistan demographic and health survey, 2006-07
6%
10%
8%
6%
3%
27%
14%
27%
Abortion related
High blood pressure during pregnancy
Iatrogenic causes/ resulting from med-ical treatment
Bleeding during pregnancy
Obstructed labour
Bleeding after delivery
Infection after delivery
Others
Trend in TFR and CPRCPR 1991 1994 1997 2001 2007 2009 MDG
Target11.9 17.8 23.9 27.6 29.6 30.8* 55
*Source: MDGs Report Pakistan 2010
TFR 1991 2007 2008 2009 MDG Target
5.4 4.1 3.85 3.75* 2.1
*Source: MDGs Report Pakistan 2010
Placement of Services Basic Emergency Obstetric and Newborn Care Services
Jhelum District
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
Gynecologists Peadiatrician SMO/MO SWMO/WMO LHV0
102030405060708090
Punjab Sindh KP GB AJK FATA/FANA
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 childIncreasing
SBA + lowering fertility
276
Current Scenario
237
Scenario 1
182
Scenario 2
156
Scenario 3
GFR = 135Skill birth attendance39%
GFR = 135Skill birth attendance50%
GFR = 100Skill birth attendance35%
GFR = 100Skill birth attendance50%
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!