Situation of Maternal Health: Pakistan

Dr. Nabeela Ali

Chief of Party

PAIMAN

Population164 Million

Population Rural67%

Growth Rate1.9%

Total fertility rate4.1 births

Contraceptive use30%

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 350-500 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 HealthTrends in Pregnancy &

Delivery

Where do we stand ?Where do we stand ?

CountryLife

Expectancy

Infant

Mortality

Rate

Under 5

Mortality

Rate

Population

Growth

Rate

Pakistan 64 74 98 1.9

Bangladesh 62 46 69 1.7

India 63 63 87 1.5

Source: Pakistan Economic Survey 2004-05

MMR by District, 1993

50

289

463

593

673

360

523

120

Karachi

Pishin

Lasbela

Loralai

Khuzdar

Abbottabad

Mansehra

Peshawar

Urban Rural Gap – “One” Antenatal Visits Urban Rural Gap – “One” Antenatal Visits

Source: PSLSM 2004-05

22%26%

40%

60%63%

66%

Target 100%

0%

20%

40%

60%

80%

100%

120%

1998-99 2001-02 2004-05 2008 2012 2015

Urban Rural Target

Recommended Four Antenatal Visits !!

•There is wide Gap between urban-rural for one antenatal visitThere is wide Gap between urban-rural for one antenatal visit

•Further, it is required to have at least 4 antenatalFurther, it is required to have at least 4 antenatal

•From 40% we have to reach 100% rural women seeking at least one antenatal visitFrom 40% we have to reach 100% rural women seeking at least one antenatal visit

Health – Human Resource Development Health – Human Resource Development

0

20000

40000

60000

80000

100000

120000

7th plan1993

8th plan1998

2000 2001 2002 2003 2004

Doctors Midwives Nurses LHVs LHWs

Status Quo in the number of LHV, Midwives and Nurses Status Quo in the number of LHV, Midwives and Nurses

0 20 40 60 80 100 120

Nepal

Bangladesh

Bhutan

Indonesia

India

Maldives

Myanmar

Sri Lanka

Thailand

DPR Korea

SBA% NMR/1000

Correlation between neonatal mortality rate and SBA

We Pledged in September 2000 The Millennium Development Goals

Goal 4Reduce child mortality by two

third between 1990-2015

Goal 5Reducing maternal mortality by

three quarters between 1990-2015

Status of MDG - Maternal Health (Goal 5)

MMR – per 100,000 live births

500

350

140

5

230

0

20

40

60

80

100

120

1990 2003/4 2015

GAPGAP

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

2000 20152005

15 years for achieving MDGs

Opportunity

Window10 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.

Investment in health is growing but is not enough

CURRENT HEALTH INVESTMENT BY GoP & PARTNERS 2004-5

MoH & DoHs74%

MoPW5%

UN system5%

Bilaterals6%

Multilateral10%

GoP (MoH & DoHs)= Rs 45 billions

Partners= Rs 11 billions

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

H om e

LHW

TBA

Village

CEmOc

DHQ/ THQ

Obstetric Emergencies (bypass RHC)

BEmOC

BHU/RHC

IEEC

11

Training22

Training33

Upgrade, Train

55

Transport44 Upgrade,

Train

66

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%

PopulationServed

40%

45%

15%

Health Expenditure

(Source: P&D Division 1994)

PHC Wing ,Ministry of Health

Health–Human Resource Development

0

20000

40000

60000

80000

100000

120000

7th plan1993

8th plan1998

2000 2001 2002 2003 2004

Doctors Midwives Nurses LHVs LHWs

Status Quo in the number of LHV, Midwives and Nurses

Confidence in Public Sector Facilities?

Source: PSLSM 2004-05

72%

20%

5%

2% 2%3%

1%

64%

21%

4%2%

1%

7%

2%

67%

21%

2% 2% 1%

5%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Private Disp/Hosp

Public Disp/Hosp

RHC/BHUs Hakeem Homeopath Chemist Others

Urban

Rural

Overall

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