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Supplementary appendixThis appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.
Supplement to: Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(12)61999-0.
1
Web Appendix Figure 1
Under 5 mortality trends in South Asia (2)
Under 5 Mortality
Afghanistan Bangladesh Bhutan India
Nepal Pakistan Sri Lanka
2
Webappendix Figure 2
Timing of maternal and newborn deaths
(Secondary analysis PDHS data)21
3
Webappendix Figure 3
Correlation between Infant Mortality and Socio-economic status (SES index) in various districts of Pakistan
R Sq Cubic= ‐0.68
4
Webappendix Figure 4 Relationship of Skilled Birth attendance by district and Multidimensional Poverty Index in
Pakistan
Adjusted R2 value is 0.52 (p< 0.001)
5
6
Webappendix Figure 5
Health work force trends for RMNCH in Pakistan
0
20000
40000
60000
80000
100000
120000
140000
160000
1993 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008
Doctors
Midwives
Nurses
LHVs
LHWs
7
Web table 1 National programs of relevance to MNCH and nutrition
Year Program Source of technical support
1965 Family Planning Program Govt of Pakistan & USAID
1974 TBA training program Govt of Pakistan & UNICEF
1976 Expanded Program for Immunization Govt of Pakistan & WHO
1979 Diarrhoeal disease control Govt of Pakistan & WHO
1988 Acute Respiratory Infections Govt of Pakistan & WHO
1991 Baby Friendly Hospital Initiative WHO/ UNICEF
1992 Child Survival Program WHO/USAID
1992 Family Health Project Sindh World Bank
1993 Social Action Program World Bank
1993 Polio Eradication Program Multi-donor support
1994 Primary Care Program (LHW Program) Govt of Pakistan
2000 Integrated Management of the Sick Child Initiative
WHO/UNICEF
2007 Maternal, Newborn & Child Health program
Govt of Pakistan (with bilaterals)
8
Webappendix Figure 6 Trends in intervention coverage (%) 1990-2006
0
10
20
30
40
50
60
70
80
90
100Coverage in year 1990‐91
Coverage in year 2005‐2006
9
Webappendix Figure 7
Place of deaths by cause (secondary analysis) 21
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
In‐transitHomeHospital/Clinic
10
11
Webappendix Table 2
Packages of care modeled and evaluated for impact
Packages Interventions included within Packages Periconceptual and post abortion care
Safe abortion services* Post abortion case management * Folic acid supplementation or fortification
Expanded Antenatal Care (ANC) Package
Basic 4 visit ANC** Syphilis detection and treatment MgSO4 management of pre-eclampsia**
Diabetes screening and management* Screening for fetal growth restriction and appropriate
management*
Childbirth & Immediate Newborn Care
Essential care for all women and immediate essential newborn care**
Clean birth practices at home and cord care** Antibiotics for preterm premature rupture of
membranes )pPRoM*) Antenatal corticosteroids for preterm labor* Basic emergency obstetric care (clinic) Comprehensive emergency obstetric care Immediate neonatal assessment and stimulation Neonatal resuscitation** Active management of 3rd stage of labor MgSO4 management of eclampsia** Induction of labour to prevent births at or beyond 41
completed weeks* Postnatal care (including community Newborn Care)
Preventive postnatal care (healthy practices and illness detection) including cord care**
Thermal care including kangaroo mother care Oral antibiotics: case management of severe neonatal
infection** Injectable antibiotics: case management of severe
neonatal infection Full supportive care: case management of severe
neonatal infection**
IMCI and community based child care
Use of improved water source within 30 minutes Use of water connection in the home Improved sanitation - Utilization of latrines or toilets Hand washing with soap**
12
Packages Interventions included within Packages Hygienic disposal of children's stools Insecticide treated materials or indoor residual
spraying ORS and zinc for treatment of diarrhea** Antibiotics for dysentery** Case management of pneumonia (oral antibiotics)** Promotion of exclusive breastfeeding till 6 month**
Expanded Nutrition Package
Exclusive breastfeeding till 6 month Calcium supplementation during preconception
period and pregnancy Balanced protein energy supplementation in
pregnancyΩ Multiple micronutrient supplementation** Vitamin A supplementation for children under 5** Preventive Zinc supplementation** Vitamin A for measles treatment Zinc for treatment of diarrhea
Expanded Immunization Package
Hib vaccine** Measles vaccine** DPT vaccination Rotavirus vaccine Pneumococcal vaccine
*Interventions applied to urban populations of Punjab, Sindh, Baluchistan and KPK ** Interventions tested in Pakistan in effectiveness settings Ω Intervention applied to rural population of all provinces
13
Web Appendix Table 3 a
Maternal lives saved by intervention Packages by residence Total
deaths Peri‐conceptual & post‐abortion
care
Expanded Antenatal Care Package
Childbirth & Immediate Newborn
Care
Expanded Nutrition Package
60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99%
Pakistan 15896 118 193 200 611 856 920 5835 7814 8180 74 209 251
Punjab 5186 0 0 0 156 220 237 1846 2439 2545 23 59 70
Urban 1280 0 0 0 46 65 70 478 651 682 2 13 16
Rural 3907 0 0 0 110 155 167 1368 1788 1862 21 46 54
Sindh 4715 118 193 200 229 323 347 1504 2056 2153 15 63 79
Urban 1347 118 193 200 93 133 143 293 456 478 0 17 24
Rural 3368 0 0 0 137 191 205 1211 1600 1675 15 46 56
Khyber 2155 0 0 0 46 65 70 812 1063 1115 3 14 17
Urban 404 0 0 0 23 33 35 114 144 149 0 5 7
Rural 1751 0 0 0 23 32 35 698 919 967 3 8 10
Baluchistan 3839 0 0 0 179 248 266 1672 2256 2367 32 72 84
Urban 808 0 0 0 70 97 104 315 527 563 3 19 24
Rural 3031 0 0 0 109 151 162 1357 1729 1804 28 53 60
Web Table 3 b Overall maternal lives saved by intervention Packages by socio-economic status (SES)
quintiles Total
deaths Peri‐conceptual & post‐abortion care
Expanded Antenatal Care
Package
Childbirth & Immediate Newborn
Care
Expanded Nutrition Package
60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99%
Quintile I 4960 165 199 203 225 313 335 1974 2447 2533 102 153 168
Quintile II 3990 164 199 203 124 173 186 1701 2147 2231 56 84 93
Quintile III 2829 52 66 68 106 148 158 1014 1325 1379 35 59 66
Quintile IV 2384 115 188 196 43 61 66 625 1100 1193 10 20 23
Quintile V 1733 18 64 68 69 98 106 245 726 812 5 22 26
14
Web Table 4 a Newborn lives saved by intervention Packages by residence
Total Deaths
Peri‐conceptual & post‐abortion
care
Expanded Antenatal Care
Package
Childbirth & Immediate Newborn
Care
Postnatal care (including community
Newborn Care)
Expanded Nutrition Package
60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99%
Pakistan 169000 355 1061 1283 854 2040 2449 69214 93662 98551 20037 19786 18947 11840 11959 12005
Punjab 64482 167 454 540 187 496 640 26993 36141 37948 6989 6914 6639 4838 4859 4867
Urban 17604 25 142 177 22 242 360 8163 11095 11617 1223 1224 1154 1000 1000 1000
Rural 46877 143 313 364 165 253 280 18829 25046 26331 5766 5690 5484 3838 3859 3867
Sindh 63174 62 295 375 363 821 959 25106 35248 37312 8310 8320 7951 4188 4275 4308
Urban 16095 0 107 148 45 85 97 5524 9249 9995 1819 1819 1694 1201 1201 1201
Rural 47079 62 188 226 317 736 861 19582 25999 27317 6491 6501 6257 2987 3074 3107
Khyber 24243 40 129 155 197 548 655 10558 13535 14116 2785 2695 2592 1401 1401 1402
Urban 6941 0 27 35 20 95 120 3395 4573 4803 747 662 611 303 303 303
Rural 17302 39 101 120 177 452 535 7164 8962 9313 2038 2033 1981 1097 1098 1098
Baluchistan 17101 86 183 212 108 175 196 6557 8739 9175 1952 1856 1766 1414 1424 1428
Urban 4124 6 32 39 21 31 35 1074 1890 2057 673 639 598 0 0 0
Rural 12977 81 152 173 87 144 161 5482 6848 7118 1279 1216 1168 1414 1424 1428
Web Table 4 b Overall newborn lives saved by intervention Packages by SES quintiles
Total
deaths Peri‐conceptual & post‐abortion
care
Expanded Antenatal Care
Package
Childbirth & Immediate Newborn
Care
Postnatal care (including community
Newborn Care)
Expanded Nutrition Package
60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99% 60% 90% 99%
Quintile I 45123 190 284 313 387 689 780 21433 26880 27997 5598 4873 4518 3424 3449 3459
Quintile II 42419 401 601 661 303 665 774 20621 25758 26779 4445 3885 3604 2923 2947 2956
Quintile III 35490 247 417 468 154 410 486 16682 21980 23044 4020 3546 3275 2342 2362 2370
Quintile IV 26195 72 143 164 61 283 363 9096 14842 15953 2464 2417 2266 2242 2245 2246
Quintile V 19773 38 154 189 34 69 80 3870 10222 11479 1904 2107 2002 906 909 909
15
Web Table 5 a Post neonatal lives saved by intervention Packages by residence
Web Table 5 b Post neonatal lives saved by intervention Packages by SES quintiles
Total Deaths Postnatal care (including community
Newborn Care)
Expanded Nutrition Package
Expanded Immunization Package
60% 90% 99% 60% 90% 99% 60% 90% 99%
Quintile I 53985 10398 15112 16084 1544 1140 869 1585 3964 4678
Quintile II 50691 8538 14033 15198 1239 880 674 393 2025 2514
Quintile III 38064 3774 7120 7799 773 704 550 0 1013 1378
Quintile IV 24156 1922 4075 4547 418 469 371 0 460 728
Quintile V 16104 943 2623 2992 239 289 241 0 122 220
Total Deaths Postnatal care (including community Newborn
Care)
Expanded Nutrition Package
Expanded Immunization Package
60% 90% 99% 60% 90% 99% 60% 90% 99%
Pakistan 183000 12618 27640 30966 5583 4226 3258 2405 7954 9664
Punjab 62588 3170 7902 9212 1871 1771 1414 136 1717 2219
Urban 14552 609 1594 1945 645 654 534 0 440 600
Rural 48036 2561 6308 7267 1226 1117 880 136 1277 1619
Sindh 63876 5545 11293 12417 2116 1380 1042 1578 3892 4591
Urban 12363 668 1867 2145 492 373 282 0 479 628
Rural 51513 4877 9426 10273 1624 1008 760 1578 3413 3963
Khyber 26014 1450 3362 3775 657 458 346 283 1151 1414
Urban 5795 144 542 643 182 135 101 0 275 360
Rural 20219 1306 2819 3132 476 323 245 283 876 1054
Baluchistan 30521 2454 5083 5561 939 617 456 408 1196 1440
Urban 5280 172 577 694 199 169 124 1 182 244
Rural 25241 2282 4506 4868 740 448 332 407 1014 1196
16
Webappendix figure 8
Maternal (8a), neonatal and post-neonatal (8b) lives saved by cause and socio-economic status
0 200 400 600 800 1000 1200 1400 1600 1800
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Hemorrhage
Hypertensive diseases
Sepsis Infection
60%
90%
99%
17
0 5000 10000 15000 20000
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
Quintile I
Quintile II
Quintile III
Quintile IV
Quintile V
NN‐Birth asphyxia
NN‐Preterm
birth
complications
Neonatal Infections
Diarrhoeal diseases
Pneu
monia
60%
90%
99%
