Reproductive Health Scenario of Pakistan: Where We Are and What Should We Be Doing?

1. Reproductive Health Scenario of Pakistan: • Where We Are and What Should We Be Doing? • Dr Ali MohammadMir • February 14, 2013

2. 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)

3. Pakistan’s Scorecard– A brief overview • 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 • 250,000-300,000new cases of TB every year. • HIV prevalence high rates in populations most-at-risk especially injecting drug users and male sex workers.

4. 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

5. What is our current agenda: Achieving the MDGs • 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

6. Goal 4: Reduce Child Mortality

7. Reducing Maternal Mortality Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

8. Why are we lagging behind?

9. Major Causes of Newborn Deaths

10. Malnutrition among < 5 Children by Province

11. Maternal Tetanus Toxoid Coverage Source: PDHS 2006-07

12. Measles Immunization Coverage Source: Pakistan Social and Living Standard Measurement Survey 2010-11

13. What should we be doing about it?

14. Longer Birth Intervals Reduce Child Mortality Source: PDHS 2006-07

15. 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

16. 2:223

17. Goal 5: Improve Maternal Health

18. Maternal Mortality Trend, 1990-2015

19. Reducing Maternal Mortality Source: Pakistan MDGs report 2010, Planning Commission, Govt of Pakistan

20. Why are we lagging behind?

21. Maternal Mortality Ratio by Province: Disparity and Inequity

22. Causes of Maternal Deaths in Pakistan Source: Pakistan demographic and health survey, 2006-07

23. Trend in TFR and CPR *Source: MDGs Report Pakistan 2010 *Source: MDGs Report Pakistan 2010

24. Placement of Services Basic Emergency Obstetric and Newborn Care Services Jhelum District

25. Placement of Services Comprehensive Emergency Obstetric and Newborn Care Services Jhelum District

26. Non Functional Services Due to Shortage of Staff Female ward locked Blood Bank non functional due to absence of B.T.O

27. Tertiary Care Crunch Tertiary care facility with doubling of patients THQ Hospital with vacant female beds

28. Vacant Positions By Province

29. 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.

30. One of the most cost effective ways of reaching MDGs 4 and 5 is raising contraceptive prevalence 35% Reduction in Fertility (alone) will Reduce Maternal Mortality by at Least One Thirds Current Scenario Increasing SBA to 50% 276 Scenario 1 Increasing fertility by 1 child 237 Increasing SBA + lowering fertility Scenario 2 Scenario 3 182 156 GFR = 135 Skill birth attendance 50% GFR = 135 Skill birth attendance 39% GFR = 100 Skill birth attendance 35% GFR = 100 Skill birth attendance 50%

31. 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

32. Goal 6:Combat HIV/AIDS, Malaria and TB

33. 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

34. THANKS!