SDG’S AND MDG’S

ACHIEVEMENT BY PAKISTAN AND

WORLD COMMUNITY

BACKGROUND OF THE COUNTRY

Pakistan is the Land of the Indus River, which flows through the country for 2500 km from
the Himalayan and Karakoram mountain ranges to the Arabian Sea. Pakistan comprises a total
land mass of 796 096 km2. There are three main regions: the mountainous region in the north,
the enormous but sparsely populated plateau of Balochistan, and the Punjab and Sindh plains of
the Indus River along with its main tributaries. Pakistan is home to one of the earliest known human
civilisations, the Indus Valley civilisation, dating back at least 5000 years. Pakistan is located in
an area where South Asia converges with Middle East and Central Asia. The country has a 1046-
km-long coastline along the Arabian Sea and Gulf of Oman in the south, and is bordered by Iran
and Afghanistan in the west, India in the east and China in the northeast. The country is one of the
world‘s largest cotton producers, with cotton being one of its primary exports. Other significant
exports include rice, leather goods, sports goods, chemicals, manufactures, carpets and rugs.
Pakistan is administratively divided into four provinces (Punjab, Sindh, Khyber Pakh toonkhaw
and Baluchistan), the federal capital of Islamabad, and seven Federally Administered Tribal
Areas.1 Pakistan ranks 125th out of 168 countries (human development index of 0.490 in 2010)
according to the UNDP International Human Development Indicators.2 Although Pakistan‘s
human development indicators have somewhat improved, they still lag behind other countries in
the region (the average human development index of SouthAsia is 0.516).2 The rural and urban
economic disparities have increased, particularly in recent years. There is a wide variation of
terrain from the level farm lands of Punjab to the inaccessible mountainous areas in the north and
southwest. Nearly 70% of the population of more than 167 million live in rural areas. The health
establishment comprises 30 teaching hospitals, 900 secondary care hospitals and 560 primary care
facilities, called rural health centres (RHCs), besides 5000 basic health units (BHUs). There are
more than 900 Maternal and Child Health (MCH) Centres. Pakistan has 134 000 registered doctors,
65 000 nurses, 35 500 midwives and lady health visitors in addition to 96 000 lady health workers.

MATERNAL AND NEWBORN HEALTH STATISTICS

Pakistan is the sixth most populous country of the world with an estimated population of
170.96 million and is growing at 1.9% per annum (Government of Pakistan, 2007). About 5 million
pregnancies occur every year. Females constitute about 48% of the population and women of
reproductive age about 22%. Sixty percent of the population is under 25 years of age. The total
adult literacy rate is 57% (males 69% and females 45%). Pakistan has a fertility rate of
4.1 and a crude birth rate of 27.8 per 1000. The contraceptive prevalence rate (CPR) is 30% and
the unmet need for contraception stands at 25%. According to the recent Pakistan Demographic
and Health Survey 2006–7, Pakistan‘s maternal mortality ratio (MMR) is 276 per 100 000 live
births. As expected, it is much higher in rural areas and in provinces with rugged terrain. The
adolescent birth rate is 51 per 1000 women. About a fourth of women give birth at <18 years or
over 35 years of age and about 20% have more than four previous births. The estimated number
of maternal deaths per annum is 16 500. One million children die before the age of 5 while 16 000
die in the first month of birth.3,4 According to the Pakistan Demographic Health Survey (PDHS)
2006–7, the neonatal mortality rate is 54 per 1000 live births, infant mortality rate is 78 per 1000
live births and the under-5 mortality rate is 94 per 1000 live births. This implies that 432 000
deaths of under 5s and 248 170 neonatal deaths occur each year in Pakistan.3 The proportion of
fully vaccinated children between ages 12 and 23 months is 47%, whereas the proportion should
be more than 90% by 2015. We still need to amplify our government policies, health systems and
other sectors such as education to bridge the gap.

MILLENNIUM DEVELOPMENT GOAL TARGETS FOR PAKISTAN

A 42.9% reduction in maternal mortality is required to achieve the target figure of 140 per
100 000 by the year 2015. Similarly under-5s mortality rate remains the most important indicator
which needs special consideration to bridge the gap of 52% to achieve the target of 45. Regarding
universal access to reproductive health, CPR and unmet need for family planning stands at 30 and
25%. In the present circumstances of internally displaced persons and flood it seems unlikely that
Pakistan will attain these targets (Table 1).
Continuum of care Antenatal care According to the PDHS survey, 61% of mothers receive
antenatal care from skilled health providers, 1% of mothers receive prenatal care from a traditional
birth attendant, and 35% of women receive no antenatal care at all. Nevertheless there is a large
difference between urban and rural women.

Urban women are more than twice (48%) as likely to seek antenatal care compared with rural
women (20%).4 Younger mothers (<35 years) and those with first-order births are more likely to
receive antenatal care from a skilled health provider than older mothers or those with births of
order six and higher (50%).5 There has been a significant improvement over the past 10
years in the proportion of mothers who receive prenatal care from a skilled health provider,
increasing from 33% in 1996 to 61% in 2006–7.5 More than 28% of pregnant women make four
or more antenatal visits during pregnancy. The urban population has more tendency to have four
or more visits than the rural population. The median duration of pregnancy at the first prenatal care
visit is 4.2 months.5 The most common reasons reported for not receiving prenatal checkups are
lack of concern, problems of accessibility and costs of services.6 The PDHS shows that 60% of
women who had had a birth in the 5 years preceding the survey were protected against neonatal
tetanus, with more than half (53%) receiving two or more tetanus toxoid injections during the last
pregnancy.
Intrapartum care The percentage of deliveries that take place in a health facility has doubled
in the past 10 years, increasing from 17% in 1996 to 23% in 2000–17 to 34% in 2006–7.8 Eleven
percent of these deliveries are in the public sector health facilities and 23% in private facilities.
The rest, that is, over 65%, take place at home. Health facility deliveries in urban areas are over
twice (56%) as common as those in rural areas (25%). Delivery in a health facility also varies by
province, being lowest in Balochistan (18%) and highest in Sindh (42%). About two-fifths (34%)
of deliveries take place with the assistance of a skilled birth attendant (doctor, nurse, midwife, or
lady health visitor). Traditional birth attendants (TBAs) assist with more than half (52%) of
deliveries. The rest are by friends and relatives (7%) or lady health workers (1%). A tiny fraction
of births take place without any assistance at all. Deliveries in urban areas are twice as likely to
be assisted by a skilled health provider (60%) than births in rural areas (30%). Births in Sindh
province are most likely to be attended by a skilled health provider (42%)6 (Figure 1).

Postnatal care According to the PDHS survey, two-fifths (43%) of women received postnatal
care for their last birth, making it far less common than prenatal care (65%). More than a quarter
of women received postnatal care within 4 hours of delivery, 6% within the first 4–23 hours, 7%
within 2 days after delivery and 3% were seen within 3–41 days of delivery.
Almost three out of five reported that they did not have any postnatal check up. The
information about the type of postnatal care provider suggests that just over one-quarter (27%)
received postnatal care from a skilled health provider and 16% from a TBA. Mothers of first- order
births, mothers with higher education and those in urban areas received postnatal care from a
skilled health provider (Table 2).6 The most common postnatal complications were heavy
vaginal bleeding, postnatal eclampsia, sepsis and urinary or fecal incontinence. The number of
women living with fistula is estimated to be 1.69 per 1000 ever married women (EnGender Health,
Dhakha) with three per 1000 ever-married women who had ever given birth reported to have
experienced symptoms associated with urinary fistula. Less than half a percent of ever- married
women reported leaking stools from the vagina.6
Family planning The CPR of 30% is an increase from 12% reported by PDHS 1990–91.
Pakistan‘s CPR still remains among the lowest in the world. Women in urban areas are more likely
to use contraceptives (41%) than those in rural areas (24%). Knowledge of family planning in
Pakistan is nearly universal; 96% of ever-married and currently married women aged 15–49 years
know of at least one method of family planning. Modern methods are more widely known than the
traditional methods. Among currently married women, pills (92%), injectables (90%), female
sterilisation (87%), IUD (75%) and condoms (68%) are the most widely known methods of family
planning. The least known methods are emergency contraception, implants and male sterilisation.
Differences in the level of contraceptive knowledge between urban and rural areas are minimal.
Among provinces, women in Punjab and Sindh report the

Highest level of knowledge (97% each) followed by Khyber Pakhtoonkhaw (92%) and
Baluchistan (88%). Currently, about three-quarters of current users are using a modern method and
slightly more than a quarter are using a traditional method. The most widely used method is female
sterilisation (8%) followed by condoms (7%), withdrawal (4%) and the rhythm method (4%). The
IUDs, injectables and pills are used by 2% of married women. Use of male sterilisation and implants
is negligible. There has been a substantial increase in contraceptive use since the mid-1980s, with
some indication of a possible plateau in recent years (Figure 2). Contraceptive use increases with
women‘s level of education, from 25% among currently married women with no education to 43%
among those with higher education. In general, women do not begin to use contraception until they
have had at least one child, after which their use increases rapidly with increasing number of
children. Working women are more likely to practise contraception than those who are not working.
Family planning increases dramatically with wealth quintiles. The CPR increases from 16% of
currently married women in the lowest quintile to 43% of those in the highest quintile. Social
marketing plays an important role in provision of contraceptive methods in Pakistan. ‗Greenstar‘ and
‗Key‘ have been providing family planning information and services to urban and per-urban
residents at reduced rates.9 They are the exclusive family planning centres established since 1991
and 1996 respectively and they provide family planning information and services to urban and per-
urban residents at subsidised rates.
Newborn care Birth weights are reported in about 10% of cases only, as the majority of births
occur at home. Among these, 26% of babies are of low birthweight (i.e. <2.5 kg) and 31% are
reported to be small or very small at birth. The incidence of ‗small or smaller than average‘ babies
has increased from 22% in 1990–918 to 31% in 2006–7.10 The analysis shows that a higher
proportion of low birthweight babies are born to mothers younger than 20 years and older than 35
years of age than to mothers aged 20–34. First births and births of sixth and higher birth orders are
also reported to have higher proportions of low birthweights compared with second to fifth births.
The woman‘s education and wealth quintile are strongly associated with low birthweight babies.10
A majority (55%) of children under the age of 2 months are exclusively breastfed. This represents
a doubling from the 27% of children under 2 months who were exclusively breastfed in 1990–
91,11 which is an encouraging trend. Overall, 37% of infants under 6 months are exclusively
breastfed. The median duration of breastfeeding is slightly higher in the rural areas (19 months)
than in urban areas (18 months). Duration of breastfeedingdecreases as the level of education and
the wealth quintile of the mother increases.
Care for the under-5s Pakistan has the fourth largest number of under-5 deaths in the world:
one child dies every minute in Pakistan. Aside from neonatal disorders, diarrhoea, pneumonia and
malaria are the major causes of death of children under 5 worldwide.12 According to the PDHS
survey 2006–7, the major causes of under-5 mortality are pneumonia (25.7%) and diarrhoea
(26.9%). Other causes include sepsis, meningitis, congenital anomalies, severe malnutrition and
accidents. Evidence-based interventions to reduce post neonatal mortality include early
recognition of signs and symptoms and appropriate treatment. Institution of oral rehydration
therapy (ORT), exclusive breast feeding and proper hygiene helps prevent diarrhoeal diseases. The
Pakistan Expanded Programme on Immunisation (EPI) recommends that all children receive a
BCG vaccination against tuberculosis, three doses of DPT vaccine for prevention of diphtheria,
pertussis and tetanus, three doses of polio vaccine and a vaccination against measles during the
first year of life. In addition, three doses of hepatitis vaccine are also recommended. In addition to
routine immunisation, special days are observed to eradicate polio. About 5.1 million children are
vaccinated every year. It is estimated that 100 000 deaths due to measles, 70 000 due to neonatal
tetanus and 20 000 cases of polio are prevented each year. Forty-seven percent of children aged
12–23 months are fully vaccinated. The percentage of children who have been fully immunised
decreases with increasing birth order (52% for the first born to 42% for the sixth born or higher).
Girls are less likely than boys to have been fully immunised against the six preventable childhood
diseases (44% and 50%, respectively). Sincethe national immunisation programme does not
discriminate by gender in service delivery, these differences are presumably due to parental
discrimination in favour of boys. Immunisation
coverage varies substantially across provinces. Provinces with the highest coverage are Punjab
(53%) and Khyber Pakhtunkhwa (47%); Sindh (37%) and Balochistan (35%) have considerably
lower levels of full immunisation coverage.

CAUSES OF MATERNAL AND NEWBORN MORTALITY AND MORBIDITY

The maternal mortality rate in Pakistan is attributed to a high fertility rate, low skilled-birth
attendance, illiteracy, malnutrition and insufficient access to emergency obstetric care services.
Haemorrhage (32.7%), eclampsia (10.4%) and sepsis (13.7%) are the main direct causes of
maternal deaths (Figure 3). Poor quality of obstetric care services results in 8% of all maternal
deaths attributed to iatrogenic causes.2 Another 6% of maternal deaths are attributed to
complications of abortion (either sepsis or haemorrhage). Neonatal mortality contributes to two-
thirds of all deaths of under-5s. The major causes are birth asphyxia (41%) followed by prematurity
(18%) and sepsis (14%) (Figure 4). Similarly, pneumonia and diarrhoea are the two main problems
related to mortality of children under 5.

The three delays (delay in decision to seek care, delay in reaching care and delay in receiving
care) are considered to be the most important operational factors in the causation of maternal
mortality.13 Most rural areas lack emergency obstetric care facilities. Poor transportation and lack
of financial resources further complicate matters. Women often become pregnant without planning
in a less than ideal nutritional state. Pre-pregnancy anaemia is common. Lack of empowerment,
especially for rural women, results in seeking medical attention often when it is too late. Their lack
of nutritional reserve leaves very little margin of error for the health professional when faced with
a bleeding pregnant or recently delivered woman.14 The risk factors for perinatal death in
Pakistan include home delivery attended by a relative, a birth interval of <24 months, pregnancy
order >6 and maternal or paternal illiteracy. Most neonatal infections are acquired at the time of
delivery or shortly thereafter. In developing countries, they
are largely due to lack of immunisation of mothers with tetanus toxoid, unhygienic delivery, and
unhygienic cord care during the first week of life. High illiteracy rates among women and lack of
awareness about feeding practices, hygiene and access to safe water or adequate sanitation cause
infectious diseases in their children. Prematurity and low birthweights are common problems
prevalent in Pakistan and the situation has not changed over the last two decades.
National strategies to address Millennium Development Goals (MDGs) 4 and 5 Overview
of health policies A lot of effort is required to bridge the gap of 49.2% to reduce the maternal
mortality rate from 276 per 100,000 live births to 140 per 100,000 live births as determined bythe
MDG target of 2015. In order to achieve better maternal health, the proportion of births attended
by skilled health personnel has to rise more than 51% to meet the MDG target. We still need to
create awareness amongst women and convince them through media and other sources to attend
antenatal clinics to bridge the gap of 40% to achieve the MDG target. Over the last 60 years,
Pakistan has experimented with various approaches to address maternal health. This has consisted
of establishing first the MCH Centres and then the RHCs. Despite various programmes,
unfortunately, a cadre of properly trained midwives could not be created and the exercise of
training the TBAs failed miserably. Currently, improvement in the healthcare delivery system is
being tried through decentralised management. • 1950s: Introduction of MCH Centers, expansion
of midwifery training and introduction of lady health visitors. • 1960s: Increasing the number of
MCH Centres and lady health visitors and introduction of RHCs. • 1970s: Shift of emphasis
towards training of physicians at the cost of training lady health visitors, and decision to appoint
doctors in all basic health units. • 1980s: Construction of new health facilities in the rural areas;
training of large numbers of TBAs in safe and clean home delivery. • 1990s: Introduction of
community-based lady health workers; increasing availability of female healthcare providers and
increasing emphasis on safe motherhood initiatives andprogrammes. • 2000s: Attempts to improve
the healthcare delivery system with decentralised management and rehabilitation of the healthcare
infrastructure. The strategies to address MDGs4 and 5 are as follows: • Strengthening of district
health systems through improvement of technical and managerial capacity at all levels, and
upgrading institutions and facilities. • Strengthening of services for the provision of basic and
comprehensive emergency obstetric and newborn care (EmONC). • Integration of all services
related to maternal, neonatal and child health (MNCH) at the district level. Introduction of a cadre
of community-based skilled birth attendants. • Increasing demand for health services through
targeted, socially acceptable communication strategies.

PROGRAMMES AND POLICIES TO IMPLEMENT STRATEGY

A number of programmes have been undertaken in the last several years in both the public
and the private sector to improve the health status of mothers and newborn babies. These include
the Social Action Program in the 1990s, supported by the World Bank, and the Asian Development
Bank‘s Women‘s Health Project in the 2000s. The current 5-year National MNCH Programme
launched in 2007 will ensure training and deployment of the new cadre of community midwives.
The National Maternal, Newborn and Child Health Programme The UN joint programme
component on maternal, newborn and child health envisages strengthening the implementation of
the National MNCH Programme (2007–12) with a planned allocation of Rs.19.994 billion. This
initiative envisages close linkages with the National Programme for Family Planning and
Primary Health Care through its network of Lady Health Workers, the National EPI Programme,
the Nutrition Programme, the Ministry of Health and the Ministry of Population Welfare. Its
priority area is to develop comprehensive and integrated MNCH services at the district level.15
Other programmes include the following.16 • The Pakistan Initiative for Mothers and Newborn
(PAIMAN): This is a megaproject which is currently working on improving access and quality of
services, providing a continuum of care from household to hospital. It tends to create awareness,
knocking at the doors and engaging communities as partners. It aims to strengthen the health
system, which is a step towards integration. • Technical assistance for capacity-building in
midwifery, information and logistics (TACMIL Health project): This project aims to build the
capacity of the midwifery and nursing profession, to strengthen the contraception logistic system
and to provide targeted health information. • Family advancement for life and health (FALAH):
The goal of the FALAH project is to promote the adoption of birth spacing and the practice of
optimal birth spacing in selected districts of Pakistan by removing barriers, improving
understanding of the value of optimal birth spacing for family health and well-being, increasing
knowledge of methods of birth spacing, and improving access to and quality of care in both the
public and private sectors. Achievements to date Progress in MDG 4 by the National MNCH
Programme There has been a considerable improvement in the use of ORT and antibiotics for the
management of diarrhoea and pneumonia consecutively. Use of ORT has increased from 19% to
48% in the last decade and use of antibiotics for children with suspected pneumonia has increased
from 16% to 50% in the last 15 years. However, the prevalence of underweight children has been
stagnant, at around 40% from the 1990s, showing no reduction in the underlying cause of under-5
mortality. Recently, there has been some improvement in rates of exclusive breastfeeding (37%).
In order to improve newborn care, MNCH has trained more than 370 service providers in
integrated management of neonatal and childhood illnesses, 80 staff members have been trained
in early neonatal care (ENC) and 10 000 lady health workers have been trained in postnatal care.
MNCH is working to provide coverage for neonatal resuscitation and child care at all EmONC
facilities, establish well-baby clinics at all hospitals, strengthen EPI services, and provide regular
training on integrated management of newborn and childhood illnesses (IMNCI) and integrated
management of pregnancy and childhood strategy (IMPAC). Expected goals of the programme by
year 2012 are to provide comprehensive EmONC services in 214 hospitals and basic EmONC
services in 726 health facilities. It also plans to train 15 000 health facility staff in IMNCI, IMPAC
and early neonatal care.
Progress in MDG 5 by the National MNCH Programme The National MNCH Programme
has succeeded in establishing 76 District Headquarters and Tehsil Headquarters and 122 RHCs,
providing basic EmONC, and in training 4233 community midwives. Tetanus toxoid
immunisation coverage is 58% at present with a target of 75% by 2012 (Table 3). The MNCH
programme aims at deploying 12 000 community-based skilled birth attendants, organising 114
midwifery schools and strengthening the Pakistan nursing council and nursing examination boards.
It aims at providing comprehensive EmONC services in 214 hospitals and basic EmONC services
in 726 hospitals. MNCH looks forward to providing training in EmMOC, refreshers and
attachments at teaching hospitals. MNCH will facilitate the provision of comprehensive family
planning services in all health facilities and provide preventive services through 5046 BHUs.
CHALLENGES AND OPPORTUNITIES
The major constraints contributing to high MMR and infant mortality rate are a limited
number of skilled attendants, especially in rural areas, lack of training of health workers and a
shortage of equipment/medicines.

Major constraints faced by Pakistan in achieving MDGs 4 and 5 Pakistan is influenced by a

range of multi-sectorial factors including household and community behaviours and cultural norms
which are a big hindrance in achieving improved maternal and child health. Lack of women‘s
access to resources such as land, credit and education limits their engagement in productive work
and ability to seek health care. The low status of women denies them the power to make decisions
that affect their lives and is a significant barrier in improving maternal health outcomes among the
poor. Cultural norms and practices in our community have a strong influence on both health-
seeking behaviour and appreciation of the quality of the available services. High fertility is still
encouraged particularly in poor families in many societies where maternal mortality is still high.
Health system factors include low affordability by the majority of people of Pakistan, reduced
access to healthcare services and limited skilled human resources. In our part of the world, with a
high MMR, referral systems are weak and emergency coverage limited. Pakistan lacks appropriate
policies to improve girls‘ education, health services, transport and energy. The political
commitment to reach poor regions and provide safety nets, health insurance and risk pooling or to
provide free maternal and child services is lacking. The poor are disproportionately affected by
policy inadequacies, resulting in low levels of investment in maternal and child health services.17
Moreover, the catastrophic floods of 2010 affected around 40 million people, damaged more
than 1.2 million houses and rendered 8 million homeless. Among those affected 40% were women
of reproductive age and children under the age of five. This has rather significantly affected the
overall progress of implementing vital interventions for improving maternal, newborn and child
health in the years to come as it badly damaged the rural healthcare delivery infrastructure.
CONCLUSIONS
Pakistan faces enormous challenges in terms of achieving the MDGs 4 and 5 and fulfilling
thecountry‘s global commitment. Though Pakistan has made progress during the last couple of
decades towards achieving these health targets, the pace has been sluggish. Despite reductions
in the MMR and the infant mortality rate, Pakistan is lagging behind other developing countries
withrespect to these indicators. This is due to the interplay between various factors such as the
low societal status of women, poor nutrition, poverty, illiteracy, inappropriate health-seeking
behaviour, a poorly functioning health system, poor access to health services and a rapidly
growingpopulation. The disaster caused by the flood in 2010 has further compromised our aim
to achievethese targets and it seems very unlikely that MDGs 4 and 5 will be met by the year
2015