Pakistan’s recent surges in antenatal care, skilled birth attendance, care seeking for common childhood illnesses and immunization coverage are notable. However, slow reductions in mortality rates, combined with stagnant contraceptive prevalence rates, mean that the country is not on pace to achieve the Sustainable Development Goal targets by 2030, based on a synthesis of various data sources published by Health Services Academy, the National Ministry of Health Services Regulation and Coordination, and other Countdown to 2030 partner organizations. The report issues a call to action with 10 steps to accelerate progress for maternal, newborn and child health.

Countdown to 2030 partners presented the report, Improving Maternal, Newborn and Child Health Outcomes in a Decade, to federal and provincial government health leaders and development partners gathered in Islamabad and virtually on 15 March.

Dr. Nausheen Hamid speaks at the report launch event.

Dr. Nausheen Hamid, parliamentary secretary for health, said, “The report comes at a time when we have just finalised the [universal healthcare] package of essential health services for implementing at district level. [Reproductive, maternal, newborn and child health] interventions comprise almost half of this package. Progress in this area will be the make-or-break factor for success of the UHC initiative in Pakistan.”

The report analyses gaps and barriers for effective quality coverage of family planning (FP) and maternal, newborn and child health (MNCH) services, national and subnational surveys, facility surveys, routine health facility data, health system data and research findings.Nutrition and adolescent health will be analyzed in the 2021 report.

During the last few decades, fertility has been declining in Pakistan at a slow pace but slowed down during years 2013-2018 to an average annual rate of decline of 1.1% per year. Total fertility was 3.6 children per woman by 2017-18, fueling a continued rapid population growth and a relatively large proportion of higher risk deliveries.  The use of modern contraceptives in Pakistan remained low at 25% of currently married women, and the unmet need was 17% with high rates of abortion.

The maternal mortality survey has shown a decline in maternal mortality ratio from 276 in 2006-07 per 100,000 live births to 186 in 2019, corresponding to an average annual rate of reduction of 3.1%. Reaching the 2030 target of 70 per 100,000 live births would require more than a doubling of the rate of decrease in the next decade.

Under-five mortality has dropped steadily during the last two decades at an annual rate of decline just under 3% to 67 per 1,000 live births by 2019. However, 65% of all under-five deaths are now due to neonatal causes, and both neonatal mortality and stillbirth rates decreased slowly at an annual rate of reduction of only 2% in the last decade. Research has shown major gaps in the availability and quality of neonatal interventions. To fasttrack progress, attention is needed to ensure quality of care around the time of birth and to invest in small and sick newborn care.

Dr Rana Mohammad Safdar, Director General of the Health Ministry of National Health Services Regulation and Coordination, remarked, “For accelerating progress towards MNCH and FP targets, we need to transform the mindsets, re-engineer our district health system and analyse our data more frequently to do course corrections”

Call to Action

Based on this analysis, the reports’ authors conclude the ten priorities for action in the next ten years should be:

1. Improving RMNCH leadership and coordination mechanisms by strengthening technical working groups at national and provincial levels.
2. Developing RMNCH acceleration package including family planning for immediate scale-up.
3. Providing operational support to RMNCH acceleration package by UHC structures or RMNCH+N directorates with quality of care units to provide support for implementing evidence-based MNCH and FP standards
4. Harnessing the role of a strong private sector, already catering to two-thirds of the RMNCH needs. Partnerships with professional associations and health care commissions can provide leverage in this regard.
5. Targeting the poor, the rural and the un-educated is imperative for reducing the coverage disparities. Linking health sector efforts with poverty reduction, nutrition sensitive and social protection initiatives will bring efficiency and reduce duplication.
6. Resolving the serious health work force crises, nurse midwife ratio to population and attaining sufficient numbers of neonatologists and neonatal nurses.
7. Improving timely referral of complicated cases by expanding pooled ambulance services and linking district level facilities with pre-identified teaching hospitals. Laying out clear referral protocols and responsibilities at each level of health system is needed.
8. Digital innovations for improving data recording and reporting as well as improving LMIS and increasing awareness through mobile messaging.
9. Investing in research and information system for tracking effective quality coverage; accounting for the private sector; bridging data gaps for CRVS (Civil Registration and Vital Statistics); birth weight measurement, reporting of still births and standardized measures for determining quality of care and cohort tracking. Extensive investment is required to scale-up and streamline MPDSR and link these efforts with continuous quality improvement.
10. Developing inter-sectoral linkages for addressing the underlying risk factors of low female social status, malnutrition, air pollution and inadequate WASH behaviours.