PRB

(December 2007) With continuing political turmoil, emergency rule declared, and concerns about how free and fair January elections will be, Pakistan has been under the spotlight recently. But the political arena isn’t the only area where challenges persist.

Beneath the surface, more problems are brewing in the sixth most populous country in the world. Some of the challenges are fueled by the country’s rapidly growing population, which is making increasing demands on social services, especially the health care system.

A comparison of population pyramids reflects how Pakistan has grown and how its needs will multiply (see below). Between 1970 and 2000, Pakistan more than doubled in population to 144 million from 60 million. Its population ages 15 to 49 more than tripled to 68 million from 14 million. As the number of people in that age group rose, so did demand for maternal and child health care. And health care needs are likely to grow as the 2025 projection for those ages 15 to 49 rises to 121 million, nearly double the 2000 estimate.¹

Pakistan’s Population by Age and Sex, 1970, 2000, and 2025

Source: UN, World Population Prospects: The 2006 Revision Population Database; and U.S. Census Bureau, International Data Base (online).

Advances in Child and Maternal Health

Data from Pakistan suggest that some progress in child and maternal health was made between the 1990-1991 and 2006-2007 rounds of the Demographic and Health Surveys.² By 2007, nearly half of infants (47 percent) had been immunized with five recommended childhood vaccinations by age 12 months.³ In 1990, only 22 percent received the recommended vaccines. And by 2007, most mothers surveyed (61 percent) had at least one antenatal care visit with a health professional, up from 30 percent. One in three babies born were delivered at a health facility by 2007, up from 13 percent in 1990-1991.

Room for Improvement

But much still needs to be done. Each year, an estimated 400,000 infants die and nearly 16,500 mothers die from pregnancy-related causes.⁴

Furthermore, while the infant mortality rate dropped from 91 infant deaths per 1,000 live births to 78 deaths per 1,000 between 1990 and 2007, it is still high by world standards. Pakistan’s infant mortality rate is well above the world average of 52 infant deaths per 1,000 live births and the infant mortality rate of 57 in all less developed countries. The average infant mortality rate is 6 deaths in more developed countries.⁵

Missing the Target

A comparison of United Nations-recommended safe motherhood targets and data from one district in Pakistan offer an even more stark contrast between the World Health Organization (WHO) recommendations and the reality of public maternal health care services.

In Pakistan’s Multan District, 14 percent of women admitted to a health facility with serious obstetric complications died in 2003. That case fatality rate is far higher than the UN’s guidelines for safe motherhood, which recommends countries lower their maternal case fatality rates to less than 1 percent. The high death rates for obstetric complications in Multan District are related to two factors: severity of complications at the time of admission and deficient quality of care at the facility. Caesarean deliveries also fell short as a share of all births that can be expected to require surgery. Following UN guidelines, between 5 percent and 15 percent of all births require an operation to address complications. In Multan District, only 2 percent of births were by Caesarean.⁶

What’s behind the poor performance? While the UN recommends that all women with obstetric complications deliver at emergency obstetric care facilities, in Multan District, that happened in only 23 percent of cases.⁷

Even when women make it to facilities that should be equipped to handle basic maternal health needs, supplies, drugs, and equipment are often lacking. Essential supplies such as ferrous sulfate and folic acid (to prevent anemia in pregnant mothers) should have been available at all facilities, but often were not. Two facilities that serve between 100,000 and 300,000 people did not have basic newborn equipment, including baby scales, fetal stethoscopes, or bulb syringes. This equipment was more often available at the smaller facilities.⁸

Another shortcoming was inadequate knowledge and skills for managing obstetric complications, according to a study that assessed health provider competency. Although most nurses’ scores for physical examination for preeclampsia were good, their management scores tended to be poor. Nurses also did not score well on knowledge surrounding high risk labor.⁹

Given that the lower levels of the health care system in Pakistan are neither adequately staffed nor equipped, what would it take to improve service delivery and reduce the maternal and infant mortality rates? Fariyal Fikree, a physician and the technical director of health communications at the Population Reference Bureau, says at least three things are needed: “More midwives need training that will give them knowledge and skills. They also need more basic functional equipment and a constant flow of supplies at the local level.”

A better-equipped and more-skilled staff could have a ripple effect, she says. “If something as basic as ferrous sulfate and folic acid were available to pregnant mothers, the news would spread about better quality of care. Women would be more likely to go to their local health centers if they knew in advance that they will get the treatment they need.”

Sandra Yin is associate editor at the Population Reference Bureau (PRB). Dr. Fariyal Fikree is PRB’s technical director of health communications. This article is adapted from her briefing in November 2007 to members of the U.S. Congress on instability in Pakistan.

PowerPoint Presentation: Pakistan’s Health Status: Past, Current and Future (PPT: 306KB)

• Burden of Disease
• Age Pyramid—2000 (ages 15-49)
• Age Pyramid—2025 (ages 15-49)
• Family Planning Trends: 1990-2007
• Child Health Trends: 1990-2007
• Maternal Health Trends: 1990-2007
• Age Pyramid—2000 (ages 35-74)
• Age Pyramid—2025 (ages 35-74)
• Imploding Health Care Needs: Noncommunicable Diseases and Injuries
• Health Deliver System: Integrated Rural Health Complex
• Meeting United Nations Standards for Safe Motherhood; Multan District, 2003
• Health Systems Constraints: Infrastructure and Resources

Pakistan at a Glance, 2007

*Infant mortality rate is the number of deaths of infants younger than 1 per 1,000 live births.
**Total fertility rate is the average number of children born to a woman during her lifetime.
Source: C. Haub, 2007 World Population Data Sheet.

References

1. 1970 pyramid: United Nations, World Population Prospects: The 2006 Revision Population Database, accessed online at http://esa.un.org on Nov. 14, 2007; and 2000 and 2025 pyramids: U.S. Census Bureau, International Data Base, accessed online at www.census.gov, on Nov. 14, 2007.
2. National Institute of Population Studies (NIPS) and IRD/Macro International Inc., Pakistan Demographic and Health Survey 1990/1991 (Columbia, MD: IRD/Macro International Inc., 1992); and National Institute of Population Studies and Measure DHS, Pakistan Demographic and Health Survey 2006-07: Preliminary Report (Calverton, MD: Macro International Inc., 2007).
3. The infants were immunized against tuberculosis, measles, and with three doses of diphtheria/pertussis/tetanus (DPT) and polio vaccines by age 12 months, following the global standard set for developing countries.
4. Fariyal F. Fikree, Sadiqua Jafarey, and Jehan Ara Pal, “Maternal Mortality,” in Maternal and Infant Mortality: Policy and Interventions, report of an international workshop at the Aga Khan University, Karachi, Pakistan, Feb. 7-9, 1994; and UNICEF, The State of the World’s Children 1994 (New York: Oxford University Press, 1994): tables 1 and 7.
5. NIPS and IRD/Macro International Inc., Pakistan Demographic and Health Survey 1990/1991; NIPS and Measure DHS, Pakistan Demographic and Health Survey 20006-07: Preliminary Report; and Carl Haub, 2007 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2007).
6. Fariyal F. Fikree, Ali M. Mir, and Inaam-ul Haq, “She May Reach a Facility but Will Still Die! An Analysis of Quality of Public Sector Maternal Health Services, District Multan, Pakistan,” Journal of the Pakistan Medical Association 56, no. 4 (2006): 156-63.
7. Fikree, Mir, and Haq, “She May Reach a Facility but Will Still Die!”
8. Fikree, Mir, and Haq, “She May Reach a Facility but Will Still Die!”
9. Fikree, Mir, and Haq, “She May Reach a Facility but Will Still Die!”