Tuesday, February 20, 2018

How Can Pakistan Reduce High Rates of Infant Mortality?

Of every 1,000 babies born in Pakistan, 45.6 die before the end of their first month – 1 in 22, the highest infant mortality rate in the world, according to a United Nations Children's Fund report titled "Every Child Alive: The urgent need to end newborn deaths".   Pakistan’s newborn mortality rate has declined by less than one quarter, from 60 in 2000 to 46 in 2016, according to UNICEF.

Highest Contributors to Newborn Deaths Source: UNICEF
Worst Countries:

Of the 2.6 million newborn dying each year worldwide, India tops with 24% share followed by Pakistan with 10%. Ten countries, Bangladesh, Ethiopia, Guinea-Bissau, India, Indonesia, Malawi, Mali, Nigeria, Pakistan and Tanzania account for more than half of the world’s newborn deaths, according to the report.  Four of these 10 countries are in South Asia while the rest are in sub-Saharan Africa.

The percentage of mothers in Pakistan who gave birth in a health facility increased from 21 per cent to 48 per cent between 2001 and 2013, and the proportion of women giving birth with a skilled attendant more than doubled, from 23 per cent to 55 per cent over the same period. But despite these remarkable increases, largely the result of rapid urbanization and the proliferation of private sector providers not subject to satisfactory oversight, Pakistan’s very high newborn mortality rate fell by less than one quarter, from 60 in 2000 to 46 in 2016, according to UNICEF.

The report says that more than 80 per cent of newborn deaths can be prevented "with access to well-trained midwives, along with proven solutions like clean water, disinfectants, breastfeeding within the first hour, skin-to-skin contact and good nutrition."

Community-Based Health Care:

How can Pakistan increase the number of childbirths in the presence of skilled attendants? The best option appears to be a skilled midwives program along the lines of the Lady Health Workers (LHW) program that is considered effective in delivering health education and care to women in remote villages.

“It (LHW) is one of the best community-based health systems in the world,” said Dr. Donald Thea, a Boston University researcher, talking about Pakistan's Lady Health Workers Program. Thea is one of the authors of a recent Lancet study on child pneumonia treatment in Pakistan. He talked with the New York Times about the study.

Published in British medical journal "The Lancet", the study followed 1,857 children who were treated at home with oral amoxicillin for five days and 1,354 children in a control group who were given standard care: one dose of oral cotrimoxazole and instructions to go to the nearest hospital or clinic. The home-treated group had only a 9 percent treatment-failure rate, while the control group children failed to improve 18 percent of the time.

Community Midwives: 

In response to the low levels of skilled birth attendance in rural Pakistan, the government has introduced a new cadre of community midwives (CMWs).

In 2008, Pakistan extended community-based health system with the introduction of an 18-month training program for community midwives. Then, in 2014, United Nations Population Fund – together with the Department of Health and Sindh Province’s Maternal, Newborn and Child Health program – launched a pilot effort to supplement the midwifery courses with hands-on training. Midwifery coaches visited the midwives’ clinics, offering guidance and mentorship, according to UNFPA. So far, over 300 midwives have benefitted from the coaching and mentorship program.

The Sindh UNFPA model needs to be scaled up across the country with the help of the federal and provincial governments in Pakistan. 


Pakistan is the riskiest country for newborns. Of every 1,000 babies born in Pakistan, 45.6 die before the end of their first month – 1 in 22, the highest infant mortality rate in the world, according to a United Nations Children's Fund report titled "Every Child Alive: The urgent need to end newborn deaths".   Pakistan’s newborn mortality rate has declined by less than one quarter, from 60 in 2000 to 46 in 2016, according to UNICEF. The country's progress in reducing infant mortality rates has been very slow. There is an urgent need to improve the situation by by scaling up community-based midwife programs nation-wide.

Related Links:

Haq's Musings

Pakistan Lady Health Workers "Best in the World"

Premature Death Rates in Pakistan

Hardware (Infrastructure) Prioritized Over Software (Education/Health) in Pakistan

Disease Burdens in Pakistan

Human Development in Pakistan

Riaz Haq's Youtube Channel


Z Basha Jr said...

good that we r doing better than India.. but worse than Afghanistan and Bengali ?!?!

Riaz Haq said...

ZB: "good that we r doing better than India.. but worse than Afghanistan and Bengali ?!?!"

No, Pakistan is not doing better than India in terms of deaths per 1000.

As to Afghanistan and Somalia, I think the data is highly suspect from such jurisdictions where there is no really functioning state.

Ras S. said...

By distributing free condoms?

The birth rate is alarming.

Riaz Haq said...

Ras: " By distributing free condoms? The birth rate is alarming."

The data shows that the birth rate is declining as are the infant mortality rates in Pakistan.

The trend is right but it needs to be accelerated by focusing on health care delivery to remote villages through programs like LHW, MCHIP etc.


Maternal, Newborn and Child Health (MNCH) Service Component 2 of the United States Agency for International Development (USAID)/Pakistan’s Maternal and Child Health (MCH) Programme, implemented under the flagship of the Maternal and Child Health Integrated Program (MCHIP),has made significant strides in mobilizing communities for family planning services using Lady Health Workers (LHWs)

The LHW program was established in 1994 by the government with the aim of providing basic health and family planning services to rural communities at their doorstep. mchip realized that the LHW program was being underutilized, as a number of issues plagued the programme, including high dropouts and lack of trained professional LHWs.

As such, mchip launched a series of essential trainings in an attempt to build the capacities of LHW’s for more efficient and effective functioning. 15,230 LHWs were trained in various packages around Maternal and Neonatal health care.

As part of the training program, mchip prepared comprehensive information, education and communication (IEC) material for LHWs, to be used during their community support group (CSG) sessions. CSG sessions covered a number of themes including Iron Folic Acid (IFA), nutrition, breastfeeding, and hygiene. These LHWs are now conducting CSGs on monthly basis in their catchment areas. Additionally, LHW’s were given a “Mother’s booklet” for dissemination. This book is an initiative to educate mothers through pictures and culturally sensitive messages. As these mothers cannot read, messages are communicated through pictures to educate them on maternal and child health and hygiene, pregnancy care and the importance of healthy timing and spacing of pregnancy. These LHW’s were also tasked with providing basic preventative and family planning services at doorstep.

A key challenge however, was a lack of resources and remote geographical access that hindered efficient and effective performance of Lady Health Supervisors (LHSs). mchip overcame these issues by fixing 25 out of order vehicles in the district of Tharparkar, so that LHSs could perform their duties with maximum efficiency. However, in areas not covered by LHWs, mchip implemented community outreach activities through community health workers (CHWs).

MCHIP has also organized a number of advocacy events to disseminate important maternal, newborn and child health (MNCH) messages and information about availability of services at the nearest facility, in different communities.

Anonymous said...

Dear Basha: there is a reason why "per 1000" is universally considered as the golden yardstick for comparison across countries which have different population size. As Riaz has already pointed out, on that count, Pak is significantly worse than India.

Saif said...

You are wrong about Afghanistan in this regard. All tribal groups council follow Naamus and Khegara which alllow medical midwifery across tribal areas since 2003. This has resulted in benefits.

Riaz Haq said...

Saif: "You are wrong about Afghanistan in this regard."

Afghanistan's socioeconomic indicators are comparable to Pakistan's tribal region which are the worst in Pakistan due to war since 911.


In any event, the UNICEF report acknowledges uncertainty in data for each country by providing a range along with the midpoint.

The range for Pakistan is 33 to 61 deaths per 1000 live births

For Afghanistan, it is 31 to 49.

The reality could be anywhere in the range provided.


nayyer ali said...

The data presented is numbers for newborn mortality (deaths per 1000 births in first 30 days of life). Infant mortality is presented as deaths per 1000 births in first year of life. Pakistan has always had relatively high infant mortality going back to 1950. I'm not sure what the reasons are, other than social and cultural factors. Between 1950 and 2016 infant mortality in Bangladesh fell from 220 to 33 per 1000, in India from 186 to 41, and in Pakistan from 255 to 70. All countries have had sharp declines but Pakistan lags. For comparison, Singapore dropped from 60 to 2. The biggest interventions would be vaccinations, clean water, and prenatal care, along with antibiotics for early infections. Pakistan should set a goal of reducing infant mortality to less than 20 by 2030, which is achievable, if the government made it a priority.

Riaz Haq said...

Community Outreach Program: Oral Health Based Education
Dental Team from Ziauddin College of Dentistry, Visits School


The department of Community & Preventive Dentistry, Ziauddin College of Dentistry in collaboration with Colgate Palmolive, organized a Community School Health trip on 26th January 2018, at Bahria Foundation Schools, to address the oral health needs of children from marginalized population.

The trip was lead by Dr.Sidra Mohiuddin (Assistant Prof & HOD), along with trained and calibrated lecturers of the department, Dr. Atiya Abdul Karim, Dr. Khizra Rehman ans Dr. Abeeha Zaidi.1

The aim of this community health based trip was to spread awareness amongst students and school teachers, regarding the importance of oral hygiene and its maintenance.

Free Dental check-ups were performed by students of 2nd year BDS(batch VIII), following World Health Organization’s Guidelines for oral examination in children (2013).

In addition to this, students of 2nd year BDS prepared posters based on oral health education and performed brushing techniques in front of the children to educate them in an effective manner.

At the end of the oral screening, an interactive session was held for the school teachers by Dr. Sidra Mouhiuddin (HOD-Community and Preventive Dentistry), during which, dissemination of oral health awareness via teachers, among their students was discussed. This area of discussion was stressed upon, as the teachers spend good 6 to 8 hours every day with their students.

The school administration was satisfied7 with the overall arrangements and services offered by Ziauddin College of Dentistry’s dental team.

As the day ended, kits inclusive of toothbrushes and toothpastes, by Colgate were distributed among school children in order to promote brushing habits and over all oral hygiene maintenance.

Riaz Haq said...

How #Bangladesh Drastically Cut Its Newborn Death Rate. What Can #India and #Pakistan Learn From it? #health #children


There were some glimmers of good news in an otherwise grim report released by UNICEF this week documenting the alarmingly high death rate of newborns worldwide: Bangladesh has managed to cut its newborn mortality rate from 64.2 deaths per 1,000 live births in 1990 to 20.1 per 1,000 today. That's 1 in every 50 births. By comparison, in neighboring Pakistan (which has the worst odds of any country) 1 in every 22 newborns doesn't survive.

For a country as populous as Bangladesh that success has translated into a staggering number of lives saved. In 1990 241,000 newborns did not live through their first month. By 2016 that figure was down to 62,000.


Mannan says a key factor was reducing the share of births that were taking place in homes instead of health-care facilities: "In 1990 about 90 percent of deliveries were happening in homes, basically just assisted by relatives [of the mother] who had no training."

Largely this was cultural, says Zaka. "If you look at all the countries in Asia it was pretty much the norm back then." There were also few birthing facilities available for people – particularly in rural areas. But even people who lived close by to a facility often eschewed it, says Mannan. "There were these beliefs that a woman should not expose herself to a male doctor."

As a result the most common cause of newborn deaths in Bangladesh back then was asphyxia — essentially a lack of oxygen brought on by obstructed labor. "When the labor is very prolonged and the woman is struggling alone at home there is often fetal distress," explains Zaka.

In fact this was even a problem in health facilities in Bangladesh – where medical staff often lacked the skills to ease the delivery or to revive a newborn.

But starting in 2010 the government of Bangladesh launched a multi-pronged effort to bring about change. Working with donor governments, including the United States, and international organizations such as UNICEF, Bangladesh trained workers at health centers on measures like infection control and resuscitation, opened many more facilities for childbirth – and just as important tried to convince families to use them.

Zaka says the effort was particularly helped by Bangladesh's "rich culture" of locally-based non-governmental aid groups including BRAC and the Grameen Bank. Both frequently partner with poor women. "There was a lot of [outreach] through those workers to promote better care [during delivery]," says Zaka. And today notes Mannan, only about 50 percent of births in Bangladesh are home deliveries.

Of course while that's a major improvement, it's hardly ideal. Zaka says one problem is that existing facilities are not open 24-7. "If there's a delivery at night, the facilities don't have the staffing to handle it."

Richard Khan said...

I am not sure about the figures, who collected them and what methodology was used. I suspect the infant mortality rate is much better than is suggested

Riaz Haq said...

Pakistan’s Gig Economy Helps Smash Obstacles To Women Working
In a country with one of the lowest rates of female participation in the labor market, the digital economy is enabling some women to become breadwinners


When 28-year-old Dr. Aqsa Sultan was nine months pregnant with her first child, she decided to leave her job at a cardiology institute in Pakistan’s port city of Karachi to be a stay-at-home mom.

But she felt a twinge of resentment watching her husband, also a doctor, go to work each day to treat patients. “I was going through an identity crisis,” Sultan says. “After a while, I got fed up and I wanted to do something to be back in the field.

Sultan found a way to practice medicine from home. DoctHERs, a telemedicine platform in Pakistan, connects unemployed or underemployed female doctors like Sultan to patients in remote areas. Despite having one of the lowest doctor-to-patient ratios in the world, pressure to prioritize families over careers means that around half of female medical school graduates never enter the workforce.

For those who do overcome myriad obstacles to practice medicine, many drop out of the labor force when they are married or have children. DoctHERs is “about them being able to participate in the workforce and feel a sense of autonomy,” says Asher Hasan, the organization’s co-founder.

Pakistan has one of the world’s lowest rates of female participation in the labor market — it is estimated only 25 percent of women over the age of 15 work. However, there are signs that technology is gradually transforming women’s participation in some areas of the labor force.

Pakistan accounts for 8 percent of the worldwide digital gig economy, trailing only India, Bangladesh and the United States. The rise of gig work (flexible, piecemeal jobs), say some experts, has provided many Pakistani women a foothold in the new digital economy, in some cases shifting women into the primary breadwinner role.

“The gig economy is a unique economic opportunity for women in Pakistan... allowing women to earn a living or access a service from the home when cultural constraints may not allow them to work outside the home,” says Saadia Zahidi, author of Fifty Million Rising: The New Generation of Working Women Transforming the Muslim World.

Sultan normally works in the evenings, when her husband can take over childcare. She selects the number of days and hours she works, and gets paid per video consultation. “They can switch their availability on and off,” adds DoctHERs’ Hasan. “They get to decide their own hours.”

Riaz Haq said...

Lancet Study: Non-infectious diseases cause early death in Pakistan


Pakistan has considerable control over infectious diseases but now struggles against cardiovascular diseases, diabetes and cancer as causes of early deaths, according to a new study published Thursday.

The Lancet Global Health, a prestigious British-based medical journal, reported that five non-communicable diseases — ischaemic heart disease, stroke, congenital defects, cirrhosis, and chronic kidney disease — were among the 10 leading causes of early deaths in the impoverished Islamic nation.

However, the journal said some of Pakistan’s work has resulted in an increase in life expectancy from 61.1 years to 65.9 over the past three decades. The change is due, it said, “to the reduction in communicable, maternal, neonatal, and nutritional diseases.” That’s still 7.6 years lower than the global average life expectancy, which increased over 30 years by 8% in women and 7% in men.

The study says “despite periods of political and economic turbulence since 1990, Pakistan has made positive strides in improving overall health outcomes at the population level and continues to seek innovative solutions to challenging health and health policy problems.”

The study, which was based on Pakistan’s health data from 1990 to 2019, has warned that non-communicable diseases will be the leading causes of death in Pakistan by 2040.

It said Pakistan will also continue to face infectious diseases.

“Pakistan urgently needs a single national nutrition policy, especially as climate change and the increased severity of drought, flood, and pestilence threatens food security,” said Dr. Zainab Samad, Professor and Chair of the Department of Medicine at Aga Khan University, one of the authors of the report.

“What these findings tell us is that Pakistan’s baseline before being hit by extreme flooding was already at some of the lowest levels around the globe,” said Dr. Ali Mokdad, Professor of Health Metrics Sciences at IHME. “Pakistan is in critical need of a more equitable investment in its health system and policy interventions to save lives and improve people’s health.”

The study said with a population approaching 225 million, “Pakistan is prone to the calamitous effects of climate change and natural disasters, including the 2005 Kashmir earthquake and catastrophic floods in 2010 and 2022, all of which have impacted major health policies and reform.”

It said the country’s major health challenges were compounded by the ongoing COVID-19 pandemic and last summer’s devastating flooding that killed 1,739 people and affected 33 million.

Researchers ask Pakistan to “address the burden of infectious disease and curb rising rates of non-communicable diseases.” Such priorities, they wrote, will help Pakistan move toward universal health coverage.”

The journal, considered one of the most prestigious scientific publications in the world, reported on Pakistan’s fragile healthcare system with the Institute for Health Metrics and Evaluation at the University of Washington’s School of Medicine. The study was a collaboration with a Karachi-based prestigious Aga Khan University and Pakistan’s health ministry.

The study also mentioned increasing pollution as one of the leading contributors to the overall disease burden in recent years. Pakistan’s cultural capital of Lahore was in the grip of smog on Thursday, causing respiratory diseases and infection in the eyes. Usually in winter, a thick cloud of smog envelops Lahore, which in 2021 earned it the title of the world’s most polluted city.