A GLOBAL assessment published by Unicef in February highlighted that a baby born in Pakistan is 50 times more likely to die in its first month than a baby born in Iceland, Japan or Singapore. One newborn out of every 22 in Pakistan dies within the first month, meaning 46 out of 1,000 newborn babies die within the first month of their life.
In contrast, India, which has similar sociocultural factors to those existing here, has a corresponding newborn mortality rate of 25 per 1,000 newborns. According to the report, Pakistan’s survival rate of newborns is ostensibly worse than many countries having compromised economies as well as weaker health infrastructure.
A critical factor responsible for the high newborn deaths is the poor state of maternal health and nutrition, especially during pregnancy. Pakistan’s stunting rate (ie children shorter than normal for that age) which is an indicator of chronic undernutrition, is one of the highest in the world. Girls who are malnourished as children grow up and become pregnant, not having received any dietary rehabilitation to correct this deficit.
This then leads to adverse consequences for the pregnant mother, newborn baby as well as a household’s overall well-being. Limited resources due to widespread poverty, combined with a lack of understanding that pregnant women need nutritious diets along with micronutrients leads to poor weight gain of pregnant women. Thus, malnourished women give birth to babies who are small and weak — increasing their likelihood of dying in the face of otherwise minor illnesses.
Interventions to reduce newborn deaths include those focusing on the nutritional health of girls and women.
The second key factor responsible for the high neonatal deaths is the poor provision of available obstetric care. Delivering in a health facility is generally considered safer as compared to delivering at home. However, according to the Pakistan Demographic and Health Survey (PDHS) of 2012-13, at least half of the births in our country are at home. Only 52pc of our births are assisted births, with the help of a skilled birth attendant, while the rest are not supervised by any trained person. The ability to care for the newborn is very limited in the home settings, with no access to immediate life-saving obstetrical procedures, otherwise provided at good health facilities. Examples of such critical services include obstetrical surgical interventions to safeguard both maternal and foetal lives as well as provision for subsequent neonatal resuscitation.
There are also major challenges within the healthcare facilities that provide obstetric care in Pakistan. Most of the private-sector obstetric facilities are concentrated in urban areas, and operate on a business model that prefers high volume of low-complexity cases. They do not invest adequately in the infrastructure and personnel to deal with labour complications and advanced neonatal care. In case of any last-minute complications related to the mother or the baby, they bank on referring the case to public-sector facilities. However, very few public-sector facilities are capable of dealing with these complicated cases, and those able to are overburdened by the magnitude and complexity of urgent cases coming their way, both from the private sector and failed attempts at assisted or otherwise unsupervised home-based deliveries.
While these two factors are critically important, they still do not explain why Pakistan’s newborn mortality rate would be higher than any of the other countries listed in the top 10 of Unicef’s list. Especially puzzling is the fact that this report comes at a time when other indicators like rates of institutional delivery, skilled birth attendance and Caesarean section have progressively improved, particularly in Punjab and KP as shown by recent provincial health surveys. Unicef estimates seem to be based largely on the findings and trends of both the 2006 and 2012-13 PDHS, and there are some fundamental differences in these two surveys with how a baby’s death has been defined and classified. We clearly need more robust data to make better-informed estimates of the number and causes of newborn deaths, ideally with district-level specificity.
There are probably additional factors in Pakistan that need scientific exploration such as cousin marriages which increases the risk of genetic disorders in subsequent generations. According to the 2012-13 PDHS, half of all marriages in Pakistan occur between first cousins. The burden of genetic disorders due to cousin marriages and its impact on the overall newborn and maternal mortality burden is currently unknown in Pakistan.
Moving forward, it seems that other than conducting research regularly, interventions most likely to reduce newborn deaths in Pakistan include those focusing both on the general and nutritional health of girls and women. It is important that this be done across the board to make certain that no female child is left behind. This can be done by ensuring that during her infancy a female child is not malnourished, during adolescence every girl is provided adequate nutritional resources for herself as well as to cope with the added requirements of pregnancy so that she gets adequate diet for two, and after childbirth so she is able to provide adequate nutrition and immunity to the newborn via breast milk. All deliveries should be in the presence of a skilled birth attendant. The health facilities need to be upgraded, with networks and services being brought closer to the people, rather than expecting people to bring the delivering woman in obstructed labour or a sick newborn all the way to the tertiary care public sector facilities of large urban areas.
Prevention, prompt diagnosis and correct treatment of illnesses in newborns are equally important, and must be given due importance in parallel to efforts focusing on women’s health. Although the government bears the primary responsibility for public health, the developmental sector, the academic institutions and civil society also need to prioritise this issue of women and girls health. Ignoring girl and women’s health any further literally threatens the future of our very nation.
The writer is the associate dean of research and associate professor of pediatrics at the Aga Khan University.
Published in Dawn, May 21st, 2018