Achieving Millennium Development Goals 4 and 5 in Pakistan

Abstract

Please cite this paper as: Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S. Achieving Millennium Development Goals 4 and 5 in Pakistan. BJOG 2011;118 (Supp. 2):69–77.

Pakistan is a signatory of many international development strategies including the Millennium Development Goals, and the government is committed to achieving a reduction in infant mortality rate from 72 to <55 per 1000 live births, the newborn mortality rate from 55 to <40 per 1000 live births and the maternal mortality rate from 276 per 100 000 to 140 per 100 000 live births by 2015. Maternal, newborn and child health play a key role in reducing poverty and promoting social and economic development. Improvement in maternal and child health is a priority agenda of the Government of Pakistan.

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 Pakhtoonkhaw 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 South Asia 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).

Table 1.   Country-specific targets for MDGs 4 and 5

	1990	2000	2006–2007 (PDHS)	2006 target (PRSP)	2010 target (MTDF)	MDG target (2015)	Gap (%)
MTDF, medium-term development framework; PRSP, poverty reduction strategy paper. Source: PDHS 2006–7; http://www.ddp-ext.worldbank.org/ext/ddpreports World Bank Group, 10 September 2008.
Millennium Development Goal 5
Target 5A: Reduce maternal mortality by three-quarters between 1990 and 2015
Maternal mortality ratio	550	350	276	350	300	140	49.2
Proportion of births attended by skilled health personnel	19	40	39	75	60	>90	>51
Target 5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate	15	30	30	41.7	51	55	25
Adolescent birth rate	69	–	51	–	–	–	–
Antenatal care coverage (at least one visit and at least four visits)	15	35	60	50	70	100	40
Unmet need or family planning (%)	32	–	25	–	–	–	–
Millennium Development Goal 4: Reduce child mortality
Under-5 mortality rate	130	105	94	80	77	45	52.1
Infant mortality rate	100	77	78	63	65	40	48
Proportion of 1-year-old children immunised against measles	50	53	47	82	90	>90	>43

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).

Figure 1.  Percentage of births delivered at a health facility, by residence, province and mother’s education (2006–7 PDHS, NIPS and Macro International).

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

Table 2.   Type or provider of first postnatal checkup

Background characteristic	Type of health provider of mother’s first postnatal checkup			No checkup	Total	Number of women
	Doctor/nurse/lady health visitor	Dai/TBA	Lady health worker/dispenser/compounder/other/don’t know/missing
Source: 2006–7 PDHS, NIPS and Macro International.
Mother’s age at birth
<20	23.4	15.3	0.3	60.9	100.0	460
20–34	29.0	16.1	0.7	54.3	100.0	4303
35–49	17.7	13.5	1.5	67.3	100.0	915
Birth order
1	35.9	13.1	0.6	50.5	100.0	965
2–3	32.8	14.0	0.7	52.4	100.0	1917
4–5	23.4	17.7	0.8	58.1	100.0	1389
6+	15.4	17.4	1.0	66.2	100.0	1406
Residence
Total urban	45.3	11.6	0.5	42.5	100.0	1714
Major city	56.9	6.5	0.3	36.3	100.0	909
Other urban	32.2	17.5	0.8	49.5	100.0	806
Rural	18.7	17.3	0.9	63.1	100.0	3962
Province
Punjab	25.1	14.4	0.5	60.1	100.0	3182
Sindh	37.1	21.4	1.5	40.0	100.0	1404
Khyber Pakhtoonkhaw	19.3	7.1	0.9	72.6	100.0	827
Balochistan	14.7	25.5	0.3	59.5	100.0	264
Education
No education	16.4	17.4	1.0	65.2	100.0	3668
Primary	31.5	16.9	0.5	51.1	100.0	854
Middle	43.3	14.0	0.3	42.3	100.0	353
Secondary	55.5	8.5	0.2	35.8	100.0	461
Higher	70.0	4.0	0.5	25.5	100.0	341
Wealth quintile
Lowest	10.3	19.6	1.6	68.5	100.0	1289
Second	13.7	16.6	0.4	69.2	100.0	1194
Middle	22.2	17.6	0.6	59.6	100.0	1099
Fourth	35.5	15.7	0.5	48.4	100.0	1066
Highest	58.1	7.2	0.6	34.1	100.0	1029

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.

Figure 2.  Trends in contraceptive use. PCPS, Pakistan Contraceptive Prevalence Survey; PDHS, Pakistan Demographic and Health Survey; PFFPS, Pakistan Fertilty and Family Planning Survey; PRHFPS, Pakistan Reproductive Health and Family Planning Survey; SWRHFPS, Status of Women, Reproductive Health, and Family Planning Survey. (2006–7 PDHS, NIPS and Macro International.)

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 breastfeeding decreases 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). Since the 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).

Figure 3.  Major causes of maternal mortality (2006–7 PDHS, NIPS and Macro International).

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.

Figure 4.  Major causes of early neonatal mortality (2006–7 PDHS, NIPS and Macro International).

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 by the 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 and programmes.

• 2000s: Attempts to improve the healthcare delivery system with decentralised management and rehabilitation of the healthcare infrastructure.

The strategies to address MDGs 4 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).

Table 3.   Present status of implementation by maternal, newborn and child health programme

	Current (2008)	Target (2012)	Achieved in 2 years (%)	Gap (%) for 3 years
No. of District Headquarter/Tehsil Headquarter hospitals	76	214	36	64
Rural health centres providing basic EmONC	122	662	18.5	81.5
No. of community midwives to be trained	4233	12 000	35.3	64.7
Percentage of tetanus toxoid immunisation coverage	58	75	83	17
Percentage of health facilities providing contraceptives	70 One method	100 Three methods	70	30

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 the country’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 with respect 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 growing population. The disaster caused by the flood in 2010 has further compromised our aim to achieve these targets and it seems very unlikely that MDGs 4 and 5 will be met by the year 2015 (Table 4).

Table 4.   Will the MDG 4 and 5 targets be reached?

	Unlikely	Potentially	No data
Target 5A: Reduce maternal mortality by three-quarters between 1990 and 2015
Maternal mortality ratio	✓
Proportion of births attended by skilled health personnel	✓
Target 5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate	✓
Adolescent birth rate	✓
Antenatal care coverage (at least one visit and at least four visits)	✓
Unmet need or family planning	✓
Target 4: Reduce child mortality
Under-5 mortality rate	✓
Infant mortality rate	✓
Proportion of 1-year-old children immunised against measles	✓

Disclosure of interests

None of the authors had any conflicts of interest.

Contribution to authorship

ZF, MG, JS, LR, SR contributed to the elaboration of the draft and revised and approved the final version.

Funding

None.

Acknowledgements

The authors wish to thank Dr Mariam Waqas for her input in researching and writing of the manuscript. We also acknowledge the contribution of the entire team of NCMNH for assisting us in compiling the draft.