Are We Measuring Correctly? A Way Forward for Improving Maternal and Newborn Health Surveillance in Pakistan
Globally, more than half a million women die each year from pregnancy-related causes, and almost all of those deaths occur in low- and middle-income countries. Pakistan is among the ten countries that comprised 58% of the global maternal deaths reported in 2013. Many births and deaths are not registered, and information on the cause of death is often unknown or unreliable. The lack of information about maternal mortality at the regional level and among high risk populations makes it difficult to identify target groups, for whom scarce resources should be focused. Similarly, risk factor data such as socioeconomic status and medical conditions are not routinely analyzed and reported. Therefore, it is not possible to determine the mortality rate of various high-risk subgroups within populations and to identify problems in a timely manner.
In Pakistan, a significant reduction in maternal mortality from 431 deaths per 100,000 live births in 1990 to 178 deaths per 100,000 live births in 2015 has been achieved. However, the Millennium Development Goals (MDGs) target of 140 maternal deaths per 100,000 live births was not achieved. The recent Pakistan Demographic and Health Survey (PDHS) estimated neonatal mortality at 55 newborn deaths per 1,000 live births, accounting for 74% of all infant deaths in Pakistan, while the perinatal mortality rate (death of an infant occurring between the seventh month of pregnancy through the first seven days of life) was estimated at 75 deaths per 1,000 pregnancies.
Many births and deaths are not registered, and information on the cause of death is often unknown. As a result, maternal mortality estimates for Pakistan are likely underestimated. In countries where there is no maternal and child health surveillance system, surveys like the PDHS provide useful information to estimate morbidity and mortality, but their reach is limited.
In our research project conducted under the University of New South Wales, Sydney, we estimated maternal, perinatal and neonatal mortality rates by complete enumeration of all pregnancies, births, and maternal, perinatal and neonatal deaths in a rural district of Pakistan using an existing information system of the Lady Health Workers (LHWs) Programme. We also extended data collection to areas without existing information systems by recruiting community health workers (CHWs). The LHWs Programme covers about 70% of population in the Pakistan. Data from the LHWs Programme covered 79% of our study population; for the remaining 21%, we recruited CHWs to ensure 100% population coverage and, therefore, a more accurate and timely estimation of maternal, perinatal and neonatal mortality rates—including area-specific causes of maternal and neonatal deaths.
A total of 51,690 women between the ages of 18 and 49 years were recruited for the study. Any of these women who became pregnant between 1 June 2015 and 31 May 2016 were registered and followed throughout their pregnancies through 42 days after delivery. Births were counted and maternal, perinatal and neonatal mortality rates calculated. A “short household questionnaire” developed by the National Institute of Population Studies and used in the 2006-2007 PDHS was adapted for a cross-sectional survey of all households in the study area. Data were compared with those from the LHWs Programme and the PDHS 2012-2013. The causes of deaths were ascertained using World Health Organization’s verbal autopsy tool.
Our research found variations in maternal, neonatal and perinatal mortality rates estimated using different information sources. Pakistan, as well as many other countries, currently have weak civil registration and vital statistics surveillance, often missing the most vulnerable women and children. Complete enumeration of all pregnancies, births, maternal, perinatal, and neonatal deaths provides the most reliable mortality estimates, thus enabling health authorities to monitor the progress and impact of ongoing public health programs in a timely fashion.
Learn more about Demographic Health Surveys.
Read about the Lady Health Workers Programme in Pakistan.
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