Muhammad Umair Mushtaq, a fourth year MBBS student from Allama Iqbal Medical College in Pakistan, writes on newborn care in Pakistan, including the challenges of the current health care system and recommendations for possible solutions.

About 4 million newborns under 4 weeks old perish each year, accounting for 37% of all under-five deaths.[1]  Nearly 75 % die in the first week and 40% in the first 24 hours after birth. Newborns in developing countries are eight times more likely to die than newborns in industrialized countries.[2]  Ninety-nine percent of all newborn deaths occur in developing countries.[3]

Pakistan has a population of about 160 million and a per capita GDP of 736 US$, with only 2.4% of GDP being spent on health.[4]  The current newborn health status of Pakistan is characterized by a high incidence of low birth-weight babies and neonatal mortality. About 0.3 million newborns die each year (Figure 3) with a neonatal mortality rate of 57 per 1000 live births (Figure 2) . About 19% of all newborns have low-birth weight and only 16% of all babies are exclusively breastfed.[5]  Neonatal diseases are a major cause of mortality, with 55.7% deaths among children under-5 years.[4]  Pakistan is a signatory to the Millennium Development Goal targets of reducing maternal and infant mortality by 66-75% by the year 2015.[6]  

To achieve the Millennium Development Goals related to newborn health, many international organizations are working in collaboration with national governments to improve mother and newborn health, such as Partnership for Maternal, Newborn and Child Health (PMNCH), United Nations Development Fund, United Nations Children’s Fund (UNICEF), and World Health Organization (WHO).

In most instances, neonatal deaths result from poor maternal care during pregnancy, poor hygiene during delivery, unskilled management of complications, harmful traditional practices, inadequate newborn care, and lack of access to emergency care. 15% of newborn infants weigh less than 2,500 g, the proportion ranging from 6% in developed countries to more than 30% in least developed parts of the world, the main cause being preterm birth.[2]  In Pakistan, intrapartum or early postnatal deaths are common and the perinatal mortality rate is 59 per 1,000 total births.[2]  This is mostly due to maternal infections or nutrient deficiency and an absence of appropriate obstetric and neonatal care. In developing countries, asphyxia causes around 7 deaths per 1,000 births, whereas in developed countries this proportion is less than 1 death per 1,000 births. 26% of newborn deaths occur as a result of severe infections like sepsis and pneumonia.[2]  Exact figures are not known for Pakistan, but the situation is not much better. Globally, neonatal tetanus causes 7% neonatal deaths. Although neonatal tetanus has been eliminated from many countries by maternal tetanus toxoid (TT) immunization, there are over 50 countries where, in some districts, the proportion of cases of neonatal tetanus is 1 per 1k000 births.[2]  In Pakistan, about 80% of newborns are prevented from neonatal tetanus by TT immunization, but cases are frequent in remote and rural areas.[7]

Table 1: Estimates of stillbirths, early neonatal, perinatal and neonatal mortality rates and numbers, 2000

Newborn Care Delivery - Current Situation

1.     Public Sector

Mother, Newborn and Child Health (MNCH) care is delivered by Provincial Departments of Health and the Federal Government is concerned with planning and policy making. The District Health System was introduced in 2001 under the charge of The Executive District Officer Health (EDOH). EDOH is now responsible for provision of MNCH care at the district level.

a)      Community-based Activities

At the community-level, the maternal health and newborn care services are provided by outreach workers that include Lady Health Workers, Female Health Technicians, Lady Health Visitors, Community Midwives and Trained Birth Attendants.

These outreach workers cover the whole community in the area assigned and provide domiciliary services. Newborn care activities include:

• Birth preparedness
• Skilled birth attendance
• Easy and prompt access to Emergency Obstetric and Newborn Care
• Routine newborn care including immediate onset of breastfeeding, promoting use of colostrums, warmth and skin contact, cord & eye care, delayed and proper bathing, newborn resuscitation, neonatal examination, and immediate referral in case of illness or abnormality
• Maternal TT; Newborn BCG, Oral Polio Vaccine (OPV), and Hepatitis B vaccination

Community activities have been significantly improved in the past decade, especially after the introduction of Lady Health Workers under the National Program for Family Planning and Primary Health Care in 1994, but still MNCH services at the community level are not effectively delivered due to low coverage in remote areas, lack of knowledge in people, insufficient training of community health workers, and poor management by supervisors.

b)      First-level (Primary) Care Facilities

These include primary-level facilities and mid-level facilities. There is at least one primary health center (Basic Health Unit or Mother & Child Health Center) in each Union Council to provide services to populations of about 10,000-25,000 people. Basic Health Units are present in rural areas while Mother & Child Health Centers are present in urban areas. Newborn care activities include:

• Facility-based normal delivery, especially to high-risk women, and timely referral for Emergency Obstetric and Newborn Care
• Diagnosis and treatment facility for common illnesses to mother and newborn babies
• Maternal TT; Newborn BCG, OPV, and Hepatitis B vaccination

Mid-level centers (Rural Health Center) provide more extensive services and serve populations of about 50,000 to 100,000 people. Newborn care services include:

• Basic Emergency Obstetric and Newborn Care to mother and newborn 24 hours a day. It includes induction of labor, use of IV sedatives, IV antibiotics, IV plasma expanders, oxygen and blood, newborn resuscitation, and management of newborn asphyxia and infections.
• Training of primary level staff in handling obstetric and newborn emergencies and providing newborn resuscitation. Technical and managerial support, supervision, and backup to community level workers.
• Maternal TT; Newborn BCG, OPV, and Hepatitis B vaccination

These facilities are providing services to a major proportion of the population. But many mothers do not receive these services due to poor referral links of primary health centers with community staff, unavailability of female doctors, poor knowledge of people, and mismanagement by technical and managerial supervisors.

c)      Referral level (Secondary) Care Facilities

These include Tehsil Headquarters Hospitals and District Headquarters Hospitals that offer first line referral services. Tehsil Hospitals serve a catchment population of about 100,000 to 300,000 people and typically have 60 beds. District Hospitals serve a catchment population of about 1 to 3 million people and typically have about 125 to more than 400 beds. Newborn care services include:

• Comprehensive Emergency Obstetric and Newborn Care including cesarean section, complete blood transfusion, neonatal special care units and management of all obstetric and newborn complications
• Training and supervision of staff and referral links with mid-level health facilities. All other services are provided at primary and mid-level facilities.

These facilities are doing a better job but can be made more useful by making a referral system with rural primary health centers and providing transportation services to rural health centers. Many mothers in rural areas cannot come a long way to urban hospitals, due to distance and financial constraints.  

d)      Tertiary Care Facilities

These provide sub-specialty care. All primary specialty departments are chaired by professors and all have essential facilities. They provide all types of obstetric and neonatal procedures and complete Emergency Obstetric and Newborn Care.

There are state-of-the-art facilities in teaching hospitals of Pakistan. These are equipped with the latest technologies and highly skilled specialists. It is a dilemma that there is no functional referral system with Tehsil and District hospitals. Females and newborns from rural areas, where 66% of the population lives, seldom reach tertiary hospitals.  Those who are able to reach them are in very complicated conditions. Many lives are lost due to delays in referral and mismanagement of complications by community and primary care staff.

Table 2: Public Health Facilities providing Newborn Care in Pakistan

Figure 1: Public Health Facilities providing Newborn Care in Pakistan

2.     Private Sector

The private sector serves nearly 75% of the population.[8]  Most of these private facilities are in urban areas, the quality of care is generally poor, and only curative services are provided. Many Non-Government Organizations (NGOs) are working in health sectors including maternal and newborn care.

 The way forward…

Pakistan has secondary and tertiary care hospitals in big cities, a network of primary care hospitals in the rural areas, an established District Health System, and a work force of community workers. But newborn care in Pakistan is still way behind many other countries.

Problems         

There are many traditional practices deep rooted in the fabric of Pakistani culture.  In most cases dais (unqualified birth attendants) attend the birth and give newborn care. About 31% of all deliveries are attended by skilled personnel, however only 8.1% in rural areas are and yet this is where 66% of population resides. The urban-rural ratio of skilled birth attendance is 5.2 while the highest-lowest wealth quintile ratio is 12. Only 11% of all deliveries are attended by skilled personnel in mothers with no education, while 62.3% of all deliveries are attended by skilled personnel in mothers with secondary or higher education.[4]  The high ratio of unskilled birth attendance in rural areas is due to poor access to skilled personnel, low-income, and lack of knowledge. Many bad practices are still prevalent including use of unclean instruments to cut the cord, application of surma (black antimony powder) on the cord, efforts to remove the vernix, first bath within 2-4 hours, massage with mustard oil, use of ghutti (some sweet after birth), and delay in initiating breastfeeding. Surma is applied on the cord as it is believed to be antiseptic in local communities. According to cultural beliefs, newborns are given the first bath early to clean the skin. Ghutti is given to the baby because it is a superstition in Pakistani communities that the baby will have a similar way of life as the person giving the ghutti. Poor hygiene at delivery, improper care of newborn, newborn infections, and no knowledge of managing complications are major causes of neonatal deaths.

Private sector facilities are poorly regulated and no actual controlling body exists, resulting in varying standards from highly reputed, costly urban hospitals to clinics run by unqualified staff. Private health services consist of over 20,000 general practitioners clinics, 340 dispensaries, 300 small MCH centers or maternity homes, 450 laboratories, and 500 small to medium private hospitals.[8]  Private sector hospitals provide only curative services and no preventive services, rendering them ineffective to prevent newborn problems.

There are 29 teaching hospitals, 947 District and Tehsil hospitals, 4,800 dispensaries, and 1,084 Mother and Child Health centers, mainly located in urban areas; whereas, 581 Rural Health Centers and 5,798 Basic Health Units are serving the population of rural areas.[8]  There are 116,298 physicians, 48,446 nurses, 6,397 LHVs, 23,318 midwifes and 65,999 community health workers in Pakistan.[4]  Despite adequate resources, Mother and Child Health care delivery is miserable. The utilization of public health facilities in Pakistan is less than 30%, probably due to absenteeism and mismanagement.[9]  There is lack of proper public sector maternal and newborn care facilities and no proper coordination exists between outreach workers in community and referral level facilities providing Emergency Obstetric and Newborn Care.

There is great need to strengthen the District Health System since 66% of Pakistan’s population live in rural areas, and provision of Mother, Newborn and Child Health care at the primary level is the only way out. Office of Executive District Officer Health lacks capacity in human and financial resource management, effectively planning and delivering preventive facilities including Mother and Child Health and supervising health activities. Political interference is frequent, especially in recruitment and disciplinary actions. Community and primary health facilities have several problems like mismanagement, lack of equipment, and poor condition of buildings. There is no functional referral system between primary-level, mid-level and secondary-level health facilities.

What is being done?

Mother, Newborn and Child Health Projects

Under the Accelerated Health Program started in 1985, birth attendants (dais) were trained and seats of Trained Birth Attendants were sanctioned at health facilities. The third health project was launched during the seventh five-year plan (1988-1993) aiming at improving MCH services. The second Family Health Project was started to improve the health of masses in general, and that of women in particular. National Program for Family Planning and Basic Health was started in 1994. It targets mainly community based Mother and Child Health care through community based Lady Health Workers and significantly improved the MNCH status in the community.[8]  

Several projects were completed with international collaboration in the past and there are many ongoing to improve mother and newborn health like: Safe Motherhood by JAICA (2003-2007) to enhance the skills of staff at the public health facilities, improve the practices of community health care providers, and strengthening of the referral system; Improve Maternal and Neonatal Health Services by USAID (ending 2009) to develop a model for safe motherhood services that involves the community, health centers, and referral centers; and, Reproductive Health Project (RHP) and Women’s Health Project (WHP) by ADB to ensure good maternal, newborn and child care and strengthen reproductive health services. Reproductive Health Project targeted 34 districts and ended in 1998. WHP was started in 1999 and targeting 20 districts in four Provinces.[8]

A Mother and Child Health package of services was approved by Government of Pakistan in April 2005. Now the National MNCH Program has been started. Its main targets include:

• All births by a skilled birth attendant (doctors, nurses and midwifes)
• Health facilities strengthening and upgrading
• District Health System reforms

The government of Pakistan Ministry of Health, with collaboration of UNICEF, piloted Child Health Week in two districts of Pakistan from November 12, 2007 to November 19, 2007. All children less than 2 years of age were immunized; all pregnant women were vaccinated with TT; all children aged 2-5 years were dewormed; and, health education sessions about pneumonia and exclusive breastfeeding were arranged. It appears to be an effective and feasible way to deliver essential interventions using the existing health system.

National MNCH Program has been implemented in the country. It will improve the situation but many of the proposed plans are still in process and the actual provision of care is still not achieved, with the basic reason being the lack of funds.

Recommendations

The centre of focus should lie on mother’s health during pregnancy, birth attendance by skilled personnel, access to emergency care, and immediate care of newborn. Some essential interventions are recommended by WHO [10-12] and a large proportion of newborn deaths can be prevented by provision of these simple interventions, like:

• Clean delivery & cord care
• Thermal protection - delayed bathing (after 12-24 hours), skin-to-skin contact with mother, and use of incubators, radiant heaters and heated beds
• Early and exclusive breast-feeding
• Initiation of breathing, resuscitation - opening the airway and/or ventilating
• Eye care - application of antimicrobial drops (1% silver nitrate solution or 2.5% povidone-iodine solution) or ointment (1% tetracycline ointment) to the baby’s eyes
• Skin care
• Immunization - BCG, Oral Polio Vaccine and Hepatitis B vaccine
• Proper and timely examination of newborn
• Care of the preterm (32-36 weeks or 1-2 months early) and/or low birth weight newborn (1500g-<2500g), and very preterm (<32 weeks or >2 months early) and/or very low birth weight newborn (<1500g) - special support to breastfeed, special care (e.g. incubators to keep newborn warm as there is risk of hypothermia) and daily reassessment
• Management of newborn illness - malformations, birth injury or infections like Neonatal Tetanus, Congenital Syphilis, Tuberculosis, Gonococcal Infection, and HIV.

The majority of these essential interventions can be practiced at home by families or health workers. This is crucial as more than 50% of newborn deaths occur at home. It is estimated that provision of these essential interventions at scale (over 90% coverage) in the community and in health facilities can reduce the neonatal mortality rate by 70%.[3]

There is great need to redesign the responsibilities of Federal, Provincial and District Governments, giving more autonomy to District Health Offices, and making them more resourceful. There should be District and Tehsil Supervisors for Mother, Newborn and Child Health. They will monitor all MNCH activities and report periodically. This will integrate the longitudinal activities of various health workers.

There should be a strengthening of community and primary-level facilities; training of skilled birth attendants and community health workers in MNCH; integration of community-based programs into regular health services; establishment of a proper referral system, including transport and telecom services; and, health education sessions at community level. Community health workers will ensure skilled birth attendance and immediate newborn care. In-Charges of primary health centers will supervise and coordinate all the community MNCH activities.

Public-Private mix partnerships can play a big role in improving MNCH facilities. NGOs and private hospitals should be involved in MNCH care by the Government Departments of Health. Operational researches for feasibility of such partnerships and collection of baseline knowledge for action should be encouraged. Advocacy, communication and social mobilization, community involvement, and health education sessions should be made a regular part of MNCH services.

Child Health Weeks should be implemented in the whole of the country. These can provide a package for integrated delivery of health, and nutrition interventions using the existing health system and can be made a part of district annual plans with budget allocation from the health sector. These weeks, if celebrated twice a year on a regular basis, can make a big difference in the current scenario without straining the health system.

In Pakistani communities, mother care and delivery by male doctors is discouraged. Many females are not allowed a skilled attendance only due to unavailability of a female doctor. Medical graduates, especially females, should be given incentives for training in preventive medicine and MNCH care. One year service at primary care facilities should be declared mandatory for all post-graduate residents in Gynecology and Obstetrics, and Pediatrics. If post-graduate students will serve in primary-care facilities for 1 year on deputation, in their own pay and scale, it will assure availability of a consultant at the door steps of people, especially in rural areas. This cost-effective intervention can be made without putting extra financial burden on current health systems.

Many efforts are being made to improve newborn care. However, an Integrated MNCH Care System, continuity of MNCH policies, strengthening of existing health systems and health education of populations is necessary to save mothers and newborns in developing countries like Pakistan.

Muhammad Umair Mushtaq, Fourth Year MBBS Student
Allama Iqbal Medical College, Lahore, Pakistan
Medical Student Member, American College of Preventive Medicine (ACPM) &
American College of Surgeons (ACS)

Email: umairmushtaq_aimc@yahoo.com
 

References

1. World Health Organization (WHO). The Lancet Neonatal Survival Series. Geneva, Switzerland: WHO; 2005.
2. World Health Organization (WHO). Neonatal and perinatal mortality: country, regional and global estimates. Geneva, Switzerland: WHO; 2006.
3. United Nations Children’s Fund (UNICEF). Newborn Health. Available at: http://www.unicef.org/health/index_newbornhealth.html. Accessed December 11, 2007.
4. World Health Organization (WHO). World Health Statistics 2007. Geneva, Switzerland: WHO; 2007.
5. United Nations Children’s Fund (UNICEF). The State of the World’s Children 2008. New York, NY: UNICEF; 2007.
6. Bhutta ZA, Gupta I, de’Silva H, Manandhar D, Awasthi S, Hossain SM, Salam MA. Maternal and child health: is South Asia ready for change? BMJ. 2004; 328(7443):816-9.
7. WHO/UNICEF Review of National Immunization Coverage 1980-2006: Pakistan, August 2007. Geneva, Switzerland: WHO; 2007.
8. Regional Health Systems Observatory, World Health Organization (WHO). Health System Profile Pakistan 2006. Cairo, Egypt: WHO Regional Office for the Eastern Mediterranean; 2006.
9. Ministry of Health-WHO. Utilization of rural basic health services in Pakistan, report of evaluation study. Islamabad: Government of Pakistan; 1993.
10. World Health Organization (WHO). Essential newborn care. Geneva, Switzerland: WHO; 1996.
11. World Health Organization (WHO). Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva, Switzerland: WHO; 2003.
12. World Health Organization (WHO). Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, Switzerland: WHO; 2006.

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