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

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There is much more to maternal mortality in Afghanistan than the appalling statistics as Mahri Zohra Haider explains

Statistics on maternal mortality in Afghanistan are among the worst in the world, second only to Sierra Leone. There are 1,800 maternal deaths per 100,000 live births (or one maternal death for every 55 births) and Afghan women have a one in eight lifetime risk of maternal death. (1) The average birth rate is 6.75 children per woman and every pregnancy is associated with a risk of death that is 600 times greater than that of a woman who is pregnant in North America. (2) Although the problem of maternal deaths in Afghanistan is clear in the numbers, the solutions lie in the details beyond the numbers. However, all too often the majority of effort is spent on dissecting the problem, with merely an afterthought to what can actually be done. One study designed to verify the above statistics concluded that “deaths could be averted if complications were prevented through improvement of general health status” and if “complications that occurred were treated to reduce their severity.” (3) These recommendations are vague and fail to draw attention to the specific challenges of addressing maternal mortality in Afghanistan. (more…)

 Islean Kinghorn discusses the public health implications of this emotive issue

WHO defines unsafe abortion as ‘the termination of an unintended pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both.’ (1) According to their statistics 19.7 million women a year undergo unsafe abortions, contributing to 13% of maternal deaths worldwide. (2) If we are to achieve Millennium Development Goal 5 of reducing maternal mortality ratio by ¾ we must address the taboo of unsafe abortion.

The consequences of unsafe abortion on a woman’s health are many. Some such as haemorrhage or infection lead to mortality, while others, including pelvic inflammatory disease, can leave women with chronic pain and an increased risk of obstetric complications or infertility.(3) Such morbidity, easily avoided with safe practice, places a staggering strain on health systems, diverting scant resources from other essential programmes. It has been estimated that each year 5.2 million women are hospitalised worldwide due to complications following unsafe abortion. (4) The global cost to health systems could be as high as US$ 1.08 billion annually. (5) However it is not only the direct but indirect costs, through loss of productivity and the vulnerable position of motherless children, that burden society. (more…)

Rachel Pope uses the story of a woman she interviewed in Tanzania to highlight the complex issues involved in the lack of appropriately trained health workers

Pili (her name has been changed to protect her privacy ) is a 27 year old woman from the Kara tribe. (1) She only made it to grade three in school, and was married at age 18. She was also 18 the first time she gave birth, but unfortunately for Pili, she does not have any children to this day due to complications in both of her labours that resulted in an obstetric fistula. (An obstetric fistula is the result of prolonged and obstructed labor. In cases where the fetus cannot pass through the birth canal safely, the constant pressure of the fetal skull in the birth canal reduces blood supply to the tissues, causing the tissues to disintegrate. Fistulas - or holes - develop, resulting in constant leaking of urine and/or feces through the vagina.) (more…)