State of the World's Midwifery 2014 - Pakistan: Achieving MDG 5

Publication date: 2014

Pakistan Achieving MDG 5 Maternal Mortality With a population of 180 million in 2013i, Pakistan is the 6th most populous country in the World. It is also among the top ten countries in the world when it comes to maternal mortality. With an estimated 7,400 women dying in pregnancy or childbirth, Pakistan accounted for 2.6% of the global maternal death burden in that yearii. Pakistan has made significant progress in reducing the maternal mortality ratio and it looks like the country is almost on track to reach its MDG5 goal of an MMR of 140 (or about 6,000 annual deaths) by 2015. According to UN data, in 2013 it had a MMR of 170 per 100,000 live birthsiii. Almost 70% of all maternal deaths in Pakistan are due to just four conditions - hemorrhage, eclampsia, sepsis and abortion complicationsiv. An estimated 1,400 of maternal deaths are among adolescentsv. Family Planning and Maternal Health vi,vii,viii,ix In addition to a 75% reduction in the MMR, MDG5 also calls for universal access to reproductive health care by 2015. The following shows current coverage with key reproductive services in Pakistan. Family Planning 26% of Pakistan women use modern family planning methods, 20% have an expressed unmet need for family planning. Antenatal Care Only 36% of women have at least 4 antenatal care visits but 73% received ANC from a skilled provider.ix Skilled Delivery Care As measured by the latest PDHS survey, 52% of the annual 4.3 million births in Pakistan were assisted by a skilled attendant. Estimated Impact of Universal Access to Reproductive Health Family Planning Providing women with access to family planning and making it possible for them to decide how many children they want and when to have them, reduces the overall number of deaths by reducing the number of women dying due to pregnancies they never intended to have. Meeting only 25% of the unmet demand for family planning in Pakistan, i.e., supplying 1.9 million additional women with access to family planning would reduce the number of unintended pregnancies by almost 600,000 and deaths related to unintended births and abortions by over 1,000. Maternal Health Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. The following interventions and drugs tackle the four top causes of maternal deaths in Pakistan:  Prevention and management of hemorrhage/treatment of postabortion complications - Oxytocin/Misoprostol:  Prevention and management of eclampsia with Magnesium sulfate  Prevention and treatment of sepsis with Clean delivery kits and antibiotics Number of Maternal Deaths that Could be Prevented Providing all women with the required maternal health medicines and supplies would prevent an additional 3,300 deaths, reducing the annual number of deaths to 3,000 and the MMR to about 75, making it possible for Pakistan to not only meet but significantly exceed its MDG target of 140 deaths per 100,000 births. In addition, these interventions would have a significant impact on child, and in particular, newborn mortality. Currently Pakistan has about 180,000 neonatal deaths a year. About 13% of those, or 24,000, could be prevented by providing women with the above life-saving interventionsx. Essential Drug Requirements and Costs Maternal Health Drugs For Universal Coverage Drug and commodity requirements to provide the care detailed above would cost about $12 million, $3.5 for additional FP supplies and $8.5 million for maternal health (detailed calculations are available in Annex 1). Required health system investments Additional investments will be necessary to strengthen countries’ logistics systems and to ensure that health providers (both at facility and community level) know how to administer these drugs. Annex 1. Methodology The following describes the methodology used to arrive at the impact and cost estimates in the factsheet. Maternal Mortality The number of current annual maternal deaths was calculated using the 2013 MMR from the 2014 publication: Trends in Maternal Mortality: 1990-2013. UNFPA, WHO, World Bank, UNICEF http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ applied to the estimated number of births in 2013 (based on population data from the UN Population Division). Deaths Prevented through Family Planning The number of unintended pregnancies averted was calculated by comparing the number of pregnancies that would have happened if the 1.6 million (25% of the 6.4 million women with currently unmet need in Pakistan) had not been able to access contraception to the number of pregnancies that would occur if these women used contraception (i.e. only experienced pregnancies due to failure of their chosen method). It was assumed that 40% of all women would have gotten pregnant if not using contraception. The average failure rate of contraceptives was estimated to be 3%. Based on regional data collected by the Guttmacher Institute for its 2014 update of “Adding It Up” it was estimated that only about 39% of unintended pregnancies would be carried to term, 49% would be aborted and 13% would end in a miscarriage. Note: Family planning reduces the absolute number of maternal deaths in a country but since it reduces both numerator AND denominator of the Maternal Mortality Ratio (defined as deaths per 100,000 live births) the reduction in maternal deaths caused by family planning is not reflected in the MMR. The estimated reduction in number of deaths required to achieve the country’s MMR goal differs therefore slightly depending on the assumption made about the number of births. The estimate in the first paragraph uses the current number of births, while the estimate in the Estimated Impact paragraph is based on a lower number of births (originally projected number of births minus unintended births averted through the provision of contraception to women with unmet need). Deaths Prevented through Maternal Health Interventions It was assumed that half of the women currently covered by skilled birth attendance, i.e. about 26%, had access to the three live-saving drugs. This coverage was then scaled up to 100%. The following effectiveness data were used in estimating the expected reduction in maternal deaths: Intervention Effectiveness Source 1. Hemorrhage Prevention - Oxytocin 62% Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. In: The Cochrane Library, Issue 1. 2. Hemorrhage Prevention - Misoprostol 43% 30% less effective than oxytocin Gulmezoglu AM, Villar J, Ngoc NTN, et al. WHO multicentre randomized trial of misoprostol in the management of the third stage of labour. Lancet. 2001; 358:689-695 3. Hemorrhage Treatment - Oxytocin 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 4. Eclampsia Management - MgSulfate 43% Cochrane Database Syst Rev. 2010 Nov 10 5. Sepsis Prevention - Facility Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 6. Sepsis Prevention - Home Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 7. Sepsis treatment - Antibiotics 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 8. PAC management - Misoprostol 50% The MMR after FP and MH scale-up was calculated by dividing the remaining number of maternal deaths by the number of births expected at the new contraceptive prevalence level (current 4.4 million births annually minus 230,000 averted through increased use of family planning). Cost Estimates Family Planning Unit costs for the different supply methods were taken from UNFPA’s RH Interchange database and multiplied by the amount required to provide one couple-year of protection (CYP). It was assumed that 15 cycles of the pill, 120 condoms or 4 injectables would provide one CYP. IUDs and Implant were assumed to provide 3.5 years of protection or CYPs. Their cost was thus divided by 3.5. The RHInterchange price for implants ($18.80) was replaced with a cost estimate per implant of $8.50 to reflect the recent price reduction seen, but not yet reflected in the database, due to the introduction of Sino- Implants. Drug and supply cost for male and female sterilization came from calculations carried out by the Guttmacher Institute for its Adding It Up 3 publication using UNFPA’s RHCT costing tool with updated 2013 price. It was assumed that new users would adopt methods based on the current modern method mix. Cost Estimates Maternal Health Interventions Based on WHO treatment guidelines the following drugs and supplies were costed using drug prices from both the MH International Drug Price Indicator and the UNICEF Supply Catalogue. Hemorrhage Prevention and Treatment Sepsis Prevention and Treatment Pre-Eclampsia/Eclampsia Treatment i UN Population Division. World Population Prospects: The 2012 Revision, data for 2013 ii WHO. 2014. Maternal Mortality 1990-2013. iii WHO. 2014. Maternal Mortality 1990-2013. iv WHO and UNICEF. 2012 Countdown, Country Profiles v Based on: Blanc et al. 2013. New Findings for Maternal Mortality Age Patterns: Aggregated Results for 38 Countries. PLoS ONE 8(4): e59864. vi UN Population Division. World Population Prospects: The 2012 Revision vii UN Population Division. World Marriage Data 2012. viii Pakistan Demographic and Health Survey(PDHS-2012-13) ix Pakistan Demographic and Health Survey(PDHS-2012-13) x Futures Institute. Spectrum, LiST module.

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