PAKISTAN: Newborns at Increased Risk

By Zofeen Ebrahim Reprint | | Print |

Zofeen Ebrahim

KARACHI, Oct 12 2011 (IPS) - A newborn baby dies every four minutes in Pakistan. It was not always so. With a sound population policy set out in the 1950s, Pakistan was second only to Sri Lanka in infant and neonatal survival rates during the 1960s and 1970s (compared to Bangladesh, India, Iran and Nepal).

But the country has seen considerable sliding down of its health indicators for mothers, infants and newborns.

According to a study spanning 20 years, conducted by the World Health Organisation, Save the Children and the London School of Hygiene and Tropical Medicine, and published in the medical journal PLoS Medicine on Aug. 30, Pakistan is one of five countries in the world that account for more than half of all neonatal deaths – the others are India, Nigeria, China and the Democratic Republic of the Congo.

Pakistan has a neonatal mortality rate of 42 per 1,000 live births, compared to a global average of 23.9 deaths per 1,000 live births.

The report said that with an increased global focus on maternal and child health, too often the newborns are overlooked.

But China, which in the 1950s had higher neonatal and infant mortality rates than Pakistan, has shown considerable progress. A new study has confirmed that China was able to bring down the deaths of newborns by two-thirds, from 24.7 per 1,000 to 9.3 per 1,000, between 1996 and 2008, a 62 percent decrease.

What did China do right to reduce its death rate And where did Pakistan fail?

A study carried out over a 12-year period by Peking University and the London School of Hygiene and Tropical Medicine found that this unprecedented success was achieved by stepping up intervention in two areas – increasing access to obstetric care in rural areas, and encouraging mothers to deliver in hospitals.

The study concluded that of the two interventions, hospital births proved much more successful. Where a mother gave birth made a difference, it said. But experts caution that hospital delivery will only save babies if “high-quality neonatal care is available and accessible” in the first few days after delivery.

In Pakistan, two in three women deliver their babies at home, usually at the hands of unskilled traditional birth attendants (TBAs). These home births, in addition to being a leading cause of maternal complications, also carry a high risk of the newborn dying.

Many birth attendants still use potentially unsafe methods of delivering babies. “In many parts of rural Sindh, the baby is provided harmful traditional care,” Fizza Qureshi, who has worked in Sindh province providing training to TBAs, tells IPS. “We never thought of bringing in mothers and mothers-in-law in our fold and telling them about the harm they were doing to the newborn by their customs.”

These harmful practices include a paste made of kohl (antimony), oil and cow-dung which is put on the baby’s umbilical cord supposedly to make it heal faster. Colostrum (the first milk after birth) is discarded, and the baby is given honey mixed with some herbal concoction, even butter or ‘kheer’ (milk cooked with rice and sugar), Qureshi says.

“Even today, for the first three days, in most villages in Sindh, the baby is given goat’s milk as it is considered lighter than cow and buffalo milk because it is believed the new mother cannot produce enough milk.” Villages where TBAs have been trained show a marked improvement, Qureshi says.

But Farid Midhet, founder of the Safe Motherhood Pakistan says evidence of the positive effect of TBAs on maternal and newborn mortality is scanty and questionable, “mostly arising from small, well-controlled projects.”

Midhet says that during the 1980s and 1990s, the government trained more than 60,000 birth attendants. “Over the years nearly every non-governmental organisation working in safe motherhood has trained TBAs at some point in time.”

He says similar training has been repeated in other developing countries. “Cumulative evidence universally suggests TBAs have no impact on maternal (or neonatal) mortality.” But training for TBAs still continues “mostly because they provide ‘some’ care where there is none.”

Dr Shershah Syed, a leading Karachi-based obstetrician and gynecologist, says the only way to bring down newborn deaths is to replace TBAs with skilled birth attendants (SBAs). Indonesia and Malaysia have done so successfully, he says.

Many TBAs still hold the baby upside down and slap it to help initiate breathing, he says. “Scientific knowledge of newborn resuscitation like rubbing the baby dry, keeping the baby warm and using a simple ventilation device to stimulate breathing can save many babies, but the TBAs are not aware of this,” he tells IPS.

He says that in one experiment, the results from using SBAs in Sindh district Tando Allah Yar were outstanding. “We placed a SBA in a government-run mother and child centre, where just one or two deliveries were taking place in a month; we were surprised when the numbers increased unusually.” If mothers get quality care, they will reach a birthing centre, he says.

But Farid insists a SBA alone cannot save the new baby or the mother “unless quality emergency obstetric and neonatal care is available at that health facility.”