Pakistan
The Making it Happen Programme
The aim of the Making it Happen Programme (MiH) is to reduce maternal and newborn mortality
and morbidity by increasing availability and improving the quality of Skilled Birth Attendance (SBA)
and emergency Obstetric and Newborn care (EmONC).
Between 2012 and 2015, the MiH Programme will be delivered in 11 countries: eight in Sub-Saharan
Africa (Ghana, Kenya, Malawi, Nigeria, Republic of South Africa, Sierra Leone, Tanzania and
Zimbabwe) and three countries in Asia (Bangladesh, India and Pakistan).
The Making it Happen Programme has five outputs:
Output 1: Increased health care provider capacity to provide Emergency Obstetric and Newborn
Care (EmONC)
Output 2: Increased availability of EmONC for mothers and babies
Output 3: Strengthened accountability for results with increased transparency
Output 4: Strengthened capacity to sustain improvements in maternal and newborn health service
delivery
Output 5: Evidence generated by programme disseminated in order to inform national, regional and
global agenda
The Centre for Maternal and Newborn Health (CMNH) at the Liverpool School of Tropical medicine
(LSTM) serves as the global coordinating centre for the MiH Programme.
The Making it Happen Programme in Pakistan
The Making It Happen Programme in Pakistan is implemented in the Punjab region (Gujranwala,
Attock, Rahim Yar Khan and Khanewal districts) with the support of the Provincial Government and
our in-country partner Child Advocacy International. The specific interventions are:
Emergency Obstetric & Newborn Care Training Courses: 750 health service providers and 75 master
trainers will be trained in Emergency Obstetric and Newborn Care (EmONC).
Making it Happen with Data: health service providers and manager from 32 health facilities and the
respective districts will be trained in the collection, aggregation and use of routine data to inform
practice.
BASELINE SURVEY RESULTS AND GRAPHS:
Under the Making it Happen Programme (MiH) baseline surveys were conducted in 2012 for 32
health care facilities. Of these, 18 health care facilities are designated to provide Comprehensive
EmONC and 14 are designated to provide Basic EmONC services. The survey identified that 13 of the
CEmONC facilities (72%) were able to provide all nine required signal functions and 8 of the BEmONC
facilities (57%) were able to provide all seven required signal functions. The total number of
deliveries was 8,579 (BEmOC=1,298 and CEmOC= 7,281) in the previous 3 months of the baseline
surveys. The total number of Health Care Providers working in maternity area was 809 (BEmOC=162
and CEmOC=647). The Case Fatality Rate in all the facilities was 1.42 (BEmOC= 0 and CEmOC=1.51).
The Still Birth Rate in all the facilities was 2.97 (BEmOC=1.31 and CEmOC=3.26).
Graphs:
Figure1: Number of facilities surveyed; facilities identified for intensive M&E:
Number of facilities
Number of facilities surveyed
20
18
16
14
12
10
8
6
4
2
0
Type of facility
Facilities for intensive
M&E
BEmOC
CEmOC
Type of facility
Figure 2: Number of deliveries in the facilities:
Number of deliveries
Number of deliveries
8000
6000
4000
Number of deliveries
2000
0
BEmOC
CEmOC
Type of facility
Country information
The Islamic Republic of Pakistan has a population of about 176.7 million (World Bank, 2011)1.
Pakistan comprises a total land mass of 796,096 square kilometres. Pakistan is divided into four
provinces: Baluchistan province is in the southwest, Punjab and Sindh provinces are plains with the
world’s largest irrigation system and North-West Frontier Province (NWFP) is located in the
northwest.
1
World Bank Data (2011) http://data.worldbank.org/country/pakistan (accessed November 2013)
Key MNH Indicators
 Maternal Mortality Ratio: 260/100,000 live births (2011) (WHO, 2013)*
 % Skilled Birth Attendance: 52%% (NIPS, 2013)**
 % Contraceptive Prevalence Rate: 35.0 (NIPS, 2013)**
 Adolescent Birth Rate: 16 (2005-2010)(WHO, 2013)*
 Ante-Natal Care (at least one visit): 73% (2005-2012)(NIPS, 2013)**
*: WHO statistics, 2013 http://apps.who.int/gho/data/kenya: Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the
World Bank. Geneva, World Health Organization, 2012 (http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf).
** National Institute of Population Studies (NIPS) (2013) [Pakistan] Pakistan Demographic and Health Survey, Preliminary Report201220132
Map of Pakistan illustrating target regions and distribution of health care facilities for MiH
The Making it Happen Programme in Pakistan will be implemented in one region between 2012 and
2015: Punjab Region.
Organisation of Health Care Delivery
In 2011, the Ministry of Health was abolished and all public health care responsibilities were
devolved to provincial Health Departments. However approximately 80 percent of all outpatient
visits are made in the private sector.
The different health care levels in Pakistan include a referral level at all teaching hospitals, Medical
Colleges, Civil Hospitals and District Headquarter Hospitals (DHQs). Hospitals at sub-district level are
Tehsil Headquarter Hospitals (THQs). First level facilities include Rural Health Centres (RHC) for a
population of 10.000-50.000 or 6-8 union councils and Basic Health Units (BHUs) covering a
population of 5.000-10.000 population or 1 union council. Other facilities include Maternal and Child
Health Centre (MCHC) that provide health care to mothers and infants including immunization and
family planning services.
Human Resources for Health
Various cadres of health care providers’ in Pakistan provide maternal and newborn care: These
include obstetricians, medical doctors, medical officers ,midwives, staff nurse, lady health visitor,
medical assistant and community midwife and skilled birth attendants.
Although the percentage of deliveries conducted in health facilities is only 34%, the majority of these
deliveries occur in private facilities (23%), whereas only 11% occur in public health facilities
according to the National Institute of Population Studies (NIPS, 2007)3. The majority of public facility
deliveries take place in District Head Quarters DHQs and less in lower level facilities such as Thesil
Head Quarters or upgraded Rural Health Centres (RHCs) or upgraded Basic Health Units (BHUs).
Maternal Mortality Ratio (MMR) and Under-five Mortality Rate
The maternal mortality ratio in Pakistan is 260 per 100,000 live births which has fallen from 490 in
1990 and 380 in 2000 (WHO 2013)2. Under-five mortality rate is 72 deaths per 1,000 live births (WHO
2013)2, falling from 122 in 1990 and 95 8h 2000.
Maternal and Newborn Health Situation
The Total Fertility Rate in Pakistan stands at 3.8 and around a third (35%) of women of reproductive
age use contraception. This is attributed to a variety of cultural, educational and religious factors.
Contraceptive use was found to increase with the women’s level of education, from 35.4% amongst
women with no education and 43.8% among women with higher education (NIPS, 2013). A survey
carried out by the National Institute of Population Studies illustrated that knowledge about any
family planning method is 96% (NIPS, 2007) 4.
In 2010 there were 12,000 maternal deaths in Pakistan with women having a one in 110 lifetime risk
of maternal mortality. Death rates are likely to be even higher in the more remote and rural areas
where access to medical care is minimal. Maternal mortality rates have been falling; in 1990 the
maternal mortality rate was 490 deaths per 100,000 live births, nearly double the current rate (WHO
et al. 2010)5
The latest under 5 mortality rate in Pakistan stands at 89 deaths per 1000 births, meaning
approximately one in eleven children in Pakistan dies before reaching the age of five. Over half of
these deaths occur during the first month of life (NIPS, 2013)3. In 2009 the still birth rate was
4
National Institute of Population Studies (NIPS) [Pakistan]. 2007a. Status of Women, Reproductive Health and
Family Planning Survey: Main report. Islamabad, Pakistan: National Institute of Population Studies.
5
WHO, UNICEF, UNFPA and World Bank (2010) Maternal Mortality Estimation Inter-Agency Group, 1990 to
2010.
estimated to be 47 still births in every 1000 total births, one of the highest rates globally (WHO
2010)6.
Skilled Birth Attendance and Emergency Obstetric and Newborn Care
Antenatal coverage is 58% overall in Pakistan and the proportion of births attended by a Skilled Birth
Attendant (SBA) is estimated to be 52%, up from 39% in 2007 (NIPS 2013)3. The percentage of
deliveries that take place in a health facility has more than doubled in the last decades increasing
from 17% in 1996 to 23% in 2000/01, 34% in 2006/07 and 48% in 2012/13.
6
World Health Organisation (2010) Estimated Still Birth Rates and Numbers for 1995 and 2009.
http://www.who.int/reproductivehealth/topics/maternal_perinatal/stillbirth/en/