An insight into under-five child mortality in Pakistan
260 children die a day due to premature birth
By Khalid Khattak
The baby boy was not named yet. Put on a ventilator in hospital, his only identity was a tag on his wrist “baby of *Rubina.”
He was only 14-day old when succumbed to multiple complications. Respiratory distress syndrome was included among them. He was under treatment at the nursery unit of the Mayo Hospital, Lahore.
This was indeed emotionally hard and painful for his parents. His sudden death, timely treatment notwithstanding, also moved the treating doctors. The initial observation of the medics says the baby might have contracted infection due to 35-week birth. He was among 260 children who die every day in Pakistan because of premature/preterm birth related complications. Yes, 260 every day!
This is a bitter fact that globally most of children under the age of five die because of premature/preterm birth related complications.
A comparative analysis of Pakistan with other South Asian countries reveal that the country ranks second vis-à-vis per day death of preterm children followed by bordering India where over 1,000 such babies die a day because of premature birth related complications.
As per the State of the World’s Children 2016, Pakistan under-five mortality rate (U5MR) is 81 and the country is globally ranked at 22nd position.
The U5MR is the probability (expressed as a rate per 1,000 live births) of a child born in a specified year dying before reaching the age of five if subject to current age-specific mortality rates.
In South Asia, Pakistan is ranked second after Afghanistan which tops the list with 91 as its under-5 mortality rate. India is on third with 48 U-5MR followed by Bangladesh 38, Nepal 36, Bhutan 22, Sri Lanka 10 and Maldives only 9.
Do you know how many children annually die due to premature births in Pakistan? The last ten-year data shows that on an average over 95,000 children under the age of five died in Pakistan each year.
The infants born before 37 weeks are considered premature/preterm babies. There are sub-categories of preterm birth, based on gestational age, including extremely preterm (<28 weeks), very preterm (28 to <32 weeks) and moderate to late preterm (32 to <37 weeks).
Premature birth is just one of the causes of under-five mortality. The other leading causes are pneumonia, birth asphyxia, diarrhea and malaria. But premature births toll is the highest as empirical data backs up this fact.
The baby boy was shifted to Mayo Hospital from nursery unit of the nearby Lady Aitchison Hospital—an attached health facility which solely provides gynecology services in the town. The hospital has a 15-bed nursery unit to provide care to the newborns. However, in case of a premature baby contracts complications and needs treatment through ventilator, he/she is immediately shifted to the Mayo Hospital’s centralized intensive care unit.
“The baby’s mother was presented with history of chronic diabetes and hypertension”, says Mayo Hospital Chief Executive Prof Dr Asad Aslam.
It was sixth baby of the mother and each time she underwent caesarean. “The multiple pregnancies is also a cause of the premature birth,” he said. Infants between one-week of age to a month usually appear to have a vulnerable time, he further explained, when they may not be able to respond effectively to cardiac and respiratory challenges.
Almost same happened in the case of the baby mentioned. He faced a serious damage to the autonomic nervous system during treatment. “When vulnerable infants are challenged by infectious toxins, heat stress and respiratory problems, they are unable to mount a protective response,” says Dr Asad while adding many infectious toxins induce hypotension and challenge the cardiovascular system.
A simple analysis of the World Health Organization’s Pakistan related data** from the year 2006 to 2015 further reveals that 94 percent of preterm babies died within the neonatal period (the first 28 days of their lives)—much before their first birthday.
The WHO data also shows though overall under-5 mortality rate has slightly dropped in Pakistan, over the years there has been gradual increase in deaths of children under five years of age in Pakistan because of premature birth related complication as against 79,434 such deaths in the year 2006 there were 101, 638 such deaths recorded in 2015.
The medical experts believe that the important factors behind preterm births are lack of awareness, malnourishment, multiple pregnancies and inadequate maternal nutrition which is critical for fetal development.
Children Hospital Lahore has the largest set up for newborn care in the public sector. The hospital has a 60-bed nursery unit where newborns with serious complications are shifted from other hospitals for treatment.
Prof Ehsan Waheed Rathore is head of the pediatric department there. According to him, the hospital’s nursery unit receives an average 140 newborns a day; most of them are referred from other government hospitals. Almost 14 of such cases are of premature births.
He informed that the nursery unit of the hospital recently did a detailed study on the 980 babies received during an entire week. The result showed that mortality rate among the babies presented with 35 to 37 week was estimated 40 percent while among those brought in 28-32 week age group the mortality rate was 60 percent.
According to the WHO globally as many as 5.9 million children under the age of five died in 2015—16,000 every day. “In 2015, the under-five mortality rate in low-income countries was 76 deaths per 1000 live births – about 11 times the average rate in high-income countries (7 deaths per 1000 live births).”
According to “Born Too Soon” 2012 Global Action Report on Preterm Birth, Pakistan is among the top 10 countries with the greatest number of preterm births. UNICEF says over 800,000 premature births are recorded each year in Pakistan.
On preterm births
Dr Khadija Waheed who is senior gynecologist at the Lady Aitchison Hospital, says on average two preterm deliveries occur per day in the hospital.
Quoting some studies, she says, the major causes of preterm/premature births are; malnourishment, medical disorders especially hypertensive disorders and diabetes mellitus, infections, especially bacterial vaginosis and urinary tract infection, previous history of preterm births, multigravidas, teen age and old age pregnancies etc.
Talking about best possible ways to avoid preterm births, she says awareness and antenatal visits are the best remedy in this regard.
The other measures that can contribute to prevent such births include patient education regarding symptoms and signs of preterm labor, quality care before and during pregnancy can, nutritional advice to pregnant females, maternal education, increase in contraceptive prevalence, reducing the number of children and screening for vaginal infections, urinary examination at antenatal visits.
Dr Khadija says the premature births can also be prevented through selection of cases for progesterone therapy and through increasing number of health facilities especially in suburbs where patient can report in case of any problem.
“The treatment of chronic medical disorders before pregnancy like hypertension, diabetes for that purpose there should be done at pre-pregnancy clinics”, she adds.
New SDG and Pakistan
As we recall the unlucky child mentioned above was actually born at the Lady Aitchison Hospital and died at the nursery of Mayo Hospital as the first hospital didn’t have treatment facilities for premature babies who contact complications. These two hospitals are situated in the heart of Punjab’s metropolis Lahore. Now think of health facilities situated in the far flung areas of Punjab and across Pakistan.
With the end of Millennium Development Goals (MDGs) era which continued from 2000 to 2015, the international community has now agreed on a new framework – the Sustainable Development Goals (SDGs). The new SDG No. 3 pertains to health.
“By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.”
All these years, Pakistan’s health spending as percent of GDP has only been higher than 3 percent (but less than 4 percent) from 2006 to 2008. Such meager allocation for this vital sector when the toll of infant mortality is on the rise certainly calls for a major policy shift not just to meet the international commitment but to save precious human lives.
* The name has been changed for privacy reasons.
** The latest available data on the WHO website is till the year 2015.
Asif Chaudhry contributed to this story from Lahore.
Main Image Credit: Dawn.com (Asif Umar)