The book reveals that currently there is neither a perinatal health policy in Pakistan, nor is the issue covered in the revised National Health Policy of 2001.
The major proximal determinants of perinatal mortality and morbidity in Pakistan are lack of education and poor care-seeking, poor quality primary and secondary care in this area, fatalism, poverty, gender inequity, status of women in society, etc.
However, the main obstacle seems to be a lack of effective implementation and ability to achieve coverage of the target population. The lack of information and programme-specific data also hinders an assessment of the interventions and their effectiveness. Because much of the information on the major categories of neonatal deaths depend upon verbal autopsy data as most births and deaths take place at home and post-mortem examinations are not conducted on religious grounds. Thus there is some disparity in information from available surveys.
Recent data from some of the most deprived provinces of Pakistan indicate that the five major causes of neonatal deaths are tetanus (18 percent), Low Birth Weight (15 percent), birth asphyxia (12 percent), acute respiratory infections (6 percent) and diarrhoea (5 percent).
Education, family planning, the status of women and the presence of other conditions such as HIV are all known to impact on child and infant health outcomes. It is indicated that there are several proximal determinants of perinatal care in Pakistan that are potentially of much greater importance to perinatal outcomes than direct medical interventions.
"It is interesting that of the policy makers, over three-quarters had no concept as to what was meant by perinatal care, many confused perinatal care with high-cost neonatal intensive care and some confessed to having 'read-up' the subject area in the few days prior to the session."
The health professionals and policy makers comment that the 'process of policy formulation is dubious' and that 'health policy is greatly influenced by donor preferences'. The lack of trained people in the relevant ministries and the lack of evidence were also cited as some of the reasons for the lack of attention on perinatal health issues.
Although perinatal and newborn mortality is a major problem in Pakistan, it has received scant attention in recent years. Perinatal health has never been and is not a current programmatic or policy reality in Pakistan. And it is true for most of the sectors - public, private, NGO, acting within the large health system.
The fact is that perinatal care has been largely orphaned between different categories of care providers at all levels, between midwives and lady health workers at the primary care level, between paediatricians and obstetricians in the referral pathway and between ministries of health and women's affair/population welfare at the policy level. There is a fundamental misperception that perinatal and newborn care is expensive and thus not cost-effective.
The bulk of antenatal, intra-partal and neonatal care in the country, is provided by a different cadre of community based workers, namely the traditional birth attendants (TBAs). And they are largely outside the remit and control of the existing health care infrastructure. Although there are plans to train a large number of 'community midwives', but these may take over a decade to materialise and cannot supplant the urgent need for action. Perinatal health is at best a secondary concern of health programmes.
The health expenditure in Pakistan is an average of US $460 per capitra, thus in the wake of limited resources any new programme faces the enormous challenge. The role of private and NGO sectors needs to be better defined for the reduction of perinatal mortality in Pakistan.
Of the existing interventions that may impact on perinatal outcomes, the ones that merit urgent attention include improved antenatal care and maternal nutrition, universal maternal tetanus immunisation coverage and effective screening for high-risk pregnancies and referral strategies. And improving the quality of care for perinatal services in the health system, as well as the training of TBAs physicians, especially obstetricians and primary care physicians.
Dr Bhutta is currently Chairman of the Department of Paediatrics and Child Health at the Aga Khan University Medical Centre. He is also an adjunct professor at the Tufts University School of Medicine in Boston (USA). He has played a key role in developing neonatal paediatrics and training programmes in Pakistan and is currently the president-elect of the Federation of the Asia-Oceania Perinatal Societies and the Commonwealth Association of Paediatric Gastroenterology and Nutrition.
He was awarded Tamgha-I-Imtiaz by the President of Pakistan in 1999 for contributions towards education and research. His wide ranging research interests include public health, community-based perinatal care, the interaction of nutrition and infections, and micronutrient malnutrition.
The book is provided with graphs and tables that help a reader in understanding the topics and to have a better insight into the situation occurring in different parts of South Asia regarding perinatal and newborn care. One can have a clear perspective of the subject explained and supported by the graphs and tables.
The book contains sixteen different chapters on perinatal and neonatal care in South Asia, including countries like Pakistan, Sri Lanka, Nepal, Bangladesh and India. The other topics discussed are epidemiology of maternal and foetal malnutrition, maternal nutrition, maternal behaviour and empowerment, morbidity and mortality: consequences of low birth weight, etc.
The principal authors of the book, other than Zulfiqar Ahmed Bhutta, comprise : Professor D G Harendra de Silva of Sri Lanka, Professor Dharma S. Manandhar of Nepal, Professor Nazmun Nahar of Bangladesh, Professor H.P.S. Sachdev of India, Ellen Girerd-Barclay of Nepal, Dr Kirsten S.Russell of USA, Professor Robert E. Black of USA, Professor A.M. de L. Costello of UK, Dr Ashok K. Deorari of India, Professor Victor Y.H. Yu of Australia, Dr Baldvin Jonsson of Sweden, Dr Anita K.M. Zaidi of Pakistan, Dr Roger Shrimpton of Switzerland, Dr Durrane Thaver of Pakistan and .Dr Adnan A. Hyder of USA.