SEPTEMBER 2015

POLICY BRIEF

REDUCING MATERNAL
AND CHILD MORTALITY IN
KHYBER PAKHTUNKHWA
The Untapped Potential of Family Planning
Family planning is recognized as a necessary tool for faster fertility
decline leading to accelerated economic development. However, its
unique and potent role in preserving mother and child health is
less well understood. This brief explains why family planning must
be prioritized in Khyber Pakhtunkhwa’s health strategy as a key
intervention for reducing maternal, infant and under-five mortality
in the province.
 B OX 1
RETHINKING THE ROLE OF
FAMILY PLANNING IN KHYBER
PAKHTUNKHWA’S HEALTH IGNORED AT PERIL
STRATEGY Evidence for family planning’s
massive potential to reduce
Khyber Pakhtunkhwa (KP) confronts a high incidence of
maternal and child mortality
preventable deaths among mothers, infants, and young
children. Maternal deaths account for 27 percent of
It is estimated that between 1990 and 2010,
mortality among women of reproductive age (PDHS 2007).
contraceptive use has accounted for about 40
In 2012, the maternal mortality ratio (MMR) was estimated
percent of the reduction in maternal deaths in
at 206 per 100,000 births (Sathar, Wazir and Sadiq 2014);
developing countries; if all the unmet need for
the infant mortality ratio (IMR) was 58 per 1,000 births;
contraception in the world were fulfilled, a fur-
and the under-five mortality ratio (U5MR) was 70 per 1,000
ther 30 percent reduction in maternal deaths
births (PDHS 2013). These ratios currently translate into an
would be achieved (Cleland et al. 2012). More-
annual death toll of nearly 1,700 women, 47,400 infants,
over, voluntary family planning could eliminate
primarily due to conditions that could easily be prevented
the 13 percent of maternal deaths that occur
with basic healthcare.
due to unsafe abortions and 36 percent of ma-
Until recently, the health system’s response to lowering ma- ternal deaths caused by unintended pregnan-
ternal and child mortality has focused on increasing women’s cies (Bongaarts et al. 2012).
access to antenatal, postnatal and obstetric care; improving
nutrition; expanding immunization; and ensuring treatment In the specific case of Pakistan, Ahmed et al.
for the two major child killers, diarrhea and pneumonia. In (2012) estimate that family planning averted
recent years, important improvements in MCH indicators 42 percent of maternal deaths in 2008 (with a
have been achieved in KP. Between 1990-91 and 2012-13, CPR of 29.2 percent).
it is estimated that skilled birth attendance rose from 12 to Birth spacing has also been recognized as one
48 percent, and the proportion of women receiving antena- of the strongest interventions to improve child
tal care went up from 18 to 61 percent (PDHS 1990-91 and survival rates. According to Rutstein (2008),
2012-13). Since 2001, complete immunization among chil- birth intervals of 33 months would reduce the
dren aged 12 to 23 months has also increased from 57 to U5MR by 13 percent, and, in Pakistan, neona-
75 percent (PIHS/PSLM 2001-02 and 2013-14). tal, infant and child mortality are almost halved
While these are important and necessary elements of the ar- when birth intervals are 4 years or more, com-
senal for improving maternal and child health (MCH), the po-
pared to when they are less than 2 years.
tential role of family planning has remained underutilized. In
the past 15 years, the contraceptive prevalence rate (CPR) in
KP has inched forward by less than half a percentage point a
year from 24 percent in 2000-01 to only 28 percent in 2012- when a woman resorts to induced abortion—especially when
13 (Fig. 1). the procedure is performed in unsafe settings, as is typically
Yet, there is strong evidence to warrant a repositioning of the case in Pakistan.
family planning in national and provincial health strategies
Furthermore, we now know that children’s risk of dying in
as a central MCH intervention (Box 1). It is internationally
infancy or before the age of five is strongly correlated with
recognized that women face significantly heightened risks of
the same high-risk fertility behaviors that endanger mothers’
pregnancy-related death when they are too young (less than
18 years) or too old (more than 34 years) at the time of birth; lives. The strong association between maternal health and
when the birth interval is less than 33 months; and when infant survival, particularly for neonates, is the basis of the
parity exceeds three children. In addition, every unintended Healthy Spacing and Timing of Pregnancies (HSTP) initiative
pregnancy represents an unnecessary risk, which escalates launched by the World Health Organization (WHO).

2 P OLI C Y B RI EF
F IGUR E 1: C ONT R AC E PTIV E PRE VA L E N C E IN K P (%) F IGURE 2: MATERNA L MO RTA L IT Y RATE I N K P -
TREND S & TA RGET S

140

Note: Dotted as estimated/projected

To meet its ambitious MMR, IMR and Sources: PDHS 2013 and Khyber Pakhtunkhwa Sector Plan (KPHSS) 2010-2017

U5MR targets, the government must

leverage every promising intervention F IGURE 3: INFA NT A ND UND ER- F IVE MO RTALIT Y RAT IO
IN KP - TREND S & TA RGET S
at its disposal. Family planning offers an
extremely effective but as yet underutilized
route for achieving huge reductions in
maternal and child mortality.

The good news is that the Khyber Pakhtunkhwa Health 33

Sector Strategy 2010-2017 and the Draft Population Policy 27

2014 both recognize the important links between raising

contraceptive use in KP and improving survival among moth-
ers, infants and children under the age of five. However, for
a faster uptake of family planning in KP, the draft population
policy emphasizes a need for “strong leadership support and
open commitment at the highest level for continued and en- Note: Dotted as estimated/projected
hanced social acceptability of birth spacing, with a mecha- Sources: PDHS 2013 and Khyber Pakhtunkhwa Sector Plan (KPHSS) 2010-2017
nism to foster inter-sectoral linkages and support.”

This renewed emphasis on family planning must be achieved

soon given the important difference it can make in current Under Vision 2025, reducing maternal and infant mortali-
trends in maternal and infant mortality. KP’s estimated MMR ty has been declared a national priority. Encouragingly, the
dropped steeply between 2001 and 2006, but the decline Government of KP, in its Health Sector Strategy, aims to low-
became much slower thereafter (Fig. 2). Similarly, a decline er the MMR to 140 per 100,000 births and the IMR to 40
in the province’s infant and child (under 5 years of age) mor- per 1,000 by 2017. However, in order to meet these difficult
tality ratios has almost plateaued since 2006-07 (Fig. 3). Re- targets, the government will need to leverage every prom-
grettably, like the other provinces, KP was unable to achieve ising intervention at its disposal. Family planning offers an
its Millennium Development Goals for MMR, IMR, and U5MR extremely effective but as yet under-exploited route for get-
in 2015. ting there.

S EP T EMB ER 2 015 3
IMPROVING MATERNAL Worryingly, however, these healthier fertility preferences are
not translating into practice. Surveys show that 54 percent
AND CHILD SURVIVAL IN KP of married women of reproductive age (MWRA) in KP would
THROUGH FAMILY PLANNING like to use contraceptives to space or limit births. However,
Among men and women in KP, there is a growing prefer- only 28 percent are using any family planning method (Fig.
ence for avoiding the high-risk fertility behaviors that threat- 5). The proportion of women using reliable modern meth-
en maternal and child health. It is estimated that 72 per- ods is even smaller, i.e., 20 percent. Therefore, nearly half
cent of women wish to limit or delay births by two years (Fig. of family planning need in KP is currently unmet—26 per-
4), and this desire is shared by 61 percent of men (PDHS cent of MWRA are not using any method, modern or tradi-
2013). tional, even though they wish to space or limit births. This
gap indicates that a significant increase in contraceptive
prevalence can be achieved capitalizing on this group even
without extensive demand generation efforts.
F IGUR E 4: FE R T ILI T Y PRE F E RE N C E S O F WO MEN IN KP
The gap between family planning demand and need also
( % ) 201 2 - 2 01 3
means, however, that a large proportion of MWRA in KP are
unable to practice healthy spacing and timing of pregnan-
cies, which exposes them and their young children to the
following sources of mortality risks:

1. Unintended pregnancies – The province’s total fer-

tility rate (TFR) is 3.9 while the estimated average
number of children wanted by women is 2.6 (PDHS
2012-13). This means a third of the 1.3 million preg-
nancies that occur in the province every year are
unintended and, on average, every woman of repro-
ductive age faces the unnecessary risk and physical
burden of more than one unintended pregnancy.

2. Unsafe induced abortions – Due to unwanted preg-

Source: PDHS 2013
nancies, there were slightly over 224,000 induced
abortions in KP in 2012, resulting in nearly 68,500
cases of post-abortion complications (PAC). With 9
F IGUR E 5 : T H E G A P B E T W E E N FA MILY PL AN N ING
D E M A N D AN D US E IN K P ( % ) out of every 1,000 women of reproductive age seek-
ing treatment, the province accounted for 8 percent
of the PAC caseload for the entire country (Popula-
26% of tion Council 2014).
currently
married
women
3. Adolescent pregnancy – At the time of the 2012-13
have PDHS, 10.9 percent of women (aged 15-19) had be-
unmet
need gun childbearing. Among every 1,000 women in this
age group, 37 had given birth in urban areas and
56 in rural areas. These young women face special
health risks that are further aggravated by poverty
and relatively lower access to MCH services.

4. Infants of teenaged mothers – Moreover, as shown

in Fig. 6, neonatal mortality among children of teen-
aged mothers is significantly higher than the level

Source: PDHS 2013

4 P OLI C Y B RI EF
 found among women aged 20-29, and there are sim-
ilar significant differentials in the post-neonatal mor-
tality rate by mother’s age.

5. Late childbearing – According to PDHS 2013, some

17 percent of women in KP had given birth after
the age of 35. Late childbearing is associated with
heightened risks of maternal and infant health is- F IGURE 6: NEO NATA L A ND PO S T- NEO NATAL MORTALIT Y
sues. RATIO S IN KP BY MOTH ERS ’ AG E AT BIRT H
(D EATH S PER 1 , 000 L IVE B IRTHS)
6. High parity – PDHS 2013 found 50 percent of wom-
en in KP had given birth to four or more children. This
situation exposes mothers as well as infants and
young children to heightened risks of malnutrition
and health complications.

7. Short birth intervals – To give mothers the best

chance to maintain sound health while delivering
and raising healthy children, WHO recommends an
interval of at least 33 months between births. Birth
spacing is also known to play an important role in the
nutritional status of children under 5 years of age,
with shorter birth intervals increasing the risk of low Source: PDHS 2013
weight, at birth and beyond, as well as stunting. How-
ever, about 28 percent of women in KP gave birth
less than 24 months after a previous birth, while 60 F IGURE 7: NEO NATA L A ND PO S T- NEO NATAL MORTALIT Y
percent gave birth less than 36 months after the pre- RATIO S IN KP BY B IRTH INTERVAL ( DEAT HS
vious birth (PDHS 2013). Fig. 7 illustrates the great PER 1 , 000 L IVE B IRTH S )

differences in mortality ratios among infants born af-

ter short and adequate birth intervals.

The above-outlined risks, which lead to maternal, infant

and young child mortality, can be addressed through family
planning. To prevent the mortality associated with high-risk
fertility behavior, the existing demand for family planning
must be fulfilled at the earliest by eliminating current un-
met need. In the longer run, the public and provincial stake-
holders must be educated about the necessity of healthy
spacing and timing of pregnancies so that demand for con-
traception increases to cover the complete family planning
needs of all MWRA. Increased use of family planning would
not only prevent the mortality and sickness caused by high- Source: PDHS 2013
risk fertility behavior, it would also reduce the pressure of
unintended pregnancies and births, and associated mater-
nal and child morbidity on the health system.

S EP T EMB ER 2 015 5
MEASURING THE POWERFUL Reduction Achievable in Maternal Mortality
LIFE-SAVING POTENTIAL OF • Eliminating unmet need for family planning would pre-
FAMILY PLANNING IN KP vent 37 percent of maternal deaths (Fig. 8)

In 2014, the Population Council, Pakistan conducted a study • Raising skilled birth attendance from 48 to 80 percent
to estimate the size of reductions achievable in maternal, would prevent 36 percent of maternal deaths (Fig. 8)
infant, and child mortality in KP through increased family • Eliminating unmet need and simultaneously increas-
planning (Sathar, Wazir and Sadiq 2014). Simulations were ing skilled birth attendance to 80 percent would pre-
conducted to gauge the change in maternal, infant and child vent 60 percent of maternal deaths (Fig. 8)
mortality when existing unmet need for family planning (26 Reduction Achievable in Infant Mortality
percent) is reduced or eliminated by raising the CPR.
• Reducing unmet need for family planning by increas-
In the case of maternal mortality, the study examined the ef- ing the CPR to 41 percent would reduce infant mortal-
fect of eliminating unmet need by raising the CPR from its ity by 28 percent (Fig. 9)
existing level of 28 percent to 54 percent (Scenario 1 in Fig.
• Eliminating unmet need altogether would reduce in-
8). For comparison purposes, the effect of increasing skilled
fant mortality by 57 percent (Fig. 9)
birth attendance from its past level of 48 percent to 80 per-
cent was also examined (Scenario 2) (Sathar, Wazir and These findings show that family planning programs should
Sadiq 2014). be an equally important component of improving maternal
health and reducing maternal and infant mortality. The same
To measure the impact of family planning on infant mortality, reductions in maternal mortality can be achieved by eliminat-
simulations of two scenarios were conducted—one in which ing unmet need for family planning as by increasing skilled
unmet need was reduced by raising the CPR to 41 percent birth attendance.
(Scenario 1 in Fig. 9) and the second in which unmet need
was completely eliminated by raising the CPR to 54 percent
(Scenario 2). The study arrived at the following eye-opening
conclusions:

FIGU R E 8 : MATE RN AL L IV E S TH AT CA N B E SAVED A NNUA L LY IN KP BY INC REA SING

C O N TRAC E PTIV E PRE VAL ENC E A ND S KIL L ED B IRTH ATTENDA NC E

6 P OLI C Y B RI EF
 FIGU R E 9 : IN FA N T L IV E S TH AT CA N B E SAVED A NNUA L LY IN KP BY INC REA S ING
C O N TRAC E PTIV E PREVA L ENC E

POLICY IMPLICATIONS ily planning must be swiftly repositioned in provincial policy

as a key mother and child health intervention. In this regard,
For a rapid reduction in maternal, infant, and child mortality
it is highly laudable that the Department of Health plans
to the levels targeted for 2017 and onwards, the most effec-
to revitalize the delivery of family planning services and, in
tive strategies for improving MCH need to be galvanized in
particular, ensure uninterrupted supply of contraceptives
KP. The evidence shows that family planning is one of the
to facilities and community-based health workers, under a
most powerful tools at the government’s disposal. Simply by
Minimum Health Service Package (MHSP) for primary and
fulfilling the existing unmet need for birth spacing and lim-
secondary healthcare that will be accessible to 70 percent
iting—which would mean raising the CPR to 54 percent—it
of the population by 2017. This intent must be supported
is possible to prevent 37 percent of maternal deaths, 57
with commitment from the highest level of government; syn-
percent of infant deaths. This will lead to proportionate de-
ergistic cooperation with other partners, especially the Pop-
clines in the maternal, infant and child mortality ratios of the
ulation Welfare and Planning & Development Departments;
province. Notably, more women’s lives can be saved in this
and adequate financial allocation.
manner than by increasing skilled birth attendance from 48
to 80 percent. The cost–benefit analysis of investing in family planning
should further take into account the profound links of this
Family planning’s wider health benefits further justify its im-
intervention with the government’s socioeconomic and pop-
mediate prioritization. These include, for example, reduced
ulation aims and policies. The benefits of family planning in
anemia among women; lower numbers of underweight,
terms of increased women’s empowerment, female partici-
wasted, and stunted children; and reduced burden on ante-
pation in the workforce, household savings, poverty reduc-
natal, obstetric, postnatal and post-abortion services.
tion, and school enrollment are well-documented (Sathar,
Moreover, family planning is highly cost-effective: every dol- Wazir and Sadiq 2014) and, to a considerable extent, ac-
lar spent on this intervention saves nearly four dollars that knowledged in KP’s Comprehensive Development Strategy.
would otherwise be spent on maternal health, immunization, These gains will be most visible when family planning inter-
malaria, water and sanitation, and education (Bongaarts ventions are targeted at the segments of KP’s population
2012). that need them most: the less developed and northern dis-
tricts; the rural areas; poor communities; and young, uned-
In view of its immediate and significant health benefits, fam- ucated women.

S EP T EMB ER 2 015 7
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Pakistan Bureau of Statistics. 2002. Pakistan Integrated Household WHO. 2000. Maternal Mortality 2000: Estimates developed by WHO,
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TH E E VID E NC E PRO J E C T The Evidence Project is made possible by the generous support of the American
Population Council people through the United States Agency for International Development (USAID)
under the terms of cooperative agreement no. AID-OAA-A-13-00087. The contents
House No. 7, Street No. 62 of this document are the sole responsibility of the Evidence Project and Population
Section F-6/3 Council and do not necessarily reflect the views of USAID or the United States Government.
Islamabad, Pakistan
tel +92 51 844 5566 The Evidence Project uses implementation science—the strategic generation,
evidenceproject.popcouncil.org translation, and use of evidence—to strengthen and scale up family planning and
reproductive health programs to reduce unintended pregnancies worldwide. The
Evidence Project is led by the Population Council in partnership with INDEPTH Network, International Planned
Parenthood Federation, Management Sciences for Health, PATH, Population Reference Bureau, and a University
C ON T R IB UTO RS Research Network.
Dr. Zeba A Sathar (T.I.)
Maqsood Sadiq © 2015 The Population Council, Inc.
Seemin Ashfaq
Suggested Citation: Sathar, Zeba A., Maqsood Sadiq, and Seemin Ashfaq. “Reducing maternal and child mortality
in Punjab: The untapped potential of family planning,” Policy Brief. Islamabad, Pakistan: Population Council, Evi-
dence Project. 2015.