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Focus on newborn survival needed in rural Pakistan. (Child Survival).

Child survival programs in the developing world have typically focused on the post-neonatal period, the interval from one month of age to one year of age. This time of life has been targeted because cost-effective treatments and preventive medicine, such as childhood immunization and oral rehydration, exist for the most common ailments that occur then. These interventions, which gained momentum in the 1980s and continue today, have significantly reduced infant and child deaths in much of the developing world. As deaths in the postneonatal period become less common, however, an increasing proportion of infant deaths occur in the neonatal period, the first month of life. Limited data exist on the causes of neonatal death in developing countries. To address this dearth of information, Population Council program associate Fariyal F. Fikree used population-based surveys and in-depth interviews to gather data on infant mortality in rural Pakistan. She collaborated with Syed Iqbal azam of Aga Khan University in Pakistan and Heinz W. Berendes of the National Institutes of Health.

Assessing infant mortality

The researchers conducted surveys and interviews in selected sites in Balochistan and North-West Frontier Province, including the Federally Administered Tribal Areas of that province. These surveys collected information on the level and clinical causes of maternal and infant mortality and their associated risk factors. The field work was conducted during 1990-91 in Balochistan, in 1991-93 in North-West Frontier Province, and in 1994 in the Federally Administered Tribal Areas. These largely rural regions were selected to reflect various levels of socioeconomic development, and accessibility, and availability of health care personnel. In all of these areas, 90 percent of births occurred at home with the assistance of traditional birth attendants or family members.

The results showed that as infant mortality decreased, the proportion of neonatal deaths rose. In Balochistan the infant mortality rate was 129 per 1000 live births; 51 percent of these deaths happened in the neonatal period. In the Federally Administered Tribal Areas, where the infant mortality rate was 106 per 1000 live births, neonatal deaths accounted for 57 percent of these deaths. In North-West Frontier Province, where infant mortality was lowest, 70 per 1000 live births, the proportion of infant deaths that occurred in the neonatal period was highest, 67 percent.


"We found that tetanus was the predominant cause of neonatal deaths in North-West Frontier Province, where it caused 23 percent of deaths in the first month of life, and in the Federally Administered Tribal Areas, where it caused 36 percent of neonatal deaths," says Fikree. Tetanus was less common in Balochistan, causing only 5 percent of neonatal deaths. Diarrhea syndrome and acute respiratory infection were the main causes of neonatal death in Balochistan. These maladies became more common in North-West Frontier Province and the Federally Administered Tribal Areas during the postneonatal period.

These findings strongly demonstrate the need for a significant addition to child survival programs, say the researchers. Program managers should emphasize maternal and neonatal care, particularly strategies aimed at tetanus, while maintaining and strengthening strategies to reduce diarrhea and acute respiratory infections.

Neonatal tetanus in developing countries is largely attributable to three risk factors: lack of maternal immunization with tetanus toxoid, unhygienic delivery, and unhygienic umbilical cord care during the first week of life. Unhygienic cord care may include practices such as applying ghee (clarified butter) to the raw stump of the umbilical cord.

The maternal tetanus toxoid coverage reported in the Pakistan Demographic and Health Survey for 1990-91 was 23 percent. Tetanus toxoid immunization in the three rural areas surveyed is likely to be lower than the national average, say the researchers. "Increasing the number of women of childbearing age in these areas who receive tetanus toxoid immunization would greatly decrease the number of newborns who develop tetanus," says Fikree.

Although improving women's access to skilled birth attendants in these areas is important, adequate coverage in the near future is unlikely. Thus, increasing the maternal tetanus toxoid coverage, an easier task, is vital.
Top clinical causes of neonatal and postneonatal deaths in
Balochistan and North-West Frontier Province, including Federally
Administered Tribal Areas, Pakistan 1990-94

 Neonatal period Postneonatal period
Clinical cause No. % No. %

Diarrhea syndrome 33 5.1 213 43.3
Tetanus 119 18.3 14 2.8
Acute respiratory infection 39 6.0 93 18.9
Low birth weight 99 15.3 12 2.4

Source: Bulletin of the World Health Organization 2002,
80(4): 271-276, Table 1


Fikree, Fariyal F., Syed Iqbal Azam, Heinz W. Berendes. 2002. "Time to focus child survival programmes on the newborn: Assessment of levels and causes of infant mortality in rural Pakistan," Bulletin of the World Health Organization 80(4): 271-276.


National Institute of Child Health and Human Development, National Institutes of Health, and UNICEF
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Publication:Population Briefs
Geographic Code:9PAKI
Date:Jun 1, 2003
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