title: Maternal and newborn outcomes in Pakistan compared to other low and middle income countries in the Global Network's Maternal Newborn Health Registry: an active, community-based, pregnancy surveillance mechanism.
abstract: BACKGROUND
  Despite global improvements in maternal and newborn health (MNH), maternal, fetal and newborn mortality rates in Pakistan remain stagnant. Using data from the Global Network's Maternal Newborn Health Registry (MNHR) the objective of this study is to compare the rates of maternal mortality, stillbirth and newborn mortality and levels of putative risk factors between the Pakistani site and those in other countries.
  
  
  METHODS
  Using data collected through a multi-site, prospective, ongoing, active surveillance system to track pregnancies and births in communities in discrete geographical areas in seven sites across six countries including Pakistan, India, Kenya, Zambia, Guatemala and Argentina from 2010 to 2013, the study compared MNH outcomes and risk factors. The MNHR captures more than 60,000 deliveries annually across all sites with over 10,000 of them in Thatta, Pakistan.
  
  
  RESULTS
  The Pakistan site had a maternal mortality ratio almost three times that of the other sites (313/100,000 vs 116/100,000). Stillbirth (56.5 vs 22.9/1000 births), neonatal mortality (50.0 vs 20.7/1000 livebirths) and perinatal mortality rates (95.2/1000 vs 39.0/1000 births) in Thatta, Pakistan were more than twice those of the other sites. The Pakistani site is the only one in the Global Network where maternal mortality increased (from 231/100,000 to 353/100,000) over the study period and fetal and neonatal outcomes remained stagnant. The Pakistan site lags behind other sites in maternal education, high parity, and appropriate antenatal and postnatal care. However, facility delivery and skilled birth attendance rates were less prominently different between the Pakistani site and other sites, with the exception of India. The difference in the fetal and neonatal outcomes between the Pakistani site and the other sites was most pronounced amongst normal birth weight babies.
  
  
  CONCLUSIONS
  The increase in maternal mortality and the stagnation of fetal and neonatal outcomes from 2010 to 2013 indicates that current levels of antenatal and newborn care interventions in Thatta, Pakistan are insufficient to protect against poor maternal and neonatal outcomes. Delivery care in the Pakistani site, while appearing quantitatively equivalent to the care in sites in Africa, is less effective in saving the lives of women and their newborns. By the metrics available from this study, the quality of obstetric and neonatal care in the site in Pakistan is poor.
  
  
  BACKGROUND
  The study is registered at clinicaltrials.gov [NCT01073475].
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.forename: Sumera
authors.initials: S
authors.lastname: Ali
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.forename: Janet L
authors.initials: JL
authors.lastname: Moore
authors.forename: Margo
authors.initials: M
authors.lastname: Harrison
authors.forename: Mabel B
authors.initials: MB
authors.lastname: Berrueta
authors.forename: K
authors.initials: K
authors.lastname: Hambidge
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.forename: Bhala
authors.initials: B
authors.lastname: Kodkany
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
mesh_terms: D000328:Adult; D000349:Africa / Q000453:epidemiology; D001724:Birth Weight; D036861:Delivery, Obstetric / Q000379:methods; D003906:Developing Countries; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D007843:Latin America / Q000453:epidemiology; D008428:Maternal Mortality / Q000639:trends; D010154:Pakistan / Q000453:epidemiology; D054238:Perinatal Mortality / Q000639:trends; D011159:Population Surveillance / Q000379:methods; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology*; D011446:Prospective Studies; D012042:Registries; D050497:Stillbirth / Q000453:epidemiology; D055815:Young Adult