Midwifery Education and Maternal and Neonatal Health Issues: Challenges in Pakistan Rafat Jan Rukanuddin, RN, RM, PhD, Tazeen Saeed Ali, RN, RM, MSc-Epidemiology, and Beth McManis, CNM, PhD Although numerous health care interventions have been implemented in Pakistan, the high maternal and neonatal mortality rates still remain a challenge. Developed countries have reduced maternal and neonatal mortality rates by improving the skill and knowledge levels of nurse-midwives. This paper reviews maternal and neonatal health issues, challenges in current midwifery education, and the role of government and international agencies in Pakistan. The exact maternal and neonatal mortality rates in Pakistan are unknown; a census has not occurred since 1998, and data provided in more recent studies were presented in summary format. A number of factors that contribute to the high mortality rate could easily be controlled by using competent nurse-midwives throughout all levels of the Pakistani health care system. A reduction in the maternal mortality rate is likely to occur if the Pakistan government and international agencies work together to implement specific recommendations in maternal and neonatal health. These recommendations include: 1) holding an invitational conference; 2) strengthening the existing midwifery and Lady Health Visitor curricula; 3) pilot testing an expanded midwifery program; and 4) advocating for and obtaining political commitments and resources for midwifery education. J Midwifery Womens Health 2007;52:398 – 405 © 2007 by the American College of Nurse-Midwives. keywords: maternal and neonatal issues in Pakistan, midwifery in Pakistan, midwifery education in Pakistan INTRODUCTION Although Pakistan produces a surplus of medical doctors, the maternal and neonatal morbidity and mortality health statistics remain high. 1,2 Improvements in the maternal and neonatal mortality and morbidity rates have occurred in developing and developed countries, such as Sri Lanka, Cuba, Malaysia, Thailand, England, China, and Sweden, through the implementation of strong midwifery and nursing education and effective management of maternal and neonatal health problems. 3–8 Pakistan con- tinues to struggle to reduce the maternal and neonatal mortality rates, despite having implemented a number of safe motherhood strategies over the past 11 years. How- ever, the strategy of using competent midwives to pro- vide care is still not emphasized. The purpose of this article is to highlight the maternal and neonatal health issues, role of government and international agencies in Pakistan, and challenges in existing midwifery educa- tion. Recommendations for improving the maternal and neonatal mortality and morbidity rates in Pakistan are proposed. MATERNAL CHILD HEALTH IN PAKISTAN Pakistan is a country of 112 million people, which is bordered by India, China, Iran, and Afghanistan. Paki- stan consists of four provinces, including Sindh, Punjab, Boluchistan, and North-West Frontier Province. Two federally-administered areas include the Northern area and Federally Administered Tribal Areas. One major challenge in determining the status of maternal– child health in Pakistan is the lack of valid maternal and neonatal mortality statistics. The re- ported maternal mortality rates range from 200 to 513 per 100,000 live births, 9 –12 and neonatal mortality ranges from 56 to 90.2 per 1000 live births. 13,14 Many experts believe that the reported values underestimate the total number of maternal deaths in Pakistan. 15 In an analysis performed in 1997 by United Nations Children’s Funds (UNICEF), the death rate among Pakistan women during the reproductive period was estimated to range between 150 and 1700 per 100,000 live births. 16 Although statis- tics have been reported, the causes of these maternal deaths are not clear. The majority of these deaths are probably avoidable, and the lives of these mothers and newborns could be saved through the use of competent midwives. However, competent midwives can only be developed through high-quality education. Pakistan is one of the few countries in the world where males outnumber females. According to the Pakistan Demographic Survey, there are 108 males for every 100 females. Researchers have hypothesized that this differ- ence is caused by the high maternal mortality rate. The fertility rate is very high in Pakistan, and reported as 4.1 live births among women of age 15 to 44 years, which may contribute to the high maternal mortality rate. 17 By 2050, Pakistan could become the third most populated country in the world. 18 Reasons for high fertility include the lack of availability of contraceptives, myths regard- ing contraceptives, and belief system models. The un- availability of contraception, accurate information, and education leads to unsafe abortions and infections, which Address correspondence to Rafat Jan Rukanuddin, RN, RM, PhD, The Aga Khan University, School of Nursing, Stadium Road, P.O. Box 3500, Karachi, Pakistan 74800. E-mail: rafat.jan@aku.edu 398 Volume 52, No. 4, July/August 2007 © 2007 by the American College of Nurse-Midwives 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.02.014 Issued by Elsevier Inc.