This study demonstrates the under-reporting of maternal and neonatal mortality rates in the study area compared to the previous 1.5 years; maternal mortality was under-estimated by 27% and neonatal mortality by 50%. The mortality rates in the study area calculated from the enhanced surveillance system were higher than those estimated from the previous routine LHWs data. This study provides accurate maternal, perinatal and neonatal mortality rates by establishing an enhanced surveillance system that captured births and deaths from 96% of the study population, through multiple data sources, including data collection from the public and private health facilities and extended community coverage, in a rural area of Khyber Pakhtunkhwa province, Pakistan. During enhanced surveillance 2015/16 higher maternal, neonatal and perinatal rates were found in CHWs areas subject to extended coverage than in the LHWs areas reflecting the more rural and remote character of the previously uncovered areas. The inclusion of the CHW areas increased coverage of women by 20%, but this could not be maintained for 4% because of difficulties associated with remoteness. Comparison of the LHWs data 2015/16 with the previous LHWs data shows that enumeration by LHWs improved with enhancement of surveillance, quite apart from expansion of coverage to new areas. Improvement in maternal, neonatal and perinatal mortality was due to improved completeness as a result of data collection on births and deaths from all sources including community, public and private health facilities, and increased coverage to CHW areas with higher maternal and neonatal mortality.
The surveillance system successfully integrated birth and death data from available routine health information system and extended the surveillance system to the areas and health facilities from where previously no birth or death data were reported. The robust enhanced surveillance system provided sufficient evidence of underestimation of mortality rates in the study area through before and after comparison of mortality rates separated by 1.5 years. The comparison of the study area with itself is closely related in time (1 year), with no change in socioeconomic status and health system, and no disaster, or epidemic diseases or civil disturbance over the comparison period. Although a higher maternal mortality was calculated using the enhanced surveillance system data in the study area compared to routine health information systems, the number of maternal deaths were not sufficient to demonstrate a statistically significant difference in maternal mortality rates. This is a consequence of the short duration of the study, and the small number of maternal deaths.
This is the first study in Pakistan to include private health facilities in a maternal and perinatal surveillance system. The proportion of deliveries reported by private health facilities was 11% of the total births in the study area. This proportion is less than the 2012/13 DHS Provincial statistics of 24% of births [5]. Possible reasons for the discrepancy may include lower affordability for private hospitals in Tehsil Havelian than that for the Province, or there may be under-reporting of births by the private hospitals for various reasons. Nevertheless, the likelihood of missing any birth or death that occurs at private health facilities is much less, because 96% of the population in the study area was covered either by the LHWs or by the CHWs during the enhanced surveillance in 2015/16.
Estimates of MMR in Pakistan suggest a decline from 431/105 live births in 1990 to 178/105 live births in 2015. Although a substantially higher maternal mortality was observed by the enhanced surveillance system in the study area of Tehsil Havelian (247/105 live births), compared to the national MMR of 178/105 estimated by the international agencies (World Bank, WHO, UNICEF, UNFPA) for the year 2015, the Provincial MMR of Khyber Pakhtunkhwa estimated by 2006/07 DHS was consistent with the enhanced surveillance system at 275/105 live births. A study by Sathar reported an estimated national MMR of 220/105 live births in 2012. The study also estimated Khyber Pakhtunkhwa Province MMR of 423/105 live births in 2001, 275/105 live births in 2006, and 206/105 live births in 2012 [17]. A population-based prospective study on active surveillance of pregnancies and their outcomes conducted in six countries, including Pakistan, during 2010-2012 reported a MMR of 313/105 live births, in a rural District of Sindh province [18], similar to MMR reported by DHS 2006/07. A retrospective study of facility-based maternal mortality which collected data for 10 years (2002–2012) in a tertiary care hospital of Khyber Pakhtunkhwa province (Pakistan) reported a MMR of 772/105 live births [19], but this may be affected by referral of complicated cases. Under-enumeration of maternal and neonatal deaths by the LHWs was noted in a study in Lahore (Punjab Province) in 2010, that reported underreporting of maternal and infant deaths by LHW due to fear of not maintaining adequate performance indicators [9]. Verification of LHWs reports showed 92.5% correctly reported maternal death, while 5% underreported and 2.5% over reported maternal deaths [9].
The neonatal mortality in Pakistan changed little during the past two decades according to survey data from the DHS, and the enhanced surveillance neonatal mortality rate is consistent with national and provincial estimates around 2015, but much higher that the LHW data (Fig. 3). The neonatal mortality rate reported by Pakistan DHS 1990/91 was 51/103 live births (1986–1990), Pakistan DHS 2006/07 (2002–2006) was 54/103 live births and Pakistan DHS 2012/13(2008–2012) was 55/103 live births [5]. A non-significant decrease in neonatal mortality was reported by DHS 2012/13 in Khyber Pakhtunkhwa, from 48/103 live births in 1990 to 41/103 live births in 2012 (Fig. 3) [5]. A population-based prospective study reported a neonatal mortality of 50/103 live births, in rural District of Sindh province during 2010–2012 [18].
The stillbirth morality rate estimated from the previous 1.5 years routine LHWs data was higher (32/103 births) compared with the stillbirth rate estimated from the LHWs data collected by the enhanced surveillance system (29/103 births). The over-enumeration of stillbirths by LHWs could be due to their under-enumeration of early neonatal mortality. An international review in 2006 found that a live birth may be recorded as a stillbirth if the baby died immediately after birth, because of various reasons including inadequate knowledge, avoidance of blame, fear of extra work, or poor assessment for the signs of life [20]. A study conducted in 2011/13 [21] reported stillbirth rates of 50/103 births in District Thatta (rural district), Sindh Province of Pakistan. Another prospective study in Sindh Province reported similar higher rates of stillbirths (66/103 births) in 2003 [22]. These rates were higher than calculated from our enhanced surveillance system, as well as that estimated by Pakistan DHS 2012/13.
It is worth noting that neonatal mortality (40/103 live births), early neonatal mortality (30/103 live births), stillbirths (32/103 births) and perinatal mortality (60/103 births) in the study area in 2015, is similar to Provincial neonatal mortality (41/103 live births), early neonatal mortality (33/103 live births), stillbirths (31/103 births) and perinatal mortality (63/103 births) estimated by the DHS in 2012/2013 [5]. However, interpretation needs to take account the differences in methods and time period of 8 years between our study in 2015/16 and those estimated by the DHS 2012/13, and the differences between the Tehsil Havelian and the entire province.
Adolescent women are considered high risk for adverse pregnancy outcomes. A recent population-based prospective study conducted from 2010 to 2013 in six low and middle-income countries including Pakistan, reported a higher rate of maternal, neonatal and perinatal mortality among women aged 15–19 years compared to women age ≥ 20 years [23]. This study does not include pregnant women aged < 18 years as the sample size would be insufficient for subgroup analyses, and extended consent would be required from parents and additional approval from research ethics committees.
Higher rates of stillbirth, early neonatal, neonatal and perinatal mortality among males than females are consistent with the Pakistan DHS 2012/13 that reported higher neonatal mortality in males compared with females in Pakistan. An analysis using data from the Pakistan Demographic Health Survey 2006/07 reported a statistically significant hazard ratio of 1.57 for neonatal mortality in males compared to female neonates [24]. This is also consistent with international statistics where neonatal and infant mortality in males are reported to be higher than females which provide further validation for the study [25]. Reasons for this higher mortality in males are explained by biological factors, including a higher risk of respiratory syndrome (related to late maturity), infectious diseases, congenital malformations of the urogenital system in males, and fetal growth retardation [26,27,28]. Population characteristics of the study population were similar to the provincial population in terms of total fertility rate, general fertility rates, body mass index and sex ratio at birth (Male/Female) [5]. Hence the results of the study likely reflect the Provincial population.
The Pakistan DHSs estimated maternal, perinatal and neonatal mortality only at the national and provincial level, which may mask the district or sub-district variations in mortality rates. The need to access district and sub-district data is also reported by a South African study in 2016 [29], which emphasizes the need to use disaggregated data at the sub-district level for equitable resource allocation and targeting the areas in need. A study on a vital events surveillance system in India estimated causes of maternal and neonatal deaths in 2012 using CHWs and supported the application of targeted community-based interventions that resulted in a significant reduction in neonatal mortality [30].
The LHW Program, having 70% coverage of national population, provides an opportunity to measure accurate mortality rates at the sub-district level if coverage is enhanced to capture the entire population. The enhanced surveillance system demonstrated that the birth and death data reported by LHWs, CHWs (for enhanced coverage), community midwives, health care facilities (public and private), and the routine health information system (DHIS), can be reconciled to provide accurate and timely mortality rates at a district and sub-district level. This could be used to strengthen the healthcare delivery system through the application of area-specific and cause-specific targeted healthcare interventions and improving the coverage of current health care program in Pakistan. This surveillance system can enable health managers to utilize resources more efficiently and target them to the area most in need, thus have a maximum impact of the targeted intervention in the reduction of mortality rates.
Following decentralization of services in Pakistan (18th Amendment of the Constitution) in 2010, it is imperative to have accurate maternal, perinatal and neonatal mortality rates at the district and sub-district level. In addition, the local government ordinance highlights the need to empower local governments and improve the governance by decentralized decision-making [8, 31].
Accurate and timely data on mortality is required to monitor progress, implement health interventions and to evaluate health programs at national and sub-national levels [32, 33]. A global assessment of civil registration and vital statistics reported most South Asian countries, including Pakistan, have weak vital civil registration with inadequate coverage and poor quality data on deaths and causes of deaths [33]. In these circumstances, maternal, perinatal and neonatal mortality data are obtained from household censuses, Demographic Health Surveys [34], Multiple Indicator Cluster Surveys [35] and reproductive age mortality surveys [36], employing direct death inquiry of household members over a retrospective period, and/or indirect methods such as children ever-born and children surviving, and orphanhood and widowhood [37, 38] questions in national and/or sub-national surveys [39]. However, these sources have various limitations, including underestimation of maternal deaths and requirement of large sample sizes [40,41,42]. Although a population census may be a better approach to measuring mortality rates than surveys, there are issues with data quality and omission of up to 50% of deaths in population censuses has been reported [42].
A small proportion (4%) of the study population living in very remote areas could not be completely covered by the surveillance system for the entire duration of the study. Eighteen CHWs recruited for these areas registered 2599 women of reproductive age (18–49 years), ten left during the first month, and eight afterwards, mostly due to the arduous nature of the work. However, 37 births and no deaths were recorded by the CHWs prior to their resignation. These data were not included in analyses.
Further research is needed to demonstrate the feasibility of using this enhanced surveillance system that integrates births and deaths data from all possible sources for application of area-specific and cause-specific interventions with measurement of the impact of the reduction in mortality rates. This is particularly required in districts with low community coverage by LHWs and Midwives. Opportunities should also be explored to link births and deaths captured by routine health information systems with civil registration authorities to strengthening civil registration and vital statistics. Research is also needed to measure the effects of adequate surveillance on Mother and Child Health Programs and expected reductions in MMR and NMR.