Pakistan is far behind neighbouring Muslim-majority countries such as Iran and nearby Bangladesh and Tajikistan on fundamental mother and child health targets, according to a major global study published in The Lancet.

Researchers from Aga Khan University, the Centre for Global Child Health at the Hospital for Sick Children in Toronto, Canada, and the Dalla Lana School of Public Health, analysed data from 1990 to 2015 relating to 75 high-burden countries across the world with a specific focus on rates and drivers of change in the Islamic world. Their findings have been published in the Lancet paper Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis. 

The study found Pakistan to be in the second-worst performing group of countries on reducing the deaths of children under the age of five. Pakistan has also made far slower progress in reducing maternal mortality than other developing countries in South and Central Asia.

Researchers found no indication that religion per se had a direct impact on health outcomes. The findings of the study point to issues such as conflict, migration, political instability, government effectiveness, literacy, and female empowerment as key drivers of differences in maternal and child mortality. 

"While rates of maternal and child mortality are generally higher in Muslim-majority countries such as Pakistan there are also several success stories," says lead author Professor Zulfiqar A Bhutta, founding director of the Centre of Excellence in Women and Child Health at AKU. "Major successes, especially in child mortality reductions, have been achieved in child mortality in Niger, Maldives, Morocco, Azerbaijan, Senegal, Bangladesh, and Egypt." 

"Notable however, are the unacceptably low rates of skilled care for mothers in childbirth, poor coverage of essential childhood immunizations and low rates of sanitary services. Poor governance, lack of accountable and democratic governments as well as insecurity, conflict and population displacement emerge as key determinants driving health disparities. Unequal societies are also fertile grounds for the growth of rebellion and militancy, especially in young people. Efforts to improve the health of almost two billion Muslims worldwide, and reduce health inequalities, will prove vital to achieving the Sustainable Development Goals, including peace building over the next 15 years," Professor Bhutta added. 

Every year, worldwide, an estimated 303,000 mothers and 5.9 million children younger than 5 years die from largely preventable causes. More than 95 per cent of these deaths occur in 75 countries of the world predominantly in south Asia, the Middle East and Africa. Around the world, the study found that Muslim-majority countries have higher maternal, stillbirth, newborn and child mortality rates compared to the global average and compared to non-Muslim-majority countries. 

On average, Muslim-majority countries had lower contraceptive use (60% vs 79%), family planning needs satisfied (83% vs 91%), antenatal care with a skilled birth attendant (79% vs 96%), skilled birth attendance (59% vs 96%), measles vaccination (76% vs 98%), DTP3 (78% vs 98%) vaccination, and worse access to improved water (87% vs 94%) and sanitation facilities (61% vs 76%). On average, exclusive breastfeeding was higher in Muslim-majority countries (39% vs 27%). 

Total health expenditure was lower for Muslim-majority countries (4.2% vs 5.4% of GDP) and out-of-pocket health expenditure was higher (55% vs 43%). The average density of health workers including physicians, nurses, and midwives was lower in Muslim-majority countries (20 vs 31 per 10,000 people) and was below the WHO recommended threshold of 23 workers per 10,000. 

On average, Muslim-majority countries also performed worse in five governance indicators including control of corruption, government effectiveness, political stability or absence of terrorism, regulatory quality and rule of law. 

The authors find that legislation and policies specifically protecting women were insufficient in Muslim-majority compared to non-Muslim-majority countries, particularly around domestic violence (21% vs 49% of countries have policies), marital rape (13% vs 38%), emotional violence (38% vs 62%), and physical violence (42% vs 66%). 

"Insufficient empowerment and lack of social support for women can limit their accessibility to basic healthcare, including family planning, and adversely impact health, nutrition and well-being of the entire family. Used as facets of female empowerment, the low levels of female literacy, high fertility rates, and early marriage of young girls seen in many Muslim-majority countries need urgent remediation," states Nadia Akseer, first author of the report from the SickKids Centre for Global Child Health in Toronto, Canada.

The authors note that while the study compared Muslim-majority and non-Muslim majority countries, it did not explore Muslim versus non-Muslim subpopulations within Islamic countries, countries such as India, China, and Nigeria, which have substantial Muslim populations (but less than 50%), or how the individual practices of Islam are implemented within countries.  Further research will be needed to examine these questions. 

Writing in a linked comment in the Lancet, Amina Mohammed, Deputy Secretary-General, United Nations, says: "Greater investments in reproductive, maternal, newborn, child, and adolescent health are also some of our greatest tools in the face of rising levels of conflict and humanitarian crisis, which disproportionately affect Muslim-majority countries. We must prioritise the potential of women and adolescents as agents of peace through greater investments across health, education, and economic sectors." 

The Lancet​ study article​.