Time to focus child survival programmes on the newborn: Assessment of levels and causes of infant mortality in rural Pakistan

Objective: Population-based surveys were conducted in selected Clusters of Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. Methods: Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. Findings: The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%) Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. Conclusion: The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care.