The nurses who emerge from the delivery room at the Ganga Ram Hospital in this eastern Pakistan city early in the morning look tired. They have completed a long shift, and attended to two women giving birth.
“One of the babies, a boy, weighs very little; under 2kg. He will probably not survive,” one of the nurses, who asked not to be named, told IRIN.
Babies born under 2.5kg are classed as having low birth weight (LBW) - and it is a categorization that is far from unusual in Pakistan.
The country has the world’s second highest recorded rate in the world (32 percent), surpassed only by Mauritania which has a rate of 34 percent (data is not available for Afghanistan), according to the UN Children’s Fund’s (UNICEF) 2013 State of the World’s Children report.
“Weight at birth is a good indicator not only of the mother’s health and nutritional status but also of the newborn’s chances for survival, growth, long-term health and psychosocial development,” says UNICEF.
Tests suggest low weight babies will on average have a 5 percent lower IQ.
But the precise reasons for Pakistan’s alarming LBW statistics are not entirely clear.
“The problem is most common among poorer families, but even so these families often eat a reasonable diet - so nutrition alone is not the factor,” said Samina Ahmed, a gynaecologist and obstetrician who has for over 20 years worked at a charitable clinic run for women in Lahore.
“Too many pregnancies, depleting the mother’s body, and a lack of access to birth control for them are probably factors,” she said.
Available evidence indicates that while 96 percent of women who have ever been married are aware of at least one contraceptive method, less than half use it due to a lack of access and advice.
Not just poverty
According to research by the Islamabad-based Pakistan Institute of Development Economics (PIDE), poverty alone is not a factor.
Indeed, the phenomenon has been hard for experts to explain, with PIDE in a July 2012 study linking LBW to a variety of factors including the Body Mass Index of mothers, the place of birth for the child and access to health care for both.
“The nutritional status of children is thus more likely to be rooted in their illness, nutritional status of their mothers, and environmental and community factors, than poverty,” the study notes.
Stunting (low height for age) for under fives is 43.7 percent nationally, according to the National Nutrition Survey.
The PIDE study also reports an increase in the incidence of stunting and wasting (low weight for height) over the last decade but says it is hard to explain why this has occurred. It notes the lack of a direct correlation between poverty and nutritional status, particularly since poor people based in rural areas are often able to grow at least some of their own food.
The National Nutrition Surveys show malnutrition among children, measured by wasting, grew from 11 to 15 percent between 1985-87 and 2011.
“I cannot say why this is the case, but as a physician working in a rural area, I can say that perhaps the quality of food children receive is poorer, with more packaged, processed items fed to them,” said Muhammad Salimuddin, a doctor in the town of Jaranwala, which also caters for people who come in from surrounding villages in Punjab.
The poor levels of nutrition feed into a cycle of malnourished adults producing malnourished children, with few health services available to help them break the pattern.
“The consequences of such inadequate health services for pregnant women at a national level, coupled with inadequate food consumption, virtually non-existent services for adolescent girls and early age of marriage are particularly serious in terms of pregnancy outcomes,” says a recent report by the provincial government of Sindh.
The link between maternal health and LBW is, however, one that experts believe to be of considerable significance.
“While economists and politicians argue over the definitions of poverty, many women remain under-served, frequently bereft of fundamental rights and access to health, education and adequate nutrition,” says a paper by Zulfiqar Bhutta, a doctor who heads the Division of Women and Child Health at Aga Khan University in Karachi.
“In contrast to Latin America and much of Southeast Asia, progress in key interventions such as female education and empowerment, enhancement of age at marriage and first pregnancy and access to family planning remain painfully slow,” Bhutta notes.
Women such as Shahida Jabeen, in the semi-rural town of Muridke on the outskirts of Lahore, testify to this.
“I was married at 17 years, and now, eight years on, have four children. I am pregnant again, and I am scared, because my third pregnancy resulted in a baby who died when she was a few weeks old. The doctors at a clinic here said she was `weak’,” said Jabeen, who fears her child, to be born this winter around mid-December, could suffer a similar fate.
She blames herself for the death, saying “I did not have enough milk because I was also feeding my one-year-old at the time.”
“For a healthy mother, this alone would not cause an LBW baby. But combined with other factors, including too many pregnancies, poor food and so on, who knows,” said Samina Ahmed.