Credit where credit is due: Pakistan’s role in reducing the global burden of reproductive, maternal, newborn, and child health (RMNCH)

In the late 1980s, Pakistan was part of an 11-country study on the aetiology of childhood pneumonia [5],[6], which contributed to the development of the WHO standard pneumonia treatment guidelines [7] and the Haemophilus influenzae B and pneumococcal vaccines. Pioneering work by Pakistan’s National Institute of Health and National Acute Respiratory Infection Control Programme in the 1990s [8] led to examination of the relationship between in vitro antimicrobial resistance and in vivo outcomes for clinical pneumonia as children responded clinically to oral co-trimoxazole [9]. A randomised controlled trial (RCT) showed that co-trimoxazole and amoxicillin were equally effective in treating pneumonia associated with fast breathing in hospitalized children and that children with high in vitro antimicrobial resistance were cured with oral co-trimoxazole [10]. An additional finding that amoxicillin was twice as effective as co-trimoxazole for pneumonia with chest in-drawing was very important at a time when WHO guidelines recommended all children with chest in-drawing pneumonia be hospitalized for injectable antibiotic therapy [11]. A RCT in eight low- and middle-income countries [12] and in Pakistan [13] showed that oral amoxicillin was as effective as injectable penicillin/ampicillin for pneumonia with chest in-drawing in children aged 2–59 months. These results had a far-reaching impact in 2012 when WHO revised pneumonia treatment guidelines, recommending that oral amoxicillin be used to treat pneumonia with chest in-drawing on an outpatient basis in low-HIV settings [14]. Data from Pakistan also contributed to the revision of WHO guidelines [15] for the management of children with wheeze [16] and for shortening antibiotic treatment for fast-breathing pneumonia from 5 to 3 days [17] in order to reduce the scope for the development of antimicrobial resistance.

In reproductive health, Pakistani researchers have been central to many ground-breaking international studies which have influenced the design and implementation of reproductive health programmes. The most important among these is the Antenatal Corticosteroid Treatment trial from the National Institute of Child Health and Human Development group [18], which has served as a primary source informing the development of new, as yet unpublished WHO guidelines on the use of antenatal corticosteroids for the prevention of pre-term births. Cognizant of the scarcity of ultrasonography equipment in remote rural areas, Pakistani researchers have initiated studies to compare the accuracy of gestational age estimates obtained through ultrasonography with those obtained through history and physical examination [19]. They have also been pioneers in the study of mental health issues among pregnant women, evident from the work of Karmaliani et al. from Hyderabad and Sind [20],[21], as well as forming part of large multi-country studies, such as that by Bloch et al. [22], to examine tobacco use and second-hand smoke prevalence among pregnant women.

Pakistan has also been a global leader in community-based strategies to expand access to RMNCH services. Learning from its lady health worker (LHW) programme, many countries have adopted integrated community-case management of common childhood illnesses as a strategy [23]. Additionally, with appropriate training, supervision, and regular supplies, LHWs have managed pneumonia with chest in-drawing in children aged 2–59 months at the community level in two cluster RCTs with low treatment failure rates and mortality [24],[25]; these findings are the first of their kind globally and have stimulated further research (Personal Communication, Shamim Qazi, WHO HQ, Geneva, Switzerland). LHWs have also contributed to the reduction of perinatal mortality through the provision of services in the community [26], which has contributed to the development of WHO recommendations for home visits in the first week of life [15].