may reach a facility but will still die! an analysis of quality of public sector maternal health services, District Multan, Pakistan

To assess the availability, utilization and functional capacity of the public health delivery system in terms of human resources, equipment, supplies and health provider knowledge regarding management of obstetric complications. A cross-sectional study was conducted in March 2003 for Multan's public health delivery system. A complete inventory of equipment, supplies, drugs, staff availability and knowledge of obstetric complications management were assessed. The number and distribution of public sector facilities serving a population of 3.2 million was well beyond the minimum requirement for basic obstetric care but fell short for comprehensive Emergency Obstetrical Care [EmOC]. Utilization patterns were skewed to the tertiary facility for normal and complicated deliveries. Partograms were not available, magnesium sulphate was only available at the tertiary facility, while basic supplies like iron and folate tablets, broad spectrum antibiotics, oxytocics, gloves and sutures were not available at primary or secondary facilities. Knowledge scores regarding management of obstetric complications were less than average, especially among nurses at basic or comprehensive EmOC facilities. Intensity of labour pains [nurses 59%] at basic EmOC facility and cervical dilatation by doctors at basic and comprehensive facilities were the most frequent responses for monitoring in labour. Strengthening the four interlinked health system elements - human resources, access to, use and quality of services is essential though not sufficient

quest for small family size among Pakistani women - is voluntary termination of pregnancy a matter of choice or necessity?

To present the socio-biologic predictors of induced abortion among married women residing in low income squatter settlements of Karachi, Pakistan. A cross-sectional survey was conducted in three squatter settlements of Karachi from June to August 1997. Interviews were conducted on 1,214 married women assessing past pregnancy history, literacy and employment status of self and spouse and specifically probing for past history of seeking an induced abortion. Fifty women reported an induced abortion during last three years prior to survey. Of these, forty% [20/50] of abortion seekers were using some method of family planning before conceiving the index pregnancy. Post abortion family planning method use was adopted by 50% [25/50] of the abortion seekers. The most parsimonious multivariate logistic regression model included grand-multigravidity [OR 2.6 CI, 1.3 - 5.2], literate status of the woman [OR 1.9 CI, 1.0 - 3.4] and the 26-35 age group [OR 3.0 CI, 1.4 - 6.6]. Unplanned/mistimed pregnancies generally result from high unmet need and ineffective use of contraceptives and culminate through induced abortions. We propose that improvement in the quality of family planning counseling should be targeted to effective use of a method, back-up support in case of method failure and the health consequences of unsafe abortions

quality of care issue: appropriate use and efficacy knowledge of five contraceptive: views of men and women living in low socioeconomic settlements of Karachi, Pakistan

To assess knowledge regarding availability, affordability, appropriate use and efficacy for five non-permanent contraceptive methods.Married Muslim women and men [500 each] were randomly selected from two low socioeconomic settlements in Karachi, Pakistan. Interviews to assess their knowledge on a range of contraceptive and abortion themes were conducted. Four hundred men and 357 women were selected from this larger sample based on their knowledge of condoms, withdrawal, oral pills, injectables and IUDs. Nearly half of the sampled men [56%] and women [48%] were contraceptive users. Knowledge regarding contraception, a specific method, its availability and affordability was high. Appropriate use knowledge for condoms was 73% among men [users 78%, non-users 60%; p-value<0.001] and 5% among women. Efficacy knowledge was generally poor. Low knowledge levels regarding appropriate use and efficacy even among contraceptive users suggests, that quality of family planning services should not be limited to service delivery issues but extend to appropriate use and efficacy knowledge levels among clients

Prevalence and risk factors of presumptive urinary tract infection in a rural community

Urinary tract infection [UTI] is an important and less investigated public health problem. Community-based information regarding magnitude and determinants of UTI is inadequate in South-Asia including Pakistan. This study reports prevalence and risk factors of UTI in a rural community of Jamshoro, Sindh, Pakistan. Trained female interviewers conducted the interviews using a pre-tested Sindhi questionnaire during a cross-sectional survey carried out in 8 villages of rural Jamshoro, Sindh from July-September 1997. Women reporting increased frequency of urine with burning sensation, with or without feeling of pain or fever while passing urine during the 3 months prior to interview were presumed to have UTI. No laboratory tests were performed to confirm it. We interviewed 738 ever married women with 2% refusal rate. One hundred twenty-five women [17%] had symptoms consistent with UTI, while 18% reproductive age women [15-49] were using a modern contraceptive. Women with UTI were 2.7 times more likely to be current user of Intra-uterine contraceptive device[IUCD]/condom [95% CI, 1.3-5.6], and 1.6 times more likely to be housewives by occupation [95% CI, 1.0 - 3.0] as compared to women who did not have UTI. UTI among IUCD/condom users may reflect existence of unhygienic conditions during application of procedure or spread of infection by the thread of IUCD. The quality of life is affected in women with UTI and may have serious consequences of developing renal damage. This warrants greater attention for reproductive health needs of the women, and health education for hygienic/safe use of family planning methods

rapid community based health evaluation of pregnant women in low socioeconomic settlements of Karachi

A rapid nutritional and health evaluation of a random sample of 163 pregnant women was conducted in low socioeconomic settlements of Karachi, with the objective of determining the morbidity and nutritional status of pregnant women. These data are expected to be used in an ongoing community-based antenatal care programme. Twenty-nine percent of women reported fever, 14% diarrhoea and 33% respiratory infections in the previous week. Mean weight was 54.8 [ +/- 10.6] kg, mean height was 151.6 [ +/- 6.0] cm and mean midarm circumference was 25.6 [ +/- 3.2] cm. The mean uterine height at gestational ages 8 months and over was 32.1 [ +/- 10.2] cm which is below the 10th%ile. These results suggest a chronic, mildly malnourished population with a high rate of infections. Specifically, we suggest that maternal height and uterine height be used to assess women at high risk for low birthweight

Risk factors for intrauterine growth retardation: results of a community-based study from Karachi

There is a serious lack of community-based information on low birth weight or intrauterine growth retardation from Pakistan. A community based prospective study was conducted in four squatter settlements of Karachi, to examine the prevalence and risk factors for adverse pregnancy outcome. This paper reports on the prevalence and risk factors for intrauterine growth retardation [<10th percentile birth weight gestational age] among 755 singleton births. The incidence of intrauterine growth retardation was 25.4% [192 intrauterine growth retarded and 563 appropriate for gestational age]. Major socioeconomic risk factors identified were low maternal education [RR=1.4, 95% Cl=1.0, 2.1] and poor housing material [RR=1.7, 95% Cl=1.0, 3.0]. Among the significant biologic factors primiparity [RR=1.9, 95% Cl=1.4, 2.7], consanguinity [RR=1.4, 95% Cl=1.1, 1.8], short birth to conception intervals [RR=1.5, 95% Cl=1.1, 2.1], short stature [RR=2.2, 95% Cl=1.6, 3.0], low maternal weight [RR=2.0, 95% Cl=1.6, 2.5] and non-vegetarian diet [RR=2.3, 95% Cl=1.3, 4.2] were especially important. Investigations to assess the adverse mortality and morbidity effects of intrauterine growth retardation are ongoing

Causes of reproductive age mortality in low socioeconomic settlements of Karachi

The Maternal and Infant Mortality Survey [MlMS] was conducted in eight squatter settlements of Karachi. The female mortality rate was 151.0 per 100,000 women aged 10-49 years and the maternal mortality ratio was 281 per 100,000 livebirths. The leading causes of deaths among women were complications of pregnancy [28.1%], infectious diseases [24.8%], cardiovascular diseases [20.7%], neoplasia [10.7%] and trauma [10.7%]. Hemorrhage [47.1% of all maternal deaths], tuberculosis [40.0% of all infectious disease deaths], oropharyngeal cancer [23.1% of all neoplastic deaths], and burns [61.5% of all trauma deaths] were among the major causes identified. Maternal deaths were associated with young age and nulliparity [p-value <0.01], and a higher proportion occurred in the hospital or on the way to the hospital as compared to non-maternal deaths

Crowding-a risk factor for perinatal mortality?

Crowding is known to be associated with an increased risk of infant and child morbidity and mortality particularly due to infections. We examined the association of crowding with perinatal mortality. Our results indicated a paradoxical relationship with the least crowded households showing the highest perinatal mortality [7.7% as compared to 4.7%]. However, further analysis indicated that the observed paradoxical relationship is a spurious one, largely explained by the confounding effect of gravidity