Approaches towards improving the quality of maternal and newborn health services in South Asia: challenges and opportunities for healthcare systems.

BACKGROUND: South Asia is experiencing a dismal state of maternal and newborn health (MNH) as the region has been falling behind in reducing the levels of maternal and neonatal mortality. Most of the efforts are focused on enhancing coverage of MNH services; however, quality remains a serious concern if the region is to achieve expected outcomes in terms of standardised MNH services within healthcare delivery systems. This research consists of a review of South Asian quality improvement (QI) approaches/interventions, specifically implemented for MNH improvement. METHODS: A literature review of QI approaches/interventions was conducted using the PRISMA guidelines. Online databases, including PubMed, the Cochrane Library and Google Scholar, were searched. Primary studies published between 1998 and 2013 were considered. Studies were initially screened and selected based upon the selection criteria for data extraction. A thematic synthesis/analysis was performed to organise, group and interpret the key findings according to prominent themes. RESULTS: Thirty studies from six South Asian countries were included in the review. Findings from these selected studies were grouped under eight broad, cross-cutting themes, which emerged from a deductive approach, representing the most commonly employed QI approaches for improving MNH services within different geographical settings. These consist of capacity building of healthcare providers on clinical quality, clinical audits and feedback, financial incentives to beneficiaries, pay-for-performance, supportive supervision, community engagement, collaborative efforts and multidimensional interventions. CONCLUSIONS: Employing and documenting QI approaches is essential in order to measure the potential of an intervention, considering its cost-effectiveness, feasibility and acceptability to communities. This research concluded that QI approaches are very diverse and cross-cutting, because they are subject to the varied requirements of regional health systems. This high level of variability leads to implementation and knowledge-management challenges for MNH programme planners and managers in the countries of the South Asia region.

Perceived social support among patients with burn injuries: A perspective from the developing world.

BACKGROUND: Social support is among the most well-established predictors of post-burn psychopathology after burn. Despite a disproportionately large burden of burns in the developing world, the nature of social support among burn patients in this context remains elusive. We, therefore, seek to investigate social support and its biopsychosocial determinants among patients with burn injuries in Pakistan. METHODS: A cross-sectional study of 343 patients presenting with burn injuries at four teaching hospitals in the Punjab province of Pakistan was conducted. Patient evaluation consisted of a multi-part survey of demographic status, clinical features, and social support as measured by the validated Urdu translation of the Multidimensional Scale of Perceived Social Support (MSPSS). Multiple regression analysis was performed to evaluate associations between patient characteristics and MSPSS score. RESULTS: Mean overall MSPSS score was 57.64 (std dev 13.57). Notable positive predictors of social support include male gender, Punjabi ethnicity, burn surface area, and ego resiliency. CONCLUSION: Our study reveals a troubling pattern of inadequate social support among certain subgroups of Pakistani burn patients. Addressing these inequities in the provision of social support must be prioritized as part of the global burn care agenda.

Predictors of post-traumatic stress disorder among burn patients in Pakistan: The role of reconstructive surgery in post-burn psychosocial adjustment.

BACKGROUND: Burns are a common cause of morbidity and mortality worldwide. Post-traumatic stress disorder (PTSD) is among the most prevalent psychopathologies documented among burn patients. However, little is known regarding the risk factors for post-burn PTSD outside the well-documented Western world context. The present study aims to elucidate the biopsychosocial correlates of PTSD among burn patients in Pakistan. METHODS: A total 343 burn patients were evaluated across four teaching hospitals in the Punjab province of Pakistan between August and December of 2016. "Patients aged 18 years or older, with no major comorbid illnesses, presenting for burn care at burn units or surgical departments of the listed hospitals were interviewed by trained healthcare providers using a validated questionnaire." Uni- and multivariate statistical analyses were used to evaluate associations between patient characteristics and PTSD symptomatology, as measured by the validated Urdu version of the Impact of Event Scale-Revised (IES-R). RESULTS: The prevalence of PTSD among our cohort was 69%. Lower educational attainment, ethnic minority status, unemployment, large burn surface area, prior suicidal ideation, and domestic violence were all associated with increased PTSD symptomatology. On the other hand, social support, ego resiliency, and reconstructive surgery were all associated with decreased PTSD symptomatology. CONCLUSION: There is a remarkably high prevalence of PTSD among burn patients in Pakistan. Improving accessibility to reconstructive surgery and social support may help to alleviate this burden.

Determining the potential scalability of transport interventions for improving maternal, child, and newborn health in Pakistan.

BACKGROUND: Pakistan is far behind in achieving the Millennium Development Goals regarding the reduction of child and maternal mortality. Amongst other factors, transport barriers make the requisite obstetric care inaccessible for women during pregnancy and at birth, when complications may become life threatening for mother and child. The significance of efficient transport in maternal and neonatal health calls for identifying which currently implemented transport interventions have potential for scalability. METHODS: A qualitative appraisal of data and information about selected transport interventions generated primarily by beneficiaries, coordinators, and heads of organizations working with maternal, child, and newborn health programs was conducted against the CORRECT criteria of Credibility, Observability, Relevance, Relative Advantage, Easy-Transferability, Compatibility and Testability. Qualitative comparative analysis (QCA) techniques were used to analyse seven interventions against operational indicators. Logical inference was drawn to assess the implications of each intervention. QCA was used to determine simplifying and complicating factors to measure potential for scaling up of the selected transport intervention. RESULTS: Despite challenges like deficient in-journey care and need for greater community involvement, community-based ambulance services were managed with the support of the community and had a relatively simple model, and therefore had high scalability potential. Other interventions, including facility-based services, public-sector emergency services, and transport voucher schemes, had limitations of governance, long-term sustainability, large capital expenditures, and need for management agencies that adversely affected their scalability potential. CONCLUSION: To reduce maternal and child morbidity and mortality and increase accessibility of health facilities, it is important to build effective referral linkages through efficient transport systems. Effective linkages between community-based models, facility-based models, and public sector emergency services should be established to provide comprehensive coverage. Voucher scheme integrated with community-based services may bring improvements in service utilization.