Using community informants to estimate maternal mortality in a rural district in Pakistan: a feasibility study.

BACKGROUND: We aimed to assess the feasibility of using community-based informants' networks to identify maternal deaths that were followed up through verbal autopsies (MADE-IN MADE-FOR technique) to estimate maternal mortality in a rural district in Pakistan. METHODS: We used 4 community networks to identify deaths in women of reproductive age in the past 2 years in Chakwal district, Pakistan. The deaths recorded by the informants were followed up through verbal autopsies. RESULTS: In total 1,143 Lady Health Workers (government employees who provide primary health care), 1577 religious leaders, 20 female lady councilors (elected representatives), and 130 nikah registrars (persons who register marriages) identified 2001 deaths in women of reproductive age. 1424 deaths were followed up with verbal autopsies conducted with the relatives of the deceased. 169 pregnancy-related deaths were identified from all reported deaths. Through the capture-recapture technique probability of capturing pregnancy-related deaths by LHWs was 0.73 and for religious leaders 0.49. Maternal mortality in Chakwal district was estimated at 309 per 100,000 live births. CONCLUSION: It is feasible and economical to use community informants to identify recent deaths in women of reproductive age and, if followed up through verbal autopsies, obviate the need for conducting large scale surveys.

To serve or to leave: a question faced by public sector healthcare providers in Pakistan.

BACKGROUND: The availability of properly trained and motivated providers is a prerequisite for provision of easily accessible healthcare. Pakistan has been listed by the World Health Organization in its World Health Report 2006 as one of 57 countries with a critical health workforce deficiency. This study examines the factors associated with the willingness of public sector healthcare providers to leave government service and recommends measures that can be adopted to attract and retain staff in the country's public healthcare system. METHODS: A stratified, random sampling methodology was adopted to recruit a nationally representative sample of 1,296 public sector healthcare providers, including paramedics, medical doctors, and specialists. A semi-structured questionnaire was used to interview these providers. Logistic regressions measured the association with determinants of their willingness to leave the public health sector for better prospects elsewhere. RESULTS: A third of all healthcare providers who were interviewed were of the view that, provided the opportunity, they would leave government service. The odds of willingness to leave service were highest among providers from the region of Azad Jammu and Kashmir (adjusted odds ratio [AOR] = 4.33; 95% CI, 2.49-7.54) followed by the province of Balochistan (AOR = 4.21; 95% CI, 2.41-7.33), and the region of Gilgit Baltistan (AOR = 3.34; 95% CI, 1.67-6.67). Providers who expressed dissatisfaction in the manner their performance was evaluated and those who were dissatisfied with the current salary, each had higher odds of considering leaving government service (AOR = 1.67; 95% CI, 1.18-2.40 and AOR = 2.03; 95% CI, 1.47-2.81, respectively). Providers who reported experiencing interference in their work by influential politicians of the area were more inclined to leave (AOR = 1.44; 95% CI, 1.05-1.98). CONCLUSION: This study clearly highlights the need to implement more focused strategies in the public healthcare system in Pakistan in order to build sufficient staff motivation and prevent providers from leaving government service. In order to improve coverage of healthcare services in Pakistan, the government will have to introduce more focused interventions to attract and retain healthcare providers, especially in remote and rural areas of the country.

Induced abortions and unintended pregnancies in pakistan.

During the past decade, unmet need for family planning has remained high in Pakistan and gains in contraceptive prevalence have been small. Drawing upon data from a 2012 national study on postabortion-care complications and a methodology developed by the Guttmacher Institute for estimating abortion incidence, we estimate that there were 2.2 million abortions in Pakistan in 2012, an annual abortion rate of 50 per 1,000 women. A previous study estimated an abortion rate of 27 per 1,000 women in 2002. After taking into consideration the earlier study's underestimation of abortion incidence, we conclude that the abortion rate has likely increased substantially between 2002 and 2012. Varying contraceptive-use patterns and abortion rates are found among the provinces, with higher abortion rates in Baluchistan and Sindh than in Khyber Pakhtunkhwa and Punjab. This suggests that strategies for coping with the other wise uniformly high unintended pregnancy rates will differ among provinces. The need for an accelerated and fortified family planning program is greater than ever, as is the need to implement strategies to improve the quality and coverage of postabortion services.

Postabortion care in Pakistan.

The current law in Pakistan permits abortion only under narrow circumstances. As a result, women resort to clandestine and unsafe abortion procedures, which often lead to complications. This report summarizes findings from a study that examined the conditions under which women obtain abortion in Pakistan; the incidence, coverage and quality of facility-based postabortion care (PAC); and the extent to which recommended standards for PAC have been implemented in health facilities.

The effect of traditional birth attendant training on maternal and neonatal care.

OBJECTIVE: To determine whether traditional birth attendants (TBAs) trained via the "SMART Dai" method were superior to untrained TBAs in knowledge and practice regarding maternal and newborn care. METHODS: In a cluster-randomized trial in the Dera Ghazi Khan District of Punjab, Pakistan, 120 rural communities each with a population of approximately 5000 were randomly assigned to a community-based intervention (CBI) or a health systems intervention (HSI). In the CBI communities, 288 TBAs underwent an innovative 8-day training course on maternal and newborn care, initially evaluated by pre- and post-tests. After an average of 19 months post-training, 277 TBAs, together with 257 comparably chosen untrained TBAs from the HSI communities, were tested and interviewed. Patients from both referred and non-referred deliveries were also interviewed. RESULTS: Characteristics of TBAs in the two groups were similar. The TBAs were evaluated according to various measures of knowledge, skill, and practice (including referral), with patient reports on practice compared with TBA reports. By most measures, trained TBAs outperformed untrained ones, often to significant degrees. CONCLUSION: SMART Dai training seemed to be an important factor in the significant reduction in perinatal mortality in the CBI areas. Properly trained TBAs can substantially contribute to improved delivery outcomes.