Predictors of voluntary uptake of modern contraceptive methods in rural Sindh, Pakistan.

The use of modern contraceptive methods (MCMs) has been stagnant for the last decade in Pakistan. The second most populous province, Sindh reports 25% of MCMs use. Various factors including demographics and health services utilization are associated with the uptake of family planning services. This research aimed to identify and assess specific predictors of MCMs among women aged 15-49 in two districts of Sindh-Matiari and Badin. A cross-sectional household survey was conducted from October 2020- December 2020. In total, 1684 Married Women of Reproductive Age (MWRA) 15-49 years were interviewed. For the selection of eligible respondents, a two-stage stratified cluster sampling strategy was used. Univariate and multivariable logistic regression was used to determine the predictors for the use of MCM. Use of modern methods of contraceptive was 26.1% (n = 441). Statistically significant socio demographic predictors of MCM included: number of children 4 or more (AOR: 5.23; 95%CI: 2.78-9.84), mother having primary education (AOR: 1.73; 95% CI: 1.26-2.36), and husband having middle education (AOR: 1.69; 95% CI: 1.03-2.76). Maternal health services indicators included: postnatal care of mother (AOR: 1.46; 95% CI: 1.09-2.05); women who were visited by Lady Health Workers in their postnatal period and were counselled on family planning (AOR: 1.83; 95% CI: 1.38-2.42). Since the primary purpose of using modern contraceptive methods is for limiting pregnancies, there is a potential to promote awareness about the benefits of birth spacing as part of implementing a more integrated approach to family planning. The integration of family planning services within maternal and newborn child healthcare services effectively promote the voluntary adoption of modern contraceptive methods. The role of Lady Health Workers in family planning counseling and service provision and uptake is important in the context of Sindh and should be fostered further by opportunities for capacity building and their empowerment.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

BACKGROUND: Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. OBJECTIVE: This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. METHODS: The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. RESULTS: The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. CONCLUSIONS: This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49578.

Predictors and disparities in neonatal and under 5 mortality in rural Pakistan: cross sectional analysis.

Background: Adopted in 2015, the sustainable development goals (SDGs) have set specific targets (SDG 3.2) for countries to reduce their neonatal mortality rate (NMR) to below 12 deaths per 1000 live births and under 5 mortality rate (U5MR) to below 25 deaths per 1000 live births by 2030. For Pakistan to achieve these targets, there is a need to measure these rates and understand the predictors of child mortality at sub-national level. Launched in 2016, the Umeed-e-Nau (UeN) or New Hope project is based on scaling up proven and effective Maternal and Newborn Child Health (MNCH) interventions in 8 of the highest burden districts of the country, using existing public sector platforms in Pakistan at both the community and facility level. The primary aim of the project is to reduce perinatal mortality in these districts by 20% from baseline. Methods: We report overall neonatal and post neonatal mortality rates for the two years preceding the UeN baseline household survey. Rates were calculated using the synthetic cohort probability method and predictors of neonatal and post neonatal mortality examined using Cox regression. To investigate spatial variations in the mortality rates, we calculated Moran's I at the district level using predicted probabilities of mortality. Finally, we create district level maps of predicted under 5 child mortality using a stochastic partial differentiation approach. Findings: A total of 26,258 children contributed to the analysis of mortality with 838 deaths in the neonatal period and 2236 under-5 deaths during the observation period from March 1, 2015 to March 17, 2017. Overall, we estimated the NMR to be 29.2 per 1000 live births (95% CI: 26.9-31.4) and the U5MR to be 86.1 per 1000 live births (95% CI: 85.5-86.8). We found evidence of within-district geospatial clustering of under 5 mortality (P < 0.0001) and that social factors (poverty, illiteracy, multiparity), poor coverage of community health workers and distance from health facilities were strongly associated with child mortality. Interpretation: Important factors associated with neonatal and post-neonatal mortality in our study population included maternal education, parity, household size and gender. Additionally, antenatal care coverage (at least 4 visits) was specifically associated with neonatal mortality only, whereas, LHW coverage and distance to health facility were strongly associated with post-neonatal mortality. These findings emphasise the need for comprehensive, multisectoral strategies to be implemented for future maternal and child health programs and outreach services in rural areas. Funding: The study was funded by an unrestricted grant from the Bill & Melinda Gates Foundation to the Aga Khan University (Grant OPP 1148892).

Effects of Integrating Family Planning With Maternal, Newborn, and Child Health Services on Uptake of Voluntary Modern Contraceptive Methods in Rural Pakistan: Protocol for a Quasi-experimental Study.

BACKGROUND: The uptake of modern contraceptive methods (MCMs) remains low, with 25% of women reporting their use in Pakistan. The overarching interventions covering service delivery platforms at facility and community levels necessitate the integration of family planning (FP) with maternal, newborn, and child health (MNCH) services. OBJECTIVE: The main aim of this study is to evaluate the impact of an integrated FP-MNCH service delivery model to increase coverage of MCMs in rural Pakistan. Moreover, we aim to measure the level of effectiveness of interventions regarding the uptake of MCMs. METHODS: A quasi-experimental, sequential, mixed methods study design with pre- and postevaluation will be adopted to evaluate the impact of integration of FP with MNCH services. The interventions include the following: (1) capacity strengthening of health care providers, including technical trainings; training in counseling of women who attend immunization centers, antenatal care (ANC) clinics, and postnatal care (PNC) clinics; and provision of job aids; (2) counseling of women and girls attending ANC, PNC, and pediatric clinics; (3) ensuring sustained provision of supplies and commodities; (4) community engagement, including establishing adolescent-friendly spaces; and (5) use of District Health Information System data in decision-making. Descriptive statistics will be used to estimate prevalence (ie, proportions) and frequencies of outcome indicators. A univariate difference-in-difference analytical approach will be used to estimate the effect of the interventions. In addition, a Blinder-Oaxaca decomposition analysis will be conducted to identify and quantify determinants of the modern contraceptive prevalence rate. RESULTS: The intervention phase began in July 2021 and will run until June 2022. The impact assessment will be conducted from July to September 2022. CONCLUSIONS: This project will evaluate the impact of integrating FP with MNCH services. Furthermore, this study will identify the drivers and barriers in uptake of MCMs and will simultaneously help in modifying the interventional strategies that can be scaled up through existing service delivery platforms within the public and private sectors, according to the local sociocultural and health system context. TRIAL REGISTRATION: ClinicalTrials.gov NCT05045599; https://clinicaltrials.gov/ct2/show/NCT05045599. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35291.

Delivering nutrition interventions to women and children in conflict settings: a systematic review.

BACKGROUND: Low/middle-income countries (LMICs) face triple burden of malnutrition associated with infectious diseases, and non-communicable diseases. This review aims to synthesise the available data on the delivery, coverage, and effectiveness of the nutrition programmes for conflict affected women and children living in LMICs. METHODS: We searched MEDLINE, Embase, CINAHL, and PsycINFO databases and grey literature using terms related to conflict, population, and nutrition. We searched studies on women and children receiving nutrition-specific interventions during or within five years of a conflict in LMICs. We extracted information on population, intervention, and delivery characteristics, as well as delivery barriers and facilitators. Data on intervention coverage and effectiveness were tabulated, but no meta-analysis was conducted. RESULTS: Ninety-one pubblications met our inclusion criteria. Nearly half of the publications (n=43) included population of sub-Saharan Africa (n=31) followed by Middle East and North African region. Most publications (n=58) reported on interventions targeting children under 5 years of age, and pregnant and lactating women (n=27). General food distribution (n=34), micronutrient supplementation (n=27) and nutrition assessment (n=26) were the most frequently reported interventions, with most reporting on intervention delivery to refugee populations in camp settings (n=63) and using community-based approaches. Only eight studies reported on coverage and effectiveness of intervention. Key delivery facilitators included community advocacy and social mobilisation, effective monitoring and the integration of nutrition, and other sectoral interventions and services, and barriers included insufficient resources, nutritional commodity shortages, security concerns, poor reporting, limited cooperation, and difficulty accessing and following-up of beneficiaries. DISCUSSION: Despite the focus on nutrition in conflict settings, our review highlights important information gaps. Moreover, there is very little information on coverage or effectiveness of nutrition interventions; more rigorous evaluation of effectiveness and delivery approaches is needed, including outside of camps and for preventive as well as curative nutrition interventions. PROSPERO REGISTRATION NUMBER: CRD42019125221.

Impact of conflict on maternal and child health service delivery - how and how not: a country case study of conflict affected areas of Pakistan.

INTRODUCTION: In conflict affected countries, healthcare delivery remains a huge concern. Pakistan is one country engulfed with conflict spanning various areas and time spans. We aimed to explore the effect of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing the prioritization and implementation in conflict affected areas of Pakistan (Balochistan and FATA). METHOD: We conducted a secondary quantitative and a primary qualitative analysis. For the quantitative analysis, we stratified the various districts/agencies of Balochistan and FATA into the conflict categories of minimal-, moderate- and severe based on accessibility to health services through a Delphi methodology with local stakeholders and implementing agencies and also based on battle-related deaths (BRD) information from Uppsala Conflict Data Program (UCDP). The coverage of RMNCAH&N indicators across the continuum of care were extracted from the demographic and health surveys (DHS) and district health information system (DHIS). We conducted a stratified descriptive analysis and multivariate analysis using STATA version 15. The qualitative data was captured by conducting key informant interviews of stakeholders working in government, NGOs, UN agencies and academia. All the interviews were audiotaped which were transcribed, translated, coded and analyzed on Nvivo software version 10. RESULTS: The comparison of the various districts based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators in Balochistan were significantly lower in severe- conflict districts when compared to minimal conflict districts, while there was no significant difference between moderate and severe conflict areas. There was no reliable quantitative data available for FATA. Key factors identified through qualitative analysis, which affected the prioritization and delivery of services included planning at the central level, lack of coordination amongst various hierarchies of the government and various stakeholders. Other factors included unavailability of health workforce especially female workers, poor quality of healthcare services, poor data keeping and monitoring, lack of funds and inconsistent supplies. Women and child health is set at a high priority but capacity gap at service delivery, resilience from health workers, insecurity and poor infrastructure severely hampers the delivery of quality healthcare services. CONCLUSION: Conflict has severely hampered the delivery of health services and a wholesome effort is desired involving coordination amongst various stakeholders. The multiple barriers in conflict contexts cannot be fully mitigated, but efforts should be made to negate these as much as possible with good governance, planning, efficiency and transparency in utilization of available resources.

Effects of preventive nutrition interventions among adolescents on health and nutritional status in low- and middle-income countries: A systematic review.

Background: Malnutrition is one of the most common causes of morbidity and mortality among children and adolescents and is now considered to be one of the largest risk factors responsible for the global burden of diseases along with poor diet. Objectives: The objective of this review was to assess the impact of preventive nutrition interventions (including nutrition education and counselling; micronutrient supplementation/fortification and macronutrient supplementation) to improve the health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). The secondary objective of the review was to assess various contextual factors based on the World Health Organisation (WHO) health system building blocks framework that might potentially impact the effectiveness of these interventions for this age group. Search Methods: The search was conducted on Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, the WHO nutrition databases, CAB Global Health, Social Science Citation Index, Scopus, WHO Global Health Index, ADOLEC and EPPI until February 5, 2019. We searched Google Scholar along with key nutrition agencies database such as Nutrition International, the Global Alliance for Improved Nutrition, the World Food Programme and HarvestPlus to search for nonindexed, grey literature to locate relevant programme evaluations and any additional trials. All searches were performed without any restrictions on publication date, language or publication status. Selection Criteria: We included randomised controlled trials, quasiexperimental studies, controlled before-after studies and interrupted time series evaluating the effectiveness of preventive nutrition interventions among adolescents between 10 and 19 years of age from LMICs. Data Collection and Analysis: Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data from included studies. Meta-analysis was conducted separately for each outcome and intervention. For dichotomous data, we reported risk ratios (RR) with 95% confidence intervals (CI). For continuous data, we reported the mean difference (MD) or standard mean difference (SMD) with 95% CI. Main Results: This review summarises findings from a total of 10 studies from 15 papers including 10,802 participants. All the studies included in this review assessed the impact of micronutrient supplementation/fortification on health and nutritional status among adolescents in LMIC. We did not find any study assessing the impact of nutrition education and counselling or on macronutrient supplementation among adolescents. Micronutrient supplementation/fortification interventions included calcium/vitamin D supplementation/fortification, iron supplementation with or without folic acid, zinc supplementation and multiple micronutrient (MMN) fortification. The majority of the studies (eight out of 10 studies) included adolescent girls aged between 10 and 19 years of age. We did not find any large scale preventive nutrition intervention programmes targeting adolescents in LMICs. We are uncertain of the effect of iron supplementation with or without folic acid on anaemia (daily supplementation; RR: 1.04, 95% CI 0.88, 1.24; one study; 1,160 participants; low quality evidence. Weekly supplementation; RR: 1.07, 95% CI: 0.91, 1.26; one study; 1,247 participants; low quality evidence). We are uncertain of the effect of various micronutrient supplementation/fortification on body mass index (calcium/vitamin D supplementation; (MD: -0.01 kg/m2; 95% CI: -1.20, 1.17; two studies; 730 participants; I 2 94%; very low quality evidence, iron supplementation with or without folic acid; MD: 0.29 kg/m2; 95% CI: -0.25, 0.83; two studies; 652 participants; I 2 69%; very low quality evidence, zinc supplementation; MD: 0.35 kg/m2; 95% CI: -0.15, 0.85; one study; 382 participants; very low quality evidence) and MMN fortification; MD: 0.23 kg/m2, 95% CI: -0.11, 0.57; two studies; 943 participants; I 2 22%; very low quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Iron supplementation with or without folic acid may improve haemoglobin concentrations (MD: 0.42 g/dL, 95% CI: 0.13, 0.71; four studies; 1,020 participants; I 2 89%; low quality evidence). Calcium/vitamin D supplementation may improve serum 25(OH) D levels (standardised mean difference [SMD]: 2.85, 95% CI: 0.89, 4.82; two studies; 395 participants; I 2 99%; low quality evidence). We are uncertain of the effect of calcium only supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 233 participants; low quality outcome) and calcium + vitamin D supplementation (MD: 0.02 g/cm2, 95% CI: -0.00, 0.04; one study; 235 participants; low quality evidence) on total bone mineral density (BMD). We are uncertain of the effect of MMN fortification on haemoglobin concentrations (MD: -0.10 g/dL, 95% CI: -0.88, 0.68; two studies; 1102 participants; I 2 100%; very low quality evidence); calcium supplementation on total body bone mineral content (BMC); (MD: 30.20 g, 95% CI: -40.56, 100.96; one study; 233 participants; low quality evidence), calcium + vitamin D supplementation on total body BMC (MD: 21.60 g, 95% CI: -45.32, 88.52; one study; 235 participants; low quality evidence) and zinc supplementation on serum zinc levels (SMD: 6.94, 95% CI: -4.84, 18.71; two studies; 494 participants; very low quality evidence). One study reported the impact of iron supplementation with or without folic acid on cognition of adolescent girls suggesting improved cognition in most of the tests with daily or twice weekly supplementation compared to once weekly or no supplementation. None of the other secondary outcomes were reported including any other development outcomes and all-cause mortality. These findings warrant caution while interpreting due to very few studies and high heterogeneity. Authors' Conclusions: There is limited evidence of micronutrient supplementation/fortification among adolescents on health and nutritional status in LMICs, with lack of evidence on nutrition education and counselling and macronutrient supplementation. The findings are generaliseable for adolescent girls since all studies (except one) targeted female adolescents.

Effects of Preventive Nutrition Interventions among Adolescents on Health and Nutritional Status in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: -0.01 kg/m2; 95% CI: -1.20, 1.17; two studies; 730 participants; I2 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m2; 95% CI: -0.17, 1.11; two studies; 652 participants; I2 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m2; 95% CI: -0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m2, 95% CI: -0.11, 0.57; two studies; 943 participants; I2 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.