Maternal Mortality due to Eclampsia in Khyber Pakhtunkhwa: Identifying Underlying Risk Factors, and Care-seeking Behaviours.

OBJECTIVE: To identify the characteristics of women at risk of death due to eclampsia, and steps to improve maternal outcome. METHODS: This study is a part of a retrospective study conducted in 2016 and included Mansehra, Swabi, Haripur, Nowshera, Kohat, and Dera Ismail Khan districts of the Khyber Pakhtunkhwa province of Pakistan, and used information cited by a 2016 study to estimate the maternal mortality rate in the province based on data pertaining to the 2013-14 period. The Maternal Death from Informants / Maternal Death Follow-on Review method was applied to identify the magnitude, causes and circumstances of maternal deaths in the province. SPSS 21 was used for data analysis. RESULTS: Of the 958 cases of maternal death identified, 167(17%) were related to eclampsia. The median age of such women was 28 years (interquartile range: 11 years). Of them, 88 (53%) died undelivered, 48 (29%) had a live birth while 31 (18%) had a stillbirth or abortion. Mothers aged 25 years or above (p<0.01), primiparous (p<0.01) and those with a previous history of stillbirth (p<0.005) carried higher risk, while higher socioeconomic status had a protective effect (p<0.007). CONCLUSIONS: Eclampsia deaths can be prevented through Continuum of Care approach and by ensuring provision of basic health facilities across the board.

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.

Exploring urban male non-marital sexual behaviours in Pakistan.

BACKGROUND: In Pakistan, sexual practices outside marriage are proscribed by law. We aimed to assess the range and magnitude of non-marital sexual behaviours of urban men, focusing on men having sex with men. METHODS: In this cross sectional survey undertaken in six cities of Pakistan, we interviewed 2400 men aged 16-45 years selected through a multistage systematic sampling design. Sexual behaviours were assessed through a structured questionnaire. Multivariable analysis was used to identify association between various individual level characteristics and probability of engaging in sexual activities involving men. RESULTS: Nearly one-third (29 percent) reported having had non-marital sex in their lifetime. Of these men 16 percent reported premarital sex, while 11 percent reported engaging in both pre- and extramarital sex. Only two percent reported exclusive extramarital sex. In total 211 respondents, 9 percent reported ever having had sexual relations with men. While 62 respondents, 2.6 percent reported exclusive sex with males. Factors that were significantly associated with MSM behaviours were being less than 27 years (adjusted OR 5.4, 95% CI 3.8-7.7, p < 0.000), less than 10 years of schooling (adjusted OR 2.1, 95% CI 1.4-3.2, p < 0.000), being unemployed (adjusted OR 2.7, 95% CI 1.6-4.3, p < 0.000), being exposed to pornographic materials (adjusted OR 4.8, 95% CI 3.0-7.7, p < 0.000) and being a migrant (adjusted OR 2.1, 95% CI 1.3-3.4, p < 0.002). Factors significantly associated with exclusive homosexual behaviour were having sexual debut at a younger age i.e. 16-22 years (adjusted OR 12.5, 95% CI: 3.8-40.7, p < 0.000), being unemployed (adjusted OR 8.8, 95% CI: 3.0-26.0, p = 0.000), having had exposure to pornographic materials (adjusted OR 3.3, 95% CI: 1.5-7.2, p = 0.002). CONCLUSIONS: To prevent the spread of STI's in Pakistan, preventive interventions should focus on reaching out to young uneducated men offering them with appropriate counselling and skills to adopt "safe sex practices" through workplace orientation sessions; while for youth in schools, life skills education be included in the curriculum. Through public-private partnership stigmatised groups should be reached through established community networks and provided with information on accessing voluntary counseling and treatment centres.

Herpes Simplex Virus-2 infection amongst urban male population in Pakistan.

OBJECTIVE: To describe the prevalence of Herpes Simplex Virus-2 (HSV-2) infection among males in six major cities of Pakistan. METHODS: A cross sectional behavioural and biological survey of urban male population aged 16-45 years was conducted in Rawalpindi, Lahore, Karachi, Faisalabad, Peshawar and Quetta to measure the prevalence of five sexually transmitted infections and assess sexual behaviours. Respondents were selected through a multistage sampling technique. In each city 10 blocks demarcated by the Population Census Organization were selected based on probability proportional to socio-economic status. In each block 40 men were selected through systematic sampling with a random start. In total 2400 men were administered a behavioural questionnaire and 2396 provided biological specimens for laboratory testing. RESULTS: This paper discusses the overall and city wise prevalence of HSV-2 infection. The overall prevalence of HSV-2 infection in the six cities was 3.4 percent (95% CI 2.8-4.3). City wise the highest prevalence was reported in Karachi 6 percent (95% CI 4.1-8.8), followed by Lahore and Quetta at 4.3 percent (95% CI 2.7-6.7), and Faisalabad at 2.5 percent (95% CI 1.4-4.5). The lowest prevalence was in Rawalpindi at 1.8 percent (95% CI 0.9-3.6). CONCLUSION: Empirical evidence from this study suggests that there is city wise variation in the prevalence of HSV-2 infection across the major cities in Pakistan. Based on possible link between HSV-2 and HIV, future HIV control strategies must also focus on the better management of HSV-2 infections in Pakistan.