Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns.

BACKGROUND: In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan. METHODS: A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment. RESULTS: Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7-9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5-6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0-3.1). CONCLUSIONS: In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.

Offering mental health services in a conflict affected region of Pakistan: who comes, and why?

BACKGROUND: North West Pakistan is an area ravaged by conflict and population displacement for over three decades. Recently, drone attacks and military operations have aggravated underlying mental disorders, while access to care is limited. Among patients attending a mental health clinic integrated in district hospital conducted by psychologists; we describe service utilization, patient characteristics, presenting complaints, morbidity patterns, and follow-up details. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective study using routinely collected programme data was conducted from February to December 2012. A total of 1545 consultations were conducted for 928 patients (86% females). There were 71(8%) children and adolescents. An increase was observed from February to July, followed by a decline. 163 new patients (18%) were on psychotropic medication at presentation. The most common morbidity in females (36%) were symptoms of adjustment disorders and acute reactions. Depression and anxiety were common in both genders while post traumatic disorder was frequent in males (21%). Out of the 928 new patients, 639(69%) had a follow up visit planned with their psychologist, but only 220(34%) new patients returned for a follow up visit. CONCLUSION: In a district hospital, mental health services managed by psychologists were well attended. There is a need to consider widening the current package of care to cater to the diversity of mental health disorders, gender difference, children and adolescents. Standardized diagnostic and monitoring tools would also need to be adapted accordingly and to assess patient progress. Innovative approaches to tackle the problem of the low return rate are needed.