Maternal Mortality in a Rural District of Pakistan and Contributing Factors.

INTRODUCTION: Pakistan is among the ten countries that account for 60% of global maternal mortality. Lack of accurate data on maternal mortality and a complex interrelation of access and quality of healthcare services, healthcare delivery system, and socio-economic and demographic factors contribute significantly to inadequate progress in reducing maternal mortality. MATERIAL AND METHODS: A population-based prospective cohort study was conducted in a rural district of Pakistan using data obtained from an enhanced surveillance system. A total of 7572 pregnancies and their outcomes were recorded by 273 Lady Health Workers and 73 Community Health Workers over 2016-2017. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (OR) for maternal mortality for each risk factor. Population Attributable Fraction (PAF) was derived from the ORs and risk factor prevalence. RESULTS: The study recorded 18 maternal deaths. The maternal mortality rate was estimated at 238/100,000 pregnancies (95% CI 141-376), and the maternal mortality ratio was 247/100,000 live births (95% CI 147-391). Half of the maternal deaths (9) were from obstetric hemorrhage, and 28% (5) from puerperal sepsis. Postpartum hemorrhage was associated with a 17-fold higher risk of maternal mortality (PAF = 40%) and puerperal sepsis with a 12-fold higher mortality risk (PAF = 29%) compared to women without these conditions. Women delivered by unskilled birth attendants had a three-fold (PAF = 21%), and women having prolonged labour had a fourfold risk of maternal mortality compared to those with these conditions. Women with leg swelling (47%) and pre-eclampsia (26%) are at seven times the risk of maternal mortality compared to those without these conditions. Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants. CONCLUSION: The study, among a few large-scale prospective cohort studies conducted at the community level in a rural district of Pakistan, provides a better understanding of the risk factors determining maternal mortality in Pakistan. Poverty emerged as a significant risk factor for maternal mortality in the study area and contributes to the underutilization of health facilities and skilled birth attendants. Incorporating poverty reduction strategies across all sectors, including health, is urgently required to address higher maternal mortality in Pakistan. A paradigm shift is required in Maternal and Child health related programs and interventions to include poverty estimation and measuring mortality through linking mortality surveillance with the Civil Registration and Vital Statistics system. Accelerated efforts to expand the coverage and completeness of mortality data with risk factors to address inequalities in access and utilization of health services.

Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan.

BACKGROUND: Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data. METHODS: An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014-15). RESULTS: Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections. CONCLUSION: Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture-Recapture Methods.

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.

Risk factors of posttraumatic stress disorder after an earthquake disaster.

This study sought to predict posttraumatic stress disorder (PTSD) from women's reproductive health events after an earthquake experience. Data on antenatal care, pregnancy outcomes, family planning, socioeconomic status, earthquake experiences, and mental health were collected from a random sample of 425 women of reproductive age using the Centers for Disease Control and Prevention Reproductive Health Assessment Toolkit and the Harvard Trauma Questionnaire. Data were analyzed using multivariate regression analysis to predict PTSD symptoms from posttrauma care variables and reproductive health events. Restricted social participation, use of temporary accommodation, pregnancy complications, and use of injectable contraceptives were significant risk factors of PTSD. These factors may be exacerbated by the social context of conservative societies, traditions about health care-seeking behavior, and access to health care. Antecedent reproductive health events influence women's reaction to major trauma including events such as an earthquake.

Reproductive health and access to healthcare facilities: risk factors for depression and anxiety in women with an earthquake experience.

BACKGROUND: The reproductive and mental health of women contributes significantly to their overall well-being. Three of the eight Millennium Development Goals are directly related to reproductive and sexual health while mental disorders make up three of the ten leading causes of disease burden in low and middle-income countries. Among mental disorders, depression and anxiety are two of the most prevalent. In the context of slower progress in achieving Millennium Development Goals in developing countries and the ever-increasing man-made and natural disasters in these areas, it is important to understand the association between reproductive health and mental health among women with post-disaster experiences. METHODS: This was a cross-sectional study with a sample of 387 women of reproductive age (15-49 years) randomly selected from the October 2005 earthquake affected areas of Pakistan. Data on reproductive health was collected using the Centers for Disease Control reproductive health assessment toolkit. Depression and anxiety were measured using the Hopkins Symptom Checklist-25, while earthquake experiences were captured using the Harvard Trauma Questionnaire. The association of either depression or anxiety with socio-demographic variables, earthquake experiences, reproductive health and access to health facilities was estimated using multivariate logistic regression. RESULTS: Post-earthquake reproductive health events together with economic deprivation, lower family support and poorer access to health care facilities explained a significant proportion of differences in the experiencing of clinical levels of depression and anxiety. For instance, women losing resources for subsistence, separation from family and experiencing reproductive health events such as having a stillbirth, having had an abortion, having had abnormal vaginal discharge or having had genital ulcers, were at significant risk of depression and anxiety. CONCLUSION: The relationship between women's post-earthquake mental health and reproductive health, socio-economic status, and health care access is complex and explained largely by the socio-cultural role of women. It is suggested that interventions that consider gender differences and that are culturally appropriate are likely to reduce the incidence.

Predictive Ability And Stakeholders' Perceptions Of The Selection Tools For Mbbs In Women Medical College: A Mixed Methods Study.

BACKGROUND: The selection criteria for entry into the MBBS programme used by Women Medical College (WMC) includes previous academic achievements, namely Secondary School Certificate (SSC) and Higher Secondary Certificate (HSC), and the Medical and Dental College Admission Test (MDCAT). This study determined the predictive validity of these selection tools and explored the perceptions of stakeholders regarding the selection process and the use of selection tools in WMC. METHODS: This study utilized both quantitative and qualitative methods. Quantitative methods involved a retrospective cohort study design to determine the statistical correlation between the performance of candidates in the selection tools and their subsequent academic achievements at medical college. This consisted of data collected from three cohorts (n=186) of students who graduated in 2014, 2015 and 2016. Qualitative methods of the study explored the perceptions of stakeholders through purposive sampling using face-to-face semi-structured interviews, which were analysed using thematic analysis. RESULTS: The study showed very weak correlations of SSC with performance in the fourth professional examination undertaken by the students and HSC with performance in the first and second professional examinations. MDCAT did not correlate with any professional examination. Qualitative analysis identified three emerging themes; a) lack of standardization, b) fairness of selection criteria, and c) assessment of noncognitive attributes. CONCLUSIONS: The selection tools showed poor predictive ability for the performance of students in the medical college. Standardizing the selection tools and including an assessment of non-cognitive attributes in the selection criteria is suggested.

Presentation of typhoid fever patients in Hazara Division and response to different treatment regimens.

BACKGROUND: Response to treatment can vary in patients with typhoid fever. This study was carried out on a group of typhoid patients who were treated in Medical B ward of Ayub Teaching Hospital. Resistance to antibiotic is commonly acquired by Salmonella typhi and is widely reported. Objective of study was to identify such resistance in patients coming from parts of Hazara Division. METHODS: All patients who presented with typhoid fever and admitted to Medical B Unit from 1st July to 30th September 2002 were included in study. Out of 76 patients 46 (60%) were male. Epidemiological date, presenting symptoms, finding on physical examination, laboratory investigation and radiological examination were recorded. Then one of six commonly used treatment regimens were started. Response to treatment was studied. RESULTS: Common presenting symptoms and signs were recorded. Headache and fever were seen in 100% of patients. Cough and hypotension were among presenting features in 65% of patients. Leucocyte count of Less than 4 x 10(3)/dl was seen in 11% of samples. Liver functions and Renal function were found altered in 30% of patients. Study of response pattern to different regimens suggested relatively poor response to flouroquinolones. Fever of those patients who were treated with chloamphenicol and cefexime, settled early as compared to patients on other regimens. CONCLUSIONS: In addition to well known presenting features of typhoid like headache, fever, cough, hypotension and leucopenia abnormalities of renal and liver functions were commonly seen. Response to quinolone was poor suggesting emergence of resistance of salmonella typhi in this area.