Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi.

INTRODUCTION: Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions. METHODS: A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis. RESULTS: Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors. CONCLUSION: The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Client-centered counseling and facilitation in improving modern contraceptive uptake in urban slum of Karachi Pakistan.

BACKGROUND: Population growth in Pakistan necessitates the implementation of comprehensive family planning (FP) initiatives. The adoption of modern contraceptives, especially long-acting reversible contraceptives (LARC), and permanent family planning methods in the country is challenging and has yet to reach an optimal level. These challenges are deeply rooted in the lack of informed decision-making, as well as demographic and maternal obstetric history. Interventions tailored according to women's needs can address the challenges faced by FP programs. This paper presents the findings of the implementation of a client-centered counseling and facilitation approach in an urban slum in Karachi, Pakistan. Such an approach has the potential to inform women and help them make better decisions regarding their health. METHODS: In Rehri Goth, a slum located in Karachi, client-centered counseling along with facilitation at the facility was implemented to encourage the adoption of any modern contraceptive methods, with a specific emphasis on promoting the use of LARCs and permanent methods (where needed) among married women of reproductive age (MWRA). This approach was integrated into the existing Maternal, Neonatal, and Child Health (MNCH) services established in 2014. During the routine delivery of services, data were collected on various aspects including demographic characteristics, obstetric history, motivation to adopt LARCs, and reasons for refusal. RESULTS: A total of N = 3079 eligible MWRA received client-centered counseling, and 60.3% accepted modern contraceptive methods after counseling. Furthermore, 32.5% of these MWRA adopted LARCs or permanent methods. Factors explaining reluctance to adopt any method by MWRA despite specialized counselling were: age >25 years (AOR:1.28, 95% CI:1.08-1.51), no formal education (AOR:1.58, 95% CI:1.36-1.89), having no decision making role at household (AOR:1.60, 95% CI:1.36-1.89), the desire of female or male progeny (AOR:1.86, 95% CI:1.59-2.25) and age of youngest alive ≥3 years (AOR:1.50, 95% CI:1.22-1.84). Factors explaining adoption of short-term methods instead of LARCs or permanent method were: being resident in high under-five mortality clusters (AOR:1.56, 95% CI:1.14-2.14), maternal age > 25 years (AOR:1.88, 95% CI: 1.47-2.40), no decision-making role (AOR:11.19, 95% CI:8.74-14.34), no history of abortions (AOR:2.59, 95% CI:1.79-3.75), no female child (AOR:1.85, 95% CI:1.30-2.65) and ≤ 2 children (AOR:1.74, 95% CI:1.08-2.81). CONCLUSION: Considering the obstacles mothers face when it comes to accessing extended contraception, public health officials can devise effective strategies that empower MWRA to make well-informed and empowered choices regarding their families and reproductive health.