Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of life in rural Pakistan: population-based study.

BACKGROUND: Pelvic organ prolapse (POP) is a gynecological condition resulting from pelvic floor dysfunction in women. The objective of this study is to estimate "the prevalence of pelvic organ prolapse" associated factors, duration and impact on women's quality of life in rural Pakistan. METHODS: A cross-sectional study was conducted with a three stage random sampling strategy. Three health centers were selected and selected Lady Health Workers from each health center interviewed a random sample of women in their households. The interview used a structured questionnaire to collect symptom data. Female gynaecologists then conducted a clinical examination at the local health center on women who reported symptoms of prolapse to verify and grade pelvic organ prolapse using Baden-Walker classification system. RESULTS: Among the 5064 women interviewed (95.8% response rate), 521 women had clinically confirmed POP, a prevalence of 10.3% (95% CI 9-11%). Among women with POP 37.8% had grade III or IV prolapse. Women with four or more children had the highest proportion of pelvic organ prolapse (75%) followed by women aged 36-40 years (25%).Among women with POP, 60.8% reported their quality of life as greatly or moderately affected; 44.3% had it for more than 5 years; and 78.7% never consulted a doctor. CONCLUSIONS: Pelvic organ prolapse is highly prevalent in rural Pakistan, impacts on women's everyday lives and remains mainly untreated. Measures should be taken to provide health care services to reduce this burden of disease among women.

Stillbirths: why they matter.

In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.

Prevalence of diabetic retinopathy in rural Pakistan: A population based cross-sectional study.

Purpose: To estimate the prevalence of diabetic retinopathy (DR), an emerging cause of sight threat and blindness from a large rural population in Pakistan. Methods: This was a population-based cross-sectional study. We selected a rural district of Matiari Sindh Province in Pakistan, where we selected all the health facilities and their attached Lady Health Workers (LHWs)/Lady Health Supervisors (LHSs). These female health workers were trained to identify high-risk diabetic individuals in their catchment areas using pre-defined criteria and to refer them to the nearest health facilities for screening and testing random blood sugar (BSR). Adults of 18 years or above, male or female, were included in the study for DM and DR screening. Ophthalmic examination was conducted by the optometrists on those who had BSR level >180 mg/dl for the evidence of DR. Identified DR patients were referred to a linked tertiary-level ophthalmology institute for their free DR treatment. Results: Of the identified and referred 24,463 participants, 23,999 were tested for BSR and 2,331 (9.74%) were found to be high-risk patients (BSR >180 mg/dl) and had ophthalmic examination conducted. Of these, 563 had clinically established DR, a prevalence of 24.2% (95% CI, 22-26%). Significantly more DR patients (228, 40.5%) were found in the age group >60 years, with more among female (327, 58.1%) with DR. Conclusion: DR is highly prevalent in the Pakistani rural population. The establishment of an integrated approach within the health care system could decrease the burden of DR in Pakistan.

Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.

BACKGROUND: There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries. METHODS: We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality. RESULTS: Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23). CONCLUSIONS: Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.

Safe delivery and newborn care practices in Sindh, Pakistan: a community-based investigation of mothers and health workers.

OBJECTIVE: to determine the prevalence of specific intrapartum practices in Sindh province, Pakistan. DESIGN: a cross-sectional, questionnaire based study. SETTING: 6 health clinics in Mirpurkhas, Sindh province, rural Pakistan. PARTICIPANTS: 225 mothers and 82 health workers. MEASUREMENTS AND FINDINGS: outcome measures were indicators of safe delivery practices and referral following an obstetric complication. Prevalence of unhygienic and unsafe practices in deliveries attended by Traditional Birth Attendants (TBAs) was common. Deliveries by skilled attendants were significantly safer but with some failures in hygienic practices. 29% of women who had experienced an obstetric complication had not received emergency obstetric care. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: safe delivery practices and newborn care needs to be improved in rural Pakistan. This may be achieved by training health workers and TBAs in safe delivery practices, using safe delivery kits and with an effective referral system.