Stillbirth--a neglected priority: understanding its social meaning in Pakistan.

Despite being ranked 3rd among the countries having highest burden of stillbirths, it remains a neglected priority in Pakistan. We review the evidence regarding social and biomedical understanding of stillbirths by both communities and healthcare providers. The terminology used to define stillbirth worldwide remains inconsistent. Not only do the health professionals mis-classify and under-report stillbirths, but also the parents and families are unclear about the difference between miscarriage, stillbirth and early neonatal deaths. Stillbirths occur more in poor families and are not recognised by tradition and religion as a loss comparable to a newborn who was born alive. There is need to understand perspective of communities and healthcare providers to identify prevention and management strategies along with providing support for coping with the implications of stillbirths. Future government policies on stillbirths must be informed by the influence of culture on the attitudes, beliefs and practices of the communities and the healthcare providers.

The final push for polio eradication: addressing the challenge of violence in Afghanistan, Pakistan, and Nigeria.

Seye Abimbola and colleagues provide a view from Nigeria, Pakistan, and Afghanistan on global efforts to eradicate polio in those countries. Please see later in the article for the Editors' Summary.

Application of systems thinking in health: opportunities for translating theory into practice Comment on "Constraints to applying systems thinking concepts in health systems: a regional perspective from surveying stakeholders in Eastern Mediterranean countries".

Systems thinking is not a new concept to health system strengthening; however, one question remains unanswered: How policy-makers, system designers and consultants with a system thinking philosophy should act (have acted) as potential change agents in actually gaining opportunities to introduce systems thinking? Development of Comprehensive Multi-Year Plans (cMYPs) for Immunization System is one such opportunity because almost all Low- and Middle-Income Countries (LMICs) develop and implement cMYPs every five years. Without building upon examples and showing practical application, the discussions and deliberations on systems thinking may fade away with passage of time. There are opportunities that exist around us in our existing health systems that we can benefit from starting with an incremental approach and generating evidence for longer lasting system-wide changes.

Job satisfaction among nurses working in the private and public sectors: a qualitative study in tertiary care hospitals in Pakistan.

BACKGROUND: Many low and middle income countries lack the human resources needed to deliver essential health interventions. A health care system with a limited number of nurses cannot function effectively. Although the recommended nurse to doctor ratio is 4:1, the ratio in Pakistan is reversed, with 2.7 doctors to one nurse. METHODS: A qualitative study using narrative analysis was undertaken in public and private tertiary care hospitals in Pakistan to examine and compare job satisfaction among nurses and understand the factors affecting their work climate. Interactive interviews were conducted with nurses working with inpatients and outpatients. RESULTS: All of the respondents had joined the profession by choice and were supported by their families in their decision to pursue their career, but now indicated that they were dissatisfied with their jobs. Three types of narratives were identified, namely, "Working in the spirit of serving humanity", "Working against all odds", and "Working in a functional system and facing pressures of increased accountability". Nurses working in a public sector hospital are represented in the first two narrative types, whereas the third represents those working in a private sector hospital. The first narrative represents nurses who were new in the profession and despite hard working conditions were performing their duties. The second narrative represents nurses working in the public sector with limited resources, and the third narrative is a representation of nurses who were working hard and stressed out despite a well functioning system. CONCLUSION: The study shows that the presence of a well trained health workforce is vital, and that certain aspects of its organization are key, including numbers (available quantity), skill mix (health team balance), distribution (urban/rural), and working conditions (compensation, nonfinancial incentives, and workplace safety). This study has identified the need to reform policies for retaining the nursing workforce. Simple measures requiring better management practices could substantially improve the working environment and hence retention of nurses.