Barriers and facilitators to accessing adolescents' mental health services in Karachi: users and providers perspectives.

INTRODUCTION: Adolescents' Mental Healthcare (MHC) is influenced by numerous factors, and adolescents occasionally seek professional help for mental health (MH) issues. These factors become more complex within low-middle-income countries (LMICs); therefore, this study aims to understand barriers and facilitators to access mental health services among adolescents aged 10 to 19 years old from the perspective of users (parents) and providers (Mental Healthcare Providers - MHPs). METHOD: Using a qualitative exploratory design, a semi-structured interview guide was developed using Andersen's health service utilization model. In-depth interviews were conducted with MHPs (n = 21) and parents of adolescents (n = 19) in the psychiatry department of public and private hospitals in Karachi, from October-December 2021. Data was thematically analyzed using an inductive approach. RESULT: The findings revealed a consensus of users and providers in all three categories of the Andersen model and referred the compulsion as the major driving force to MHC access and utilization rather than personal choices. Within pre-disposing, need, and enabling factors; the participants highlighted a unique perspective; users regarded frequent migration, daily wage loss, and women's societal status as barriers while the need for marriage and patient willingness were stated as facilitators. Whereas, MHPs indicated societal tolerance, the burden on the health system, and the absence of Child and Adolescent Mental Health (CAMH) services as major gaps in service delivery. CONCLUSION: Service utilization is mainly facilitated by the severity of illness rather than healthy choices and beliefs, and accessibility and affordability. It is therefore imperative to prioritize adolescent MH through promotion and prevention approaches and address service delivery gaps to prevent treatment delays via task-shifting and capacity building of the health workforce.

The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative phenomenological study.

BACKGROUND: Pakistan has the highest rate of stillbirth (30.6 stillbirths per 1000 total births) as compared to other South Asian countries. The psychological impact of stillbirths on bereaved women is well documented; however, there is a dearth of literature on lived experiences of women with multiple stillbirths in Pakistan. OBJECTIVE: The purpose of this research is to understand the lived experiences of women who had multiple stillbirths in Thatta, Pakistan. METHODS: An interpretative phenomenological study was conducted in district Thatta with eight women who experienced more than one stillbirth. A semi-structured in-depth interview guide was used for data collection. The data were analyzed by using thematic analysis approach. RESULTS: The results of this study show that experiencing multiple stillbirths has a devastating impact on women's mental and social wellbeing. The women who experienced multiple stillbirths are stigmatized as "child-killer" or cursed or being punished by God. They are avoided in social gatherings within the families and community, because of these social pressures these women seek spiritual and religious treatment, and struggle to conceive again to deliver a live baby. It was observed that the psycho-social and medical needs of these bereaved women remain unaddressed not only by the healthcare system but also by the society at large. CONCLUSIONS: The physical, social and mental well-being of women who experience multiple stillbirth are at stake. These women are being considered social outcast. Health care providers including physicians, lady health workers, and traditional birth attendants should be trained on provision of psychosocial support along with the routine care that they provide in communities and health facilities. The health care providers should also inform the bereaved women about the biomedical causes of stillbirths that would be helpful to mitigate the stigma associated with stillbirths. Moreover, the health care providers should also counsel family members especially in-laws of these sorrowful women about the biomedical causes of stillbirths that would also be helpful to mitigate the stigma associated with stillbirths.

Development and validation of a psychometric scale to assess attitude towards safe abortions in Pakistan.

Despite severe health and economic consequences that women face because of the negative attitude of healthcare providers towards safe abortion and post-abortion care (SA/PAC), no psychometric tool has yet been validated for assessing the attitude towards SA/PAC. Only a handful of studies have attempted to assess healthcare providers' attitude towards safe abortions in Pakistan. Therefore, this study aimed to develop and validate a psychometric scale to assess attitude towards safe abortions in Pakistan. The study collected data from 106 workers of an NGO that provides SA/PAC through an online and anonymous survey using the organisation's network. The study used factor analytic techniques and structural equation modelling to validate the factor structure and a final hierarchical model. A final scale of seven items relating to attitude towards elective abortions and moral attitude towards safe abortions was validated. The scales were highly reliable with both factors having reliability indicators greater than 0.7. The scale can be easily implemented to assess providers' attitude towards safe abortions. This will allow programmers to screen healthcare providers with a negative attitude, and evaluate the efficacy of their Value Clarification and Attitude Transformation (VCAT) programmes that are aimed at transforming providers' attitude towards safe abortions.

Evaluating Quality of Contraceptive Counseling: An Analysis of the Method Information Index.

The Method Information Index (MII) is calculated from contraceptive users' responses to questions regarding counseling content-whether they were informed about methods other than the one they received, told about method-specific side effects, and advised what to do if they experienced side effects. The MII is increasingly reported in national surveys and used to track program performance, but little is known about its properties. Using additional questions, we assessed the consistency between responses and the method received in a prospective, multicountry study. We employed two definitions of consistency: (1) presence of any concordant response, and (2) absence of discordant responses. Consistency was high when asking whether users were informed about other methods and what to do about side effects. Responses were least consistent when asking whether side effects were mentioned. Adjusting for inconsistency, scores were up to 50 percent and 30 percent lower in Pakistan and Uganda, respectively, compared to unadjusted MII scores. Additional questions facilitated better understanding of counseling quality.

A study protocol for an mHealth, multi-centre randomized control trial to promote use of postpartum contraception amongst rural women in Punjab, Pakistan.

BACKGROUND: Provision of family planning services during the immediate post-partum phase is considered effective and cost-efficient for promoting healthy timing and spacing of pregnancies. This research aims to test the effectiveness of mobile phone-based interventions in promoting use of postpartum contraception. Moreover, it will also test the non-inferiority of text and voice messages compared to interactive phone-based counselling. METHODS: A three-arm, 10-month, multicentre, randomized controlled trial will be conducted at 15 social franchise (SF) health facilities in Punjab province of Pakistan. Pregnant women aged 15-44 years who are in their first or second trimester and have a mobile phone for their own use will be eligible to participate in this study. The participants will be randomly allocated to one of three study arms: a) voice and text messages; b) interactive telephone-based counselling; or c) control arm (no additional phone-based support). The intervention counselling module will be developed based on the Integrated Behaviour Model which was recently adapted, and tested for the family planning context in Pakistan. It will broadly cover birth-preparedness, importance of birth spacing, and postnatal care. The phone-based intervention aims to improve women's ability to use contraception by providing them with information about a range of methods, access to family planning methods through outlets such as Suraj SF providers, connecting them with MSS field health educators to help them reach the centres, motivation by re-enforcing the benefits of contraceptive use on women's quality of life, and dispelling myths and misconceptions about modern contraceptive methods. Risk differences will be used as the measure of effect of the intervention on the outcomes. DISCUSSION: The study findings will highlight effectiveness of mobile phone in raising awareness of maternal health and contraception, which in turn, is expected to be translated into increased proportion of: at least four antenatal visits, skilled birth or institutional delivery, postpartum contraceptive use, postnatal check-up, child immunization, and breastfeeding. Moreover, if the text and voice messages approach is proven to be non-inferior to interactive calls, it will provide evidence to making promotion of healthcare less resource intensive, and thereby contribute in improving the efficiency of the healthcare system. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trials registry ( NCT03612518 ) on August 2nd, 2018.

Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan.

BACKGROUND: Low modern contraceptive prevalence rate and high unmet need in Pakistan aggravates the vulnerabilities of unintended pregnancies and births contributing to maternal morbidity and mortality. This research aims to assess the effectiveness of a free, single-purpose voucher approach in increasing the uptake, use and better targeting of modern contraceptives among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan. METHODS: A quasi-interventional study with pre- and post-phases was implemented across an intervention (Chakwal) and a control district (Bhakkar) in Punjab province (August 2012-January 2015). To detect a 15% increase in modern contraceptive prevalence rate compared to baseline, 1276 women were enrolled in each arm. Difference-in-Differences (DID) estimates are reported for key variables, and concentration curves and index are described for equity. RESULTS: Compared to baseline, awareness of contraceptives increased by 30 percentage points among population in the intervention area. Vouchers also resulted in a net increase of 16% points in current contraceptive use and 26% points in modern methods use. The underserved population demonstrated better knowledge and utilized the modern methods more than their affluent counterparts. Intervention area also reported a low method-specific discontinuation (13.7%) and high method-specific switching rates (46.6%) amongst modern contraceptive users during the past 24 months. The concentration index indicated that voucher use was more common among the poor and vouchers seem to reduce the inequality in access to modern methods across wealth quintiles. CONCLUSION: Vouchers can substantially expand contraceptive access and choice among the underserved populations. Vouchers are a good financing tool to improve equity, increase access, and quality of services for the underserved thus contributing towards achieving universal health coverage targets.

Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions.

BACKGROUND: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society--Pakistan implemented an operational research project--'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. METHODS: We conducted a quasi-experimental (pre- and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, (1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and (2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. RESULTS: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14% percentage points, current contraceptive use by 5% percentage points and long term modern method--intrauterine device (IUD) use by 6% percentage points. The CMW model significantly increased contraceptive awareness by 28% percentage points, ever use of contraceptives by 7% percentage points and, IUD use by 3% percentage points. Additionally the Suraj intervention led to a 35% greater prevalence (prevalence ratio: 1.35, 95% CI: 1.22-1.50) of contraceptive use among MWRA. CONCLUSION: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Comparing effectiveness of two client follow-up approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) among the underserved in rural Punjab, Pakistan: a study protocol and participants' profile.

BACKGROUND: Pakistan observes a very high i.e. 37 percent modern contraceptive method related discontinuation rates within 12 months of their initiation. And almost 10 percent of these episodes of discontinuation happened due to the side effects or health concerns experienced by the women. Most importantly, it was noted that more than 12,000 first-level care facilities are located in the rural areas, including rural health centers, basic health units, and family welfare centers, but more than 30% of these facilities are nonfunctional. This paper presents a study protocol and participants' profiling of a prospective cohort follow-up to compare the effectiveness of household based and telephonic approaches in sustaining the use of Long Acting Reversible Contraceptives (LARC) whilst to facilitate lowering method related discontinuation and increasing switching amongst the contraceptive users. METHODS: A 12-month multi-centre, non-inferiority prospective user follow-up is employed using three different study categories: a) household based follow-up; b) telephonic follow-up; and c) passive or need-based follow-up along with the hypothetical assumption that the telephonic client follow-up is not inferior to the household based follow-up by continuation rate of LARC and the telephonic follow-up is less-costly than the household based client follow-up. This follow-up will be conducted in 22 health facilities - (16 rural and 6 urban based facilities) in district Chakwal. The first two study categories will receive scheduled but different follow-up from the field workers at 1, 3, 6, 9, and 12 month while the third one i.e. the 'passive or need-based follow-up' will serve as a control group. Using sampling software PASS 11, it was estimated to have 414 clients in each study category and around 1366 clients will be recruited to account for 10% attrition rate. DISCUSSION: The study will help us to examine a more convenient method of effective follow-up for managing side effects, decreasing method discontinuation and increasing switching amongst users. The study information will also facilitate to develop a robust, effective and efficient mechanism for client follow-up to promote the continuation rates of LARC methods. The follow-up results and lessons learnt will be widely shared with stakeholders for their implementation and streamlining in health system.

Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: results of a cross-sectional baseline survey.

BACKGROUND: Although Pakistan was one of the first countries in Asia to launch national family planning programs, current modern contraceptive use stands at only 26% with a method mix skewed toward short-acting and permanent methods. As part of a multiyear operational research study, a baseline survey was conducted to understand the predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the baseline survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed. METHOD: A cross-sectional baseline household survey was conducted with randomly selected 3,998 married women of reproductive age (MWRA) in the Chakwal, Mianwali, and Bhakkar districts of Punjab. The data were analyzed on SPSS 17.0 using simple descriptive and logistic regression. RESULTS: Most of the women had low socio-economic status and were younger than 30 years of age. Four-fifths of the women consulted private sector health facilities for reproductive health services; proximity, availability of services, and good reputation of the provider were the main predicators for choosing the facilities. Husbands were reported as the key decision maker regarding health-seeking and family planning uptake. Overall, the current contraceptive use ranged from 17% to 21% across the districts: condoms and female sterilization were widely used methods. Woman's age, husband's education, wealth quintiles, spousal communication, location of last delivery, and favorable attitude toward contraception have an association with current contraceptive use. Unmet need for contraception was 40.6%, 36.6%, and 31.9% in Chakwal, Mianwali, and Bhakkar, respectively. Notably, more than one fifth of the women across the districts expressed willingness to use quality, affordable long-term family planning services in the future. CONCLUSION: The baseline results highlight the need for quality, affordable long-term family planning services close to women's homes. Furthermore, targeted community mobilization and behavior change efforts can lead to increased awareness, acceptability, and use of family planning and birth spacing services.

Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up.

BACKGROUND: Long-acting reversible contraceptives, such as the intrauterine device (IUD), remain underutilised in Pakistan with high discontinuation rates. Based on a 24-month prospective client follow-up (nested within a larger quasi-experimental study), this paper presents the comparison of two intervention models, one using private mid-level providers branded as "Suraj" and the other using community midwives (CMWs) of Maternal Newborn and Child Health Programme, for method continuation among IUD users. Moreover, determinants of IUD continuation and the reasons for discontinuation, and switching behaviour were studied within each arm. METHODS: A total of 1,163 IUD users, 824 from Suraj and 339 from the CMW model, were enrolled in this 24-month prospective client follow-up. Participants were followed-up by female community mobilisers physically every second month to ascertain continued IUD usage and to collect information on associated factors, switching behaviour, reasons for discontinuation, and pregnancy occurrence. The probabilities of IUD continuation and the risk factors for discontinuation were estimated by life table analysis and Cox proportional-hazard techniques, respectively. RESULTS: The cumulative probabilities of IUD continuation at 24 months in Suraj and CMW models were 82% and 80%, respectively. The difference between the two intervention areas was not significant. The probability distributions of IUD continuation were also similar in both interventions (Log rank test: χ(2) = 0.06, df = 1, P = 0.81; Breslow test: χ(2) = 0.6, df = 1, P = 0.44). Health concerns (Suraj = 57.1%, CMW = 38.7%) and pregnancy desire (Suraj = 29.3%, CMW = 40.3%) were reported as the most prominent reasons for IUD discontinuation in both intervention arms. IUD discontinuation was significantly associated with place of residence in Suraj and with age (15-25 years) in the CMW model. CONCLUSION: CMWs and private providers are equally capable of providing quality IUD services and ensuring higher method continuation. Pakistan's National Maternal Newborn and Child Health programme should consider training CMWs and providing IUDs through them. Moreover, private sector mid-level providers could be engaged in promoting the use of IUDs.

A study protocol: using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan.

BACKGROUND: High fertility rates, unwanted pregnancies, low modern contraceptive prevalence and a huge unmet need for contraception adversely affect women's health in Pakistan and this problem is compounded by limited access to reliable information and quality services regarding birth spacing especially in rural and underserved areas. This paper presents a study protocol that describes an evaluation of a demand-side financing (DSF) voucher approach which aims to increase the uptake of modern contraception among women of the lowest two wealth quintiles in Punjab Province, Pakistan. METHODS/DESIGN: This study will use quasi-experimental design with control arm and be implemented in: six government clinics from the Population Welfare Department; 24 social franchise facilities branded as 'Suraj' (Sun), led by Marie Stopes Society (a local non-governmental organization); and 12 private sector clinics in Chakwal, Mianwali and Bhakkar districts. The study respondents will be interviewed at baseline and endline subject to voluntary acceptance and medical eligibility. In addition, health service data will record each client visit during the study period. DISCUSSION: The study will examine the impact of vouchers in terms of increasing the uptake of modern contraception by engaging private and public sector service providers (mid-level and medical doctors). If found effective, this approach can be a viable solution to satisfying the current demand and meeting the unmet need for contraception, particularly among the poorest socio-economic group.

Barriers and facilitators to perinatal care of women with disabilities in lower- and middle-income countries: a study protocol for scoping review of qualitative studies.

BACKGROUND: The Sustainable Development Goals have put emphasis on equitable healthcare access for marginalised groups and communities. The number of women with disabilities (WWD) to marry and have children is rapidly increasing in low- and middle-income countries (LMICs). However, these women experience multifaceted challenges to seeking perinatal care in LMICs. The objective of this scoping review is to document key facilitators and barriers to seeking perinatal care by WWD. We also will propose strategies for inclusive perinatal healthcare services for women with disabilities in LMICs. METHODS: We will conduct a scoping review of peer-reviewed and grey literature (published reports) of qualitative and mixed-methods studies on facilitators and barriers to seeking perinatal care for women with functional disabilities from 2010 to 2023 in LMICs. An electronic search will be conducted on Medline/PubMed, Scopus and Google Scholar databases. Two researchers will independently assess whether studies meet the eligibility criteria for inclusion based on the title, abstract and a full-text review. ETHICS AND DISSEMINATION: This scoping review is based on published literature and does not require ethics approval. Findings will be published in peer-reviewed journals and presented at conferences related to reproductive health, disability and inclusive health forums.

Performance and measurement of a community-based distribution model of family planning services in Pakistan.

INTRODUCTION: Community-based distribution (CBD) has been successfully applied to family planning (FP) services worldwide. It forms the basis for the large lady health worker (LHW) programme in Pakistan which serves a limited number of women with contraception services. Thus, the concept has seen limited application in Pakistan. We present the outcomes of a CBD model that was implemented in 49 districts across Pakistan by a non-government organization (NGO). METHODS: The Marie Stopes Society (MSS) developed a CBD model around its fixed centres and reached around half a million married women of reproductive age (MWRA) with services. The services provided included outreach, counselling, condoms, pills, injections, and referrals for intrauterine contraceptive devices (IUCDs) and other reproductive health services. Services were provided in peri-urban locations for a subsidized fee using a businesslike target setting approach. The results of the programme were assessed by triangulating inception records against a cross-sectional end-of-project survey and service delivery records. RESULTS: The contraceptive prevalence rate (CPR) had increased from 38% to 51% by project-end with modern method use increasing by 50-200% and traditional method use remaining unchanged. Unmet need and self-reported pregnancy rates fell correspondingly. Approximately 73,500 new users were added to the initial user registered numbers to a total of 132,300; MSS accounted for 53,000 per year at the end of the project, which matched the commodities supplied by the NGO. CONCLUSIONS: The MSS CBD model presents a viable option for scaling effective FP services that may be replicated and scaled up with either donor support or by contracting out by the government. Triangulation of multiple data sources can provide more in-depth assessment of service delivery programmes and provide inferences that can inform service delivery.

Social franchising and vouchers to promote long-term methods of family planning in rural Pakistan: a qualitative stocktaking with stakeholders.

BACKGROUND: The overall use of modern contraception in Pakistan is quite low, especially in rural areas. Several studies have demonstrated the effectiveness of social franchising (SF) approaches in increasing access to modern contraception and improving the quality of healthcare in resource-poor areas in Asia and Africa. Drawing on best practices in SF, the Marie Stopes Society (MSS) implemented an SF model in certain rural areas of Pakistan to increase access to affordable and quality family planning (FP) services. The model was branded as Suraj (sun) and complemented with an innovative voucher scheme for intrauterine contraceptive devices (IUCDs). This paper describes the perspectives of Suraj clients, field workers mobilization (FWMs), and providers on various components of the Suraj model. METHODOLOGY: A qualitative exploratory study was conducted in six randomly selected intervention districts in the Sindh and Punjab provinces. Data were collected using focus group discussions (FGDs) with clients and in-depth interviews (IDIs) with providers and FWMs. Data were manually analyzed using constant comparison and the thematic analysis approach. FINDINGS: Clients showed positive attitudes towards modern contraceptive methods and identified Suraj FWMs and signboards as sources of information. Almost all clients reported IUCDs as effective methods as they have manageable side effects and require fewer visits to clinics. They spoke highly of voucher schemes as these enabled them to avail free IUCD services. Clients also appreciated many components of Suraj clinics, including cleanliness, privacy, confidentiality, the sterilization of instruments, and courteous Suraj providers and FWMs. Most Suraj providers said that IUCD insertion and infection-prevention training enhanced their ability to provide IUCD services and increased their standing in local communities. They reported that the role of FWMs was crucial in mobilizing the community and increasing their FP clientele. The FWMs said that attitudes towards FP were changing because of economic pressure at the household level, increases in literacy, and community mobilization efforts. CONCLUSION: The Suraj intervention influenced attitudes towards FP and modern contraception, positively. Women using IUCDs showed greater satisfaction with the method. The findings emphasize that SF approaches like Suraj, when complemented with vouchers and community mobilization efforts, can improve the utilization of long-term contraceptive methods among rural and underserved women. The study also identified the need for integrating FP, antenatal care, and safe delivery services.

Inequalities in utilisation of essential antenatal services for women with disabilities in Pakistan: analysis of a cross-sectional demographic and health survey of Pakistan 2017-2018.

OBJECTIVES: Although the number of disabled women entering motherhood is growing, there is little quantitative evidence about the utilisation of essential antenatal care (ANC) services by women with disabilities. We examined inequalities in the use of essential ANC services between women with and without disabilities. DESIGN, SETTING AND ANALYSIS: A secondary analysis of cross-sectional data from recent Demographic and Health Survey of Pakistan 2017-2018 was performed using logistic regression. PARTICIPANTS: A total weighted sample of 6791 ever-married women (age 15-49) who had a live birth in the 5 years before the survey were included. OUTCOME MEASURES: Utilisation of ANC: (A) antenatal coverage: (1) received ANC and (2) completed four or more ANC visits and (B) utilisation of essential components of ANC. RESULTS: The percentage of women who were at risk of disability and those living with disability in one or more domains was 11.5% and 2.6%, respectively. The coverage of ANC did not differ by disability status. With utilisation of essential ANC components, consumption of iron was lower (adjusted OR, aOR=0.6; p<0.05), while advice on exclusive breast feeding (aOR=1.6; p<0.05) and urine test (aOR=1.7; p<0.05) was higher among women with disabilities as compared with their counterparts. Similarly, the odds of receiving advice on maintaining a balanced diet was higher (aOR=1.3; p<0.05) among women at risk of any disability as opposed to their counterparts. Differences were also found for these same indicators in subgroup analysis by wealth status (poor/non-poor) and place of residence (urban-rural). CONCLUSION: Our study did not find glaring inequalities in the utilisation of ANC services between women with disabilities and non-disabled women. This was true for urban versus rural residence and among the poor versus non-poor women. Some measures, however, should be made to improve medication compliance among women with disabilities.

Psychosocial support during childbirth: Development and adaptation of WHO's Mental Health Gap Action Programme (mhGAP) for maternity care settings.

INTRODUCTION: Poor psychosocial support and lack of respectful care for women during childbirth are commonplace in health facilities in low- and middle-income countries. While WHO recommends providing supportive care to pregnant women, there is a scarcity of material for building the capacity of maternity staff to provide systematic and inclusive psychosocial support to women in the intrapartum phase, and prevent work stress and burnout in maternity teams. To address this need we adapted WHO's mhGAP for maternity staff to provide psychosocial support in labour room settings in Pakistan. Mental Health Gap Action Programme (mhGAP) is an evidence-based guidance which provides psychosocial support in resource-limited health care settings. This paper aims to describe the adaptation of mhGAP to develop psychosocial support capacity building materials for maternity staff to provide support to maternity patients, and also to staff, in the labour room context. METHODS: Adaptation was conducted within the Human-Centered-Design framework in three phases: inspiration, ideation, and implementation feasibility. In inspiration, a review of national-level maternity service-delivery documents and in-depth interviews of maternity staff were conducted. Ideation involved a multidisciplinary team to develop capacity-building materials by adapting mhGAP. This phase was iterative and included cycles of pretesting, deliberations, and revision of materials. In implementation feasibility, materials were tested via the training of 98 maternity staff and exploring system feasibility via post-training visits to health facilities. RESULTS: Inspiration phase identified gaps in policy directives and implementation and formative study identified limited understanding and skills of staff to assess patients' psychosocial needs and provide appropriate support. Also, it became evident that staff themselves needed psychosocial support. In ideation, team developed capacity-building materials comprising two modules: one dedicated to conceptual understanding, the other to implementing psychosocial support in collaboration with maternity staff. In implementation feasibility, staff found the materials relevant and feasible for the labour room setting. Finally, users and experts endorsed usefulness of the materials. CONCLUSION: Our work in developing psychosocial-support training materials for maternity staff extends the utility of mhGAP to maternity care settings. These materials can be used for capacity-building of maternity staff and their effectiveness can be assessed in diverse maternity care settings.

Comparing the effectiveness of mother-focused interventions to that of mother-child focused interventions in improving maternal postpartum depression outcomes: A systematic review.

BACKGROUND: Most empirically researched interventions for postpartum depression (PPD) tend to target mothers' depression alone. Harmful effects of PPD on physical and mental health of both mother and child has led researchers to investigate the impact of interventions on PPD and child outcomes together. So far, the evidence is limited regarding how these interventions compare with those focusing only on mothers' depression. This review compares the effectiveness of PPD-improving interventions focusing only on mothers with those focusing on mother and child together. METHODS: Nine electronic databases were searched. Thirty-seven studies evaluating mother-focused (n = 30) and mother-child focused interventions (n = 7) were included. Under each category, three theoretical approaches-psychological, psychosocial and mixed-were compared using standardized qualitative procedures. The review's primary outcome was maternal PPD. RESULTS: A higher proportion of mother-focussed interventions [20/30 (66.7%)] brought significant reduction in PPD outcomes as compared to a lower proportion of mother-child focused interventions [4/7 (57.14%)]. Mother-focused mixed approaches [3/3 (100%)] performed better in improving PPD than psychological [16/24 (67%)] or psychosocial approaches [1/3 (33.3%)] alone. Amongst mother-child focused interventions, psychosocial approaches performed well with two-thirds demonstrating positive effects on PPD. CONCLUSION: The evidence strongly favors mother-focused interventions for improving PPD with mixed interventions being more effective. Psychosocial approaches performed better with PPD once child-related elements were added, and also seemed best for child outcomes. Psychological approaches were most practiced and effective for PPD, irrespective of the intervention's focus. Further trials are needed to unpack intervention components that improve PPD and increase uptake, especially in lower-and middle-income countries.

Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff.

INTRODUCTION: Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women's experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan. METHODS: Applying the COM-B (capability-opportunity-motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model. RESULTS: We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers' knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth. CONCLUSIONS: Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients' feedback should be incorporated for continuous improvement in providing maternity care services that meet patients' preferences and needs.

Promoting Supportive and Respectful Maternity Care in Public Health Facilities in Sindh, Pakistan: A Theory-Informed Health System Intervention.

BACKGROUND: Disrespect, abuse, discrimination, and lack of emotional support characterize intrapartum care in the health systems of many low- and middle-income countries. Although the World Health Organization (WHO) provides frameworks and guidelines to address this issue, no operational model exists that effectively incorporates WHO intrapartum care guidelines into routine public health services. We aimed to develop and pilot-test a theory-driven, service-delivery intervention package linking dignified care with perinatal mental health to promote psychosocially supportive and respectful maternity care (S-RMC) in public health facilities in Sindh, Pakistan. METHODS: Using a mixed-method, pre-post design, the study was implemented in 6 secondary-level public health facilities in 2 rural districts of Southern Sindh, Pakistan. Its development was guided by the COM-B framework and informed by a literature review, formative research, and consultative sessions with implementers. The intervention was implemented in March-September 2021 and compared women's experiences of S-RMC during childbirth at baseline (n=313) and endline (n=314). We used descriptive statistics and linear regression techniques for analysis. RESULTS: A substantial reduction was observed in the cumulative level of overall mistreatment from baseline to endline, yielding a relative change of 50% (P<.001). Similar change was evident across different types of mistreatment: physical abuse (75%), verbal abuse (72%), ineffective communication (60%), nonconfidential care (78%), health system conditions and constraints (25%), noninclusive care (28%), lack of supportive care (52%), and stigma and discrimination (82%). Furthermore, we observed a significant reduction in the proportion of women experiencing symptoms of anxiety and depression before and after the intervention. CONCLUSION: This intervention built the capacity of maternity teams while improving accountability, health information systems, and governance measures. Given its promise to promote supportive and respectful childbirth in public health facilities, a large-scale effectiveness evaluation across diverse settings is warranted.

Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives.

INTRODUCTION: We conducted this qualitative investigation to explore the mechanisms of change in providing respectful care resulting from the supportive and respectful maternity care intervention (S-RMC) in Sindh, Pakistan. METHODS: We applied the principles of realist evaluation methodology with a descriptive explanatory research design. We conducted in-depth interviews with 36 maternity care providers at secondary-level public health facilities where S-RMC was implemented for 6 months. The S-RMC broad components included capacity-building of maternity teams and systemic changes for improvements in governance and accountability within public health facilities. Data were analyzed using a deductive content analysis approach. RESULTS: We identified mechanisms of change, categorized by the S-RMC components: (1) S-RMC training: insight into women's feelings and rights, realization of the value that nonclinical staff can play, understanding of team coordination, orientation in psychosocial components of maternity care; (2) assessment of women's psychosocial vulnerabilities: identification of women's differential needs beyond routine care to provide woman-centered care; (3) psychosocial support: effective engagement with women and within maternity teams and the customization of woman- and companion-focused care; (4) care coordination: improved coordination among clinical and nonclinical staff to provide personalized care and psychosocial support and proper handover to ensure continuity of care; (5) assessment of quality of care: identification of service gaps from women's feedback; and (6) performance review and accountability: monthly performance review meetings to establish team member communication, systematic awareness of the maternity team's performance and challenges, and implementation of collective corrective actions. CONCLUSION: Our findings pointed to S-RMC working along multiple pathways-and concertedly with various health system components-to enable positive processes and behavioral change in maternity teams.