Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys.

BACKGROUND: Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions. METHODS: Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers' age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains. RESULTS: The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15-19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas. CONCLUSIONS: Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups.

Role of social network in decision making for increasing uptake and continuing use of long acting reversible (LARC) methods in Pakistan.

INTRODUCTION: Despite evidence from recent Demographic Health Surveys that show 98% of the adult Pakistani population have an awareness of at least one modern contraceptive method, only 25% of married couples in Pakistan used a modern method of contraception. Of the modern contraceptive methods, LARC usage has increased only from 2.1 to 3%. This low uptake is puzzling in the context of high awareness of LARC methods and its availability through public sector facilities at subsidized costs. This study aimed to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan. METHODS: In-depth interviews were conducted with 27 women who were using a LARC method for contraception. Data was managed using NVivo 12 and themes were identified using a content analysis approach to analyze the transcripts. RESULTS: Four key themes, supported by sub-themes relating to a temporal model, were identified to explain women's experiences with initiating and continuing use of a LARC. The themes were (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC. Results highlight the significant role of immediate social network of female family members in supporting the women in initiating LARCs and maintaining the method's use. CONCLUSION: This study contributes to an in depth understanding of the decision-making process of women who adopted LARC and maintained its use. Women who proceeded to use an LARC and who persisted with its use despite the experience of side effects and social pressures, were able to do so with support from other female family members and spouse.

Perceptions and practices among married women of child bearing age regarding obstetric danger signs in rural Islamabad: A qualitative study.

OBJECTIVE: To explore women's perceptions regarding obstetric danger signs and their practices to deal with them in their cultural context. METHODS: The exploratory qualitative study was conducted in Moorian, Jagiot and Kurri, three rural areas around Islamabad, Pakistan, from June to September, 2016. Data about understanding and practices regarding obstetric danger signs was collected from married women of reproductive age through focus group discussions. Data analysis was done manually using the content analysis approach. RESULTS: There were 85 women with a mean age 32±6.80 years who participated in a total of 12 focus group discussions in batches of 6-8 subjects each. Majority of women 64(75%) were unaware of key obstetric danger signs and symptoms. Traditional practices and several home remedies were commonly used to manage complications in pregnancy before seeking medical care, which was only done when the condition became unmanageable at home. However, mostly women 78(92%) preferred hospital for antenatal care services, especially private health facilities, due to perceived better quality of services. CONCLUSIONS: Cultural practices were found to be deep-rooted in rural population.

Preferences Of Doctors For Working In Rural Islamabad Capital Territory, Pakistan: A Qualitative Study.

BACKGROUND: Developing countries are faced with acute shortages of human resources in rural/remote areas. Decisions of human resources for health to work in rural areas are influenced by many financial and non-financial factors. This study focused on preferences of doctors for working in rural and resource constrained areas of Pakistan. METHODS: The study was based on qualitative research techniques. Focus group discussions (FGDs) were conducted with final year medical students and house officers and In-depth Interviews (IDIs) with senior health managers of Islamabad Capital Territory (ICT). Results were analyzed using qualitative content analysis technique to present the findings. RESULTS: The results showed that quality of facilities; career development, lack of incentives, quality of life, and lack of connectivity between rural and urban health facilities, transportation services and governance issues are some of the main factors identified by young doctors of ICT that contribute in their decision of choosing a certain job or not in rural areas. CONCLUSIONS: Study results show the indepth detail of deciding factors for attracting and retaining health workforce in rural areas. These can be used for designing DCE (Discrete Choice Experiment) questionnaire to further analyze the preference incentive packages for attracting doctors to work in rural Islamabad.

SOCIAL AND SOCIETAL BARRIERS IN UTILIZATION OF MATERNAL HEALTH CARE SERVICES IN RURAL PUNJAB, PAKISTAN.

BACKGROUND: The health status of pregnant women depends largely on the quality of the antenatal and delivery services available to them. Maternal mortality remains a major public health problem with antenatal and delivery care utilization remaining low in Pakistan. This study explores the perspectives of rural community members about the antenatal and delivery care services' utilization by the community. METHODS: A qualitative study was undertaken in the rural community of District Attock. Focus Group Discussions (FGD) were conducted with husbands, married women of child-bearing age with young children and mothers-in-law. Data was analysed manually using content analysis techniques. RESULTS: Majority of the respondents sought antenatal care (ANC) after 3-4 months. They further reported that home was the preferred place of delivery followed by the local "rural health centre". The preferred attendant for delivery was the local Dai (traditional birth attendant). Major limitations to accessing ANC and delivery services were lack of knowledge about ANC, long distance and high transport costs to health care facilities. People had strong beliefs on faith healers (Pirs) and insufficient knowledge about danger signs. Traditional and customary practice as taweez dhaga, saya, purdah, non-availability of health care providers, and lack of trust on young community midwives led to people favouring the home based package of services provided by traditional birth attendants (Dais). CONCLUSION: The findings of this study indicate that demand side barriers such as lack of knowledge regarding home based care, social barriers, financial constraint and non-acceptability of community midwives (CMW) because services offered by traditional birth attendants (TBA) were more accessible in terms of distance and cost are a major challenge affecting utilization. Efforts towards ensuring the utilization of ANC and delivery services should be targeted towards rural areas and the importance of skilled care should be emphasized. Women should be encouraged to utilize antenatal and delivery services.

Challenges in delivery of skilled maternal care - experiences of community midwives in Pakistan.

BACKGROUND: Maternal mortality ratio in Pakistan remains high at 276 per 100000 live births (175 in the urban areas and 319 in rural) with a mother dying as a result of giving birth every 20 minutes. Despite the intervening years since the Safe Motherhood Initiative launch and the Millennium Development Goals (MDGs), there have been few improvements in MDGs 4 and 5 in Pakistan. A key underlying reason is that only 39% of the births are attended by skilled birth attendants. Pakistan, like many other developing countries has been struggling to make improvements in maternal and neonatal health, amongst other measures, which include a nationwide health infrastructure network. Recently, government of Pakistan revised its maternal and newborn health program and introduced a new cadre of community based birth attendants, called community midwives (CMW), trained to conduct home-based deliveries. There is limited research available on field experiences of community midwives as maternal health care providers. Formative research was designed and conducted in a rural district of Pakistan with the objective of exploring role of CMWs as home based skilled service providers and the challenges they face in provision of skilled maternal care. METHODS: A qualitative research using content analysis was conducted in one rural district (Attock) of Pakistan. Focus group discussions were conducted with CMWs and other community based health workers as LHWs and LHSs, focusing on the role of CMWs in the existing primary health care infrastructure. RESULTS: Results of this study reveal that the community midwives are struggling for survival in rural areas as maternal care providers as they are inadequately trained, lack sufficient resources to deliver services in their catchment areas and lack facilitation for integration in district health system. CONCLUSIONS: CMWs face many challenges in the field related to the communities' attitude and the health system. With adequate training and facilitation by health department, CMWs have potential to play a vital role in reducing burden of maternal morbidity and in achieving significant gains in improving maternal and child health.

'The wife should do as her husband advises': Understanding factors influencing contraceptive use decision making among married Pakistani couples-Qualitative study.

This paper explores the perceptions and attitudes of married couples which prevent them from using modern contraceptive for purpose of family planning, based on semi-structured interviews with 16 married couples from rural Pakistan. This study, with married couples, not using any modern contraceptives, discussed issues of spousal communication and religious norms using qualitative methods. Despite near universal knowledge of modern contraceptives among married Pakistani women, the use continues to be low, with high unmet need. Understanding the couple context about reproductive decision making, pregnancy and family planning intentions is imperative to helping individuals fulfil their reproductive desires. Married couples may have varying intentions and desires about family size; a lack of alignment between partners may lead to unintended pregnancies and affect uptake and use of contraception. This study specifically explored the factors which prevent married couples from using LARCs for family planning, despite their availability, at affordable prices in the study area of rural Islamabad, Pakistan. Findings show differences between concordant and discordant couples regarding desired family size, contraceptive communication and influence of religious beliefs. Understanding the role that male partners play in family planning and use of contraceptives is important in preventing unintended pregnancies and improving service delivery programmes. This study also helped identify the challenges married couples, particularly men have in understanding family planning and contraceptive use. The results also show that while men's participation in family planning decision making is limited, there is also a lack of programs and interventions for Pakistani men. The study findings can support development of appropriate strategies and implementation plans.

A Cross-Sectional Study to Assess HIV/AIDS-Related Stigma and Its Drivers Among Dental Healthcare Providers in Islamabad, Pakistan.

Introduction HIV-related stigma and discrimination among healthcare providers are some of the strongest obstacles to effectively responding to HIV and achieving health-related quality of life. In the Pakistani context, HIV-related discrimination has been explored mainly among people living with HIV (PLHIV), and no study has investigated HIV-related stigma from the perspective of dental healthcare providers. Aim This study aimed to investigate the HIV-related stigma among dental healthcare workers in Pakistan and understand the factors associated with it. Methodology This cross-sectional study was conducted for a period of three months (December 2021 to February 2022) among 601 consenting dental healthcare providers in all public and private dental healthcare facilities in Islamabad, Pakistan. Pretested questionnaires collected information on demographics, work-related characteristics, knowledge, attitudes, and practices regarding HIV/AIDS. HIV-related stigma was assessed through "the stigma index" developed by USAID and was measured as a continuous variable. Multivariate linear regression analysis evaluated the independent effect of different factors associated with HIV-related stigma. Results HIV-related stigma remains highly prevalent within both public and private dental healthcare facilities in ICT and among all cadres of dental healthcare providers. Among associated factors, misconceptions in HIV knowledge are highly significant (p < 0.001) and those with a higher score of incorrect HIV knowledge had higher levels of stigma. Healthcare providers who read any HIV-related manual or guidelines were found to be less stigmatized as compared to those who have not been exposed to any such literature (p=0.029). Dentists (p=0.04) showed higher levels of stigma as compared to dental assistants and dental hygienists, while employees of private hospitals (p=0.0) and private clinics (p=0.0) were far more stigmatized by HIV in comparison to dental healthcare providers in public hospitals. Conclusion This study provides the first-ever analysis of HIV-related stigma and its drivers in the dental healthcare settings in Pakistan and highlights multiple individual, clinical, and policy-level factors associated with it. In order to address this stigma, it is essential for healthcare institutions to create supportive and inclusive healthcare settings, by providing education and training to care providers in order to increase their understanding of the disease itself. In addition, healthcare institutions can take steps to ensure that their policies and practices are inclusive and non-discriminatory, such as implementing policies that prohibit discrimination based on HIV status and providing confidential care. On the other hand, care providers must work to recognize their own biases and strive to provide non-discriminatory and culturally sensitive care to all patients. The findings of this study could be used as a baseline and insight by organizations like the National AIDS Control Program into possible targets for future exploration and interventions to effectively reduce the stigma toward PLHIV in dental healthcare settings.

An assessment of facility readiness for comprehensive abortion care in 12 districts of Pakistan using the WHO Service Availability and Readiness Assessment tool.

Although Pakistan's Essential Package of Health Services was recently updated to include therapeutic and post-abortion care, little is known about current health facility readiness for these services. This study assessed the availability of comprehensive abortion care, and readiness of health facilities to deliver these services, within the public sector in 12 districts of Pakistan. A facility inventory was completed in 2020-2021 using the WHO Service Availability and Readiness Assessment, with a newly developed abortion module. A composite readiness indicator was developed based on national clinical guidelines and previous studies. Just 8.4% of facilities reported offering therapeutic abortion, while 14.3% offered post-abortion care. Misoprostol (75.2%) was the most common method provided by facilities that offer therapeutic abortion, followed by vacuum aspiration (60.7%) and dilatation and curettage (D&C) (59%). Few facilities had all the readiness components required to deliver pharmacological or surgical therapeutic abortion, or post-abortion care (<1%), but readiness was higher in tertiary (22.2%) facilities. Readiness scores were lowest for "guidelines and personnel" (4.1%), and slightly higher for medicines and products (14.3-17.1%), equipment (16.3%) and laboratory services (7.4%). This assessment highlights the potential to increase the availability of comprehensive abortion care in Pakistan, particularly in primary care and in rural areas, to improve the readiness of health facilities to deliver these services, and to phase out non-recommended methods of abortion (D&C). The study also demonstrates the feasibility and utility of adding an abortion module to routine health facility assessments, which can inform efforts to strengthen sexual and reproductive health and rights.

A Qualitative Study of Stakeholders' Views on Pharmacovigilance System, Policy, and Coordination in Pakistan.

Objectives: Due to the absence of necessary rules, poor coordination, and various challenges, the pharmacovigilance system of Pakistan is not optimally functional at all levels of the health system. The objective of the study was to assess the stakeholders' perceptions of the current ADR reporting system and to identify the pharmacovigilance policy issues and problems of effective coordination. Methodology: Stakeholders from a broad range of disciplines, academia, regulatory authorities, the pharmaceutical industry, international health organizations, as well as pharmacovigilance experts, and healthcare professionals were included in the study. A total of 25 stakeholders throughout Pakistan were interviewed during exploratory semi-structured interviews. The interviews were recorded digitally, transcribed, coded, compared, and grouped according to their similarity of themes. Participants provided insights into gaps, limitations, and challenges of Pakistan's current ADR reporting system, issues with proposed pharmacovigilance rules, and coordination difficulties. Results: The majority of the participants considered the ADR reporting system in Pakistan to be improving but in a nascent phase. The identified gaps, challenges, limitations of the system, and barriers to reporting were labeled as reasons for limited functioning. Almost all stakeholders were aware of the existence of draft pharmacovigilance rules; however, participants in the industry were familiar with the contents and context of draft pharmacovigilance rules. Bureaucratic red tape and lack of political will appeared to be the top reasons for delaying the approval of the pharmacovigilance rules. Wider consultation, advocacy, and awareness sessions of policymakers and HCPs were suggested for early approval of rules. Participants unanimously agreed that the approval of rules shall improve the quality of life and reduce the economic burden along with morbidity and mortality rates. The need for greater and collaborative coordination among the stakeholders in promoting medicines' safety was highlighted. All participants suggested the use of media and celebrities to disseminate the safety information. Conclusion: Participants showed partial satisfaction with the way pharmacovigilance in Pakistan is moving forward. However, stakeholders believed that engagement of multi-stakeholders, approval of pharmacovigilance rules, and the establishment of pharmacovigilance centers in provinces, hospitals, and public health programs (PHPs) shall support in achieving the desired results.

Association Of Antenatal Depression And Household Food Insecurity Among Pregnant Women: A Crosssectional Study From Slums Of Lahore.

BACKGROUND: Pregnant women are more likely to develop antenatal depression due to multiple factors including sickness and death of close family member, unwanted pregnancy, unplanned pregnancy, economic and relationship difficulties. Food insecurity is a major issue in low resource settings, especially in developing countries. Malnourishment in pregnant women along with antenatal depression can lead to adverse effect on growth of foetus and can lead to adverse pregnancy outcomes. The aim of this study was to determine an association between food insecurity and antenatal depression among pregnant women living in slum settlements of Lahore. METHODS: A community based, crosssectional study was conducted in slum settlements of district Lahore, with a sample of 367 pregnant women. Antenatal depression and household food insecurity was measured using Edinburgh Postnatal Depression Scale (EPDS) and Household food insecurity access scale (HFIAS). Data was entered and analysed in SPSS-20.0. Chi-square and multivariate logistic regression analysis was used to estimate effect of food insecurity on antenatal depression among pregnant women. RESULTS: Prevalence ofantenatal depression was 39.5% among pregnant women. Majority of the sample, i.e., 46% were food insecure. In an adjusted model, multivariate logistic regression showed existence of strong association between food insecurity and antenatal depression (AOR=2.58, 95%, CI: 1.64-4.075) in women surveyed. CONCLUSIONS: Study results show strong association between food insecurity and antenatal depression. Findings also suggest the need of an effective intervention at community level to combat food insecurity and antenatal depression in marginalized populations.

Exploring Managers' Perspectives on MNCH Program in Pakistan: A Qualitative Study.

BACKGROUND: Pakistan's Maternal, Newborn and Child Health (MNCH) Program is faced with multiple challenges in service delivery, financial and logistic management, training and deployment of human resources, and integration within the existing health system. There is a lack of evidence on managerial aspects of the MNCH program management and implementation. METHODS AND FINDINGS: This study used qualitative methods to explore the challenges national, provincial and district program managers have faced in implementing a community midwifery program in province of Punjab while also exploring future directions for the program under a devolved health system. While the program had been designed in earnest, the planning lacked critical elements of involving relevant stakeholders in design and implementation, socio-demographic context and capacity of the existing health system. Financial limitations, weak leadership and lack of a political commitment to the problem of maternal health have also had an impact on program implementation. CONCLUSIONS: Our study results suggest that there is a need to re-structure the program while ensuring sustainability and collaboration within the health sector to increase uptake of skilled birth attendance and improve maternal health care in Pakistan.