Women's perceptions about mobile health solutions for selection and use of family planning methods in Karachi: a feasibility study.

BACKGROUND: The qualitative study explored the feasibility and acceptability of potential mHealth intervention for women living in low socio-economic areas to increase the uptake of family planning. The study also examined providers' perceptions' potential benefits of mHealth intervention. METHODS: The qualitative exploratory study recorded the perception of 23 women and conducted seven in-depth interviews with the providers of family planning services. These interviews assessed women's attitudes through; personal experience based on the usage of smartphones and family planning, acceptability for personal benefits, features of mobile applications and the convenient language, and self-efficacy for identifying the potential impact of mHealth intervention to increase women's empowerment for family planning usage. RESULTS: Three predetermined themes were used to record women's perceptions. Women's personal experience identified that women in low-socioeconomic areas use mobile phones frequently and also use them for gaining information related to health. Few women have experience using mobile phones to get information about sexual and reproductive health. Women considered; poor counselling and high transport costs to the facilities as significant barriers to getting family planning services. Perceived acceptability discussed the potential features of the mHealth app. Women considered that including short videos instead of written material would help them to understand its usage and complete information about family planning methods, including; dosage, expected side effects, and potential benefits suggested to include in the app. Women perceived that the mHealth intervention would save their transport costs to the facility and fill the information gap about family planning methods. In comparison, providers considered it would save time in counselling and motivating women at the facility. One of the significant factors discussed was self-efficacy in the form of women's empowerment in deciding on family planning. Women discussed that the mHealth intervention would increase their self-confidence to discuss the method with their husbands. CONCLUSION: There is a high potential for mHealth interventions for family planning in Pakistan. The usage of mobile phones can increase women's acceptability and accessibility for family planning uptake in the country.

We Won't Go There: Barriers to Accessing Maternal and Newborn Care in District Thatta, Pakistan.

Accessibility and utilization of healthcare plays a significant role in preventing complications during pregnancy, labor, and the early postnatal period. However, multiple barriers can prevent women from accessing services. The aim of this study was to explore the multifaceted barriers that inhibit women from seeking maternal and newborn health care in Thatta, Sindh, Pakistan. This study employed an interpretive research design using a purposive sampling approach. Pre-tested, semi-structured interview guides were used for data collection. The data were collected through eight focus group discussions with men and women, and six in-depth interviews with lady health workers and analyzed through thematic analysis. The study identified individual, sociocultural, and structural-level barriers that inhibit women from seeking maternal and newborn care. Individual barriers included mistrust towards public health facilities and inadequate symptom recognition. The three identified sociocultural barriers were aversion to biomedical interventions, gendered imbalances in decision making, and women's restricted mobility. The structural barriers included ineffective referral systems and prohibitively expensive transportation services. Increasing the coverage of healthcare service without addressing the multifaceted barriers that influence service utilization will not reduce the burden of maternal and neonatal mortality. As this study reveals, care seeking is influenced by a diverse array of barriers that are individual, sociocultural, and structural in nature. A combination of capacity development, health awareness, and structural interventions can address many if not all of these barriers.

Factors affecting Maternal-care during labour at maternity centres of Karachi, Pakistan: Exploratory study.

Globally 529,000 women die every year due to harmful consequences of childbirth. This study aimed to explore the barriers and facilitators that influence the provision of quality care during labour at maternity centres in Karachi, Pakistan. The qualitative exploratory study design was used to study such factors from public and private maternity health facilities of Karachi, Pakistan. A total of 12 in-depth interviews were conducted through purposive sampling by using validated semi-structured interview guide. Data was analysed using content analysis manually. Among major barriers, unhygienic environment, lack of basic equipment, supplies and medicine, unprofessional attitude of staff, physical infrastructre and shotrage of staff were explored. Among facilitators, caring and supportive attitude of healthcare personnel during labour were identified. These identified determinants would guide policy-makers, Maternal, Newborn and Child Health (MNCH) planners and health managers to take appropriate actions to enhance the quality of maternal care which will subsequently result in considerable reduction in maternal mortalities.

Task Sharing of Injectable Contraception Services in Pakistan: A Randomized Controlled Trial.

Provision of injectable contraceptive services by lay health workers is endorsed by normative bodies, but support for this practice is not universal. We assessed whether lay providers (lady health workers, LHWs) could perform as well as clinically trained providers (family welfare workers, FWWs) on appropriate screening, counseling, and injection of intramuscular and subcutaneous depot medroxyprogesterone acetate (DMPA) using a randomized controlled trial. In the urban sample (n = 355), 88 percent of FWW DMPA clients were appropriately screened versus 77 percent of LHW clients (noninferiority test p = 0.88). In rural facilities (n = 105), over 90 percent of both providers' clients were screened appropriately. Appropriate counseling was low overall, but LHWs were significantly noninferior to FWWs (p = 0.003). Notably, LHWs demonstrated better injection technique than FWWs. We could not conclude that LHWs screened new DMPA users as well as FWWs from an urban sample of providers but results from the rural sample suggests that service delivery context played an important role.

Use of Smokeless Tobacco Before Conception and Its Relationship With Maternal and Fetal Outcomes of Pregnancy in Thatta, Pakistan: Findings From Women First Study.

INTRODUCTION: Smokeless tobacco (SLT) consumption during pregnancy has adverse consequences for the mother and fetus. We aimed to investigate the effects of maternal pre-pregnancy SLT consumption on maternal and fetal outcomes in the district of Thatta, Pakistan. AIMS AND METHODS: We conducted a secondary data analysis of an individual randomized controlled trial of preconception maternal nutrition. Study participants were women of reproductive age (WRA) residing in the district of Thatta, Pakistan. Participants were asked questions regarding the usage of commonly consumed SLT known as gutka (exposure variable). Study outcomes included maternal anemia, miscarriage, preterm births, stillbirths, and low birth weight. We performed a cox-regression analysis by controlling for confounders such as maternal age, education, parity, working status, body mass index, and geographic clusters. RESULTS: The study revealed that 71.5% of the women reported using gutka, with a higher proportion residing in rural areas as compared with urban areas in the district of Thatta, Pakistan. In the multivariable analysis, we did not find a statistically significant association between gutka usage and anemia [(relative risk, RR: 1.04, 95% confidence interval, CI (0.92 to 1.16)], miscarriage [(RR: 1.08, 95% CI (0.75 to 1.54)], preterm birth [(RR: 1.37, 95% CI (0.64 to 2.93)], stillbirth [(RR: 1.02, 95% CI (0.39 to 2.61)], and low birth weight [(RR: 0.96, 95% CI (0.72 to 1.28)]. CONCLUSIONS: The study did not find an association between gutka usage before pregnancy and adverse maternal and fetal outcomes. In the future, robust epidemiological studies are required to detect true differences with a dose-response relationship between gutka usage both before and during pregnancy and adverse fetomaternal outcomes. IMPLICATIONS: While most epidemiological studies conducted in Pakistan have focused on smoking and its adverse outcomes among males, none of the studies have measured the burden of SLT among WRA and its associated adverse outcomes. In addition, previously conducted studies have primarily assessed the effect of SLT usage during pregnancy rather than before pregnancy on adverse fetal and maternal outcomes. The current study is unique because it provides an insight into the usage of SLT among WRA before pregnancy and investigates the association between pre-pregnancy SLT usage and its adverse fetomaternal outcomes in rural Pakistan.

Perceptions and experiences of men and women towards acceptability and use of contraceptives in underserved areas of Karachi, Pakistan: a midline qualitative assessment of Sukh initiative, Karachi Pakistan.

BACKGROUND: Family planning (FP) is an essential component of Sustainable Development Goals (SDG) and contributes directly to SDG targets 3.7 and 5.6. In Pakistan, contraceptive use has remained stagnant over the past 5 years. This change has been very slow when compared to the FP2020 pledge. The Sukh initiative project was conceived and implemented to alleviate these challenges by providing access to quality contraceptive methods in some underserved areas of Karachi, Pakistan. A qualitative study was conducted to understand the perceptions and experiences of men and women towards acceptability and contraceptive use. METHODS: A qualitative study was conducted at ten Sukh stations located in four towns of Karachi. Focus group discussions (FGDs) were conducted with married women of reproductive age (MWRA) and married men who received FP services through the Sukh initiative. Study participants were purposively sampled for focus group discussions (FGDs). Interview data was manually transcribed and analyzed using thematic analysis. RESULTS: A total of 20 FDGs (Men = 10 FGDs; MWRA = 10 FGDs) were conducted. Three overarching themes were identified: (I) Appropriateness and means to promote contraceptive use; (II) Equity and Accessibility to contraceptives; and (III) Perspective on available FP services. Generally, both men and women were informed about FP methods but women were more cognizant of FP information. The door to door services by community health workers in Sukh initiative areas was largely appreciated both by women and men as it has made the accessibility and availability of the information and services easy. Women suggested that the Sukh initiative should bring some strategies that can help men broaden their perspective towards FP. The study informed that the men feel left out from the FP programs. Therefore, male participants expressed keen interest in initiatives for men in their communities that would cater to their FP needs. CONCLUSIONS: This qualitative study provided a unique opportunity to understand the perceptions of men and women towards the phenomena of contraceptive use. The study identified the need for trained and qualified female and male healthcare providers and well-established health facilities alongside door-to-door services.

Factors associated with the discontinuation of modern methods of contraception in the low income areas of Sukh Initiative Karachi: A community-based case control study.

INTRODUCTION: Discontinuation of a contraceptive method soon after its initiation is becoming a public health problem in Low middle income countries and may result in unintended pregnancy and related unwanted consequences. A better understanding of factors behind discontinuation of a modern method would help in designing interventions to continue its use till desired spacing goals are achieved. OBJECTIVE: To determine factors associated with the discontinuation of modern contraceptive methods within six months of its use compared to continued use of modern method for at least six months in low-income areas of Karachi, Pakistan. METHODS: A community-based case-control study was conducted in low-income areas of Karachi. Cases were 137 users who discontinued a modern contraceptive method within 6 months of initiation and were not using any method at the time of interview, while controls were 276 continuous users of modern method for at least last six months from the time of interview. Information was collected by using a structured questionnaire. Applied logistic regression was used to identify the associated factors for discontinuation. RESULTS: The mean ages of discontinued and continued users were 29.3±5.3 years and 29.2±5.4 years respectively. A larger proportion of the discontinued users had no formal education (43.8%) as compared to the continued users (27.9%). The factors associated with discontinuation of a modern method of contraception were belonging to Sindhi ethnicity [OR: 2.54, 95%CI 1.16-5.57], experiencing side effects [OR: 15.12; 95% CI 7.50-30.51], difficulty in accessing contraceptives by themselves [OR: 0.40, 95%CI 0.19-0.83] and difficulty in reaching clinics for management of the side effects [OR: 4.10, 95%CI 2.38-7.05]. Moreover, women having support from the husband for contraceptive use were less likely to discontinue the method [OR: 0.58, 95% CI 0.34-0.98]. CONCLUSIONS: Sindhi ethnicity and side effects of modern methods of contraception were identified as major factors for discontinuation in low-income populations. Similarly, women who had difficulty in travelling to reach clinics for treatment also contributed to discontinuation. Furthermore, women using long acting methods and those supported by their husbands were less likely to discontinue the contraceptive methods. Findings emphasize a need to focus on Sindhi ethnicity and trainings of service providers on management of side effects and provision of high quality of services.

Challenges of Implementing an Individual Randomized Controlled Trial (Women First: Preconception Maternal Nutrition Study) in a Rural Study Site: A Case Study From Pakistan.

Persistent global disparities in maternal and neonatal outcomes associated with poor maternal nutrition provided the genesis of the Women First (WF) study, an individually randomized controlled trial on preconceptional maternal nutrition. This article describes the challenges that arose in implementing this trial related to nutrition or diet of the mother, in District Thatta-Pakistan. During different phases of the study, we encountered problems in identifying the eligible participants, taking consent from couples, randomizing participants in different arms, conducting biweekly follow-up visits on time, ensuring compliance to the intervention, and measuring the primary outcome within the 24 hours of birth. Each challenge was itself an opportunity for the research team to address the same through effective coordination and teamwork. Moreover, with adequate resources and dedicated staff with diverse backgrounds, it was possible to implement the WF study across the widely scattered geographic clusters of District Thatta. In addition, there are some broad strategies that could be applied to other studies such as very close contact either in person or at least by talking to mothers via phones and rapport with the study participants, the study leadership of country coordinator and the field supervisors to build trust between those on front lines and the study leadership. Moreover, continuous monitoring and supervision with frequent training and refreshers were also found to be more important to assure the data quality and to meet the study targets. Community meetings were also found to be very helpful and effective to follow the participants for a long time. Researchers conducting a similar type of studies particularly in rural areas can learn many lessons from such experiences. Thus, the process of implementing the study in one of the rural areas of Pakistan provides an insight into where and how similar individual randomized trials might be deployed.

Using mobile phones to improve young people's sexual and reproductive health in low- and middle-income countries: a systematic review protocol to identify barriers, facilitators and reported interventions.

BACKGROUND: Due to a growing reliance on mobile phone technology and decreasing mobile phone costs, the use of mobile phones is on the rise, especially among the youth population. Young people are responsive and enthusiastic to use novel approaches such as mHealth to access sexual and reproductive health information and services. Globally, reproductive health programs have used mHealth to provide sexual and reproductive health education and services to young people, through diverse communication channels. However, few attempts have been made to systematically review the mHealth programs for young people sexual and reproductive health (SRH) in low- and middle-income countries (LMICs). In addition, very little is known regarding the potential barriers and facilitators to the uptake of mobile phone interventions for improving young people SRH. This review aims to highlight facilitators and inhibitors to implementing and increasing uptake of mHealth interventions for young people's SRH, in LMICs specifically. Additionally, the review will identify the range of mHealth solutions which can be used for improving young people's SRH in LMICs. METHODS: The review will focus on comparing the various types of mHealth interventions/strategies that are used to improve young people's SRH services in LMICs. PubMed, CINAHL Plus, Science Direct, Cochrane, and gray literature will be explored using a detailed search strategy. The studies involving young people (adolescents and youth) aged 10-24 years to which mHealth interventions were delivered for improving their SRH outcomes will be included in this review. LMICs will be selected according to the World Bank's (WB) 2018 Country Classification list. Studies published between January 2005 and March 2018 will be included as the field of mHealth has emerged over the last decade. English language articles will be included as the authors are proficient in this language. DISCUSSION: The systematic review will assist researchers and SRH professionals in understanding facilitators and barriers to implementing and increasing the uptake of mHealth interventions for SRH in LMICs. Finally, this review will provide more detailed information about embracing the use of mobile phones at different levels of the healthcare system for improving young people's SRH outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018087585.

Monitoring of birth registry coverage and data quality utilizing lot quality assurance sampling methodology: A pilot study.

BACKGROUND: Effectively monitoring the coverage and quality of data in low-resource settings is challenging. Lot quality assurance sampling (LQAS) is a method to classify coverage as adequate or inadequate. The aim of this pilot study is sought to determine the coverage and quality of a birth registry in a rural district in Pakistan. METHODS: This survey was conducted in 14 clusters of Thatta, Pakistan. LQAS methodology was used to monitor the birth registry from December 2015 to February 2016. We randomly selected 19 villages from each cluster. We used a short questionnaire to review the quality of data collection for select variables. Frequency and percentages were reported for categorical variables. For data validation, Kappa statistics (κ) were applied to assess the agreement between categorical observations, and the Bland-Altman test was used to assess agreement for continuous data. RESULTS: Of the 14 clusters sampled, 12 clusters had adequate coverage. Agreement of hemoglobin performance between the women's response and information in birth registry data was good (κ = 0.718) (95% confidence interval [CI]: 0.58-0.82); agreement on birth outcome recorded by the workers in the registry and as mentioned by women was very good (κ = 1.0); and agreement whether birth weight was assessed within 48 h of delivery was good (κ = 0.648) (0.37-0.92). CONCLUSION: LQAS is a powerful tool to monitor coverage and data quality of the birth registry maintained by the global network for women's and children's health in Pakistan and potentially for data from other surveillance systems.

Barriers or gaps in implementation of misoprostol use for post-abortion care and post-partum hemorrhage prevention in developing countries: a systematic review.

BACKGROUND: Around 303,000 maternal deaths occur every year; most of these are preventable (World Health Organization), ICD-10: International classification of diseases and related health problems, 10th revision. Volume 2: Instruction manual, 2010). Ninety-nine percent of these maternal deaths occur in developing countries. PPH contributed 35 % (35%) of total maternal. Several interventions being done to reduce the number of maternal deaths. It has been noted that a simple low cost intervention of providing misoprostol timely could prevent these deaths. OBJECTIVES: The objectives of this systematic review was to identify barriers/gaps in the implementation of misoprostol use for prevention of postpartum hemorrhage and management of Post-abortion care services in developing countries. METHODS: This study was a systematic review of published qualitative and quantitative literature on misoprostol in developing countries. Documents included were local and international peer reviewed articles and program reports on misoprostol implementation. PubMed, Google Scholars and Science direct databases were used along with Grey literature and manual search using terms "implementation gaps", "misoprostol use", "postpartum hemorrhage", "post-abortion care" and "developing countries". RESULTS: Gaps or barriers in misoprostol use identified through systematic review can be categorized into six broader thematic areas including: inconsistency in supplies and its distribution; inadequate staffing; lack of knowledge of providers and end users, absence of the registration of drug and fear and apprehensions related to its use at provider and policy level. CONCLUSION: It is concluded that barriers and gaps can be addressed through providing enabling environment through supportive policies, designing a formal plan for supplies, task shifting strategies and use of guidelines and protocols for successful implementation.

Nature, scope and use of economic evaluation of healthcare programmes: with special reference to Pakistan.

Economic evaluation (EE)/cost effectiveness analysis(CEA) of healthcare programmes is an emerging area, yet the resource base to apprehend EE/CEA is very limited in Pakistan. This paper attempts to fill this gap by providing a basic text in the field of EE with special reference to Pakistan. We used four dimensional criteria (available, relevant, complete and accurate) for reviewing the EE contents in the locally available textbooks and reading material on public health. We find CEA as core competency and skill of medical doctors in undergraduate medical curricula yet we could not find EE contents in the recommended textbooks. We find that economic evaluation entails two rules: both cost and effectiveness should be included in the analysis, and there must be a comparison of at least two drugs or medical intervention. We describe EE/CEA in this article and recommend that EE content should be included in the medical and public health curriculum in Pakistan.

COST OF PRIMARY HEALTH CARE IN PAKISTAN.

BACKGROUND: Detailed cost analysis is an important tool for review of health policy and reforms. We provide an estimate of cost of service and its detailed breakup on out-door patient visits (OPV) to basic health units (BHU) in Pakistan. METHOD: Six BHUs were randomly selected from each of the five districts in Khyber Pukhtonkhawa (KPK) and two agencies in Federally Administered Tribal Areas (FATA) of Pakistan for this study. Actual expenditure data and utilization data in the year 2005-06 of 42 BHUs was collected from selected district health offices in KPK and FATA. Costs were estimated for outpatient visits to BHUs. Perspective on cost estimates was district-based health planning and management of BHUs. RESULTS: Average recurring cost was PKR.245 (USD 4.1) per OPV to BHU. Staff salaries constituted 90% of recurrent cost. On the average there were 16 OPV per day to the BHUs. CONCLUDION: Recurrent cost per OPV has doubled from the previous estimates of cost of OPV in Baluchistan. The estimated recurrent cost was six times higher than average consultation charges with the private general practitioner (GP) in the country (i.e., PKR 50/ GP consultation). Performance of majority of the BHUs was much lower than the performance target (50 patients per day) set in the sixth five-year plan of the government of Pakistan. The Government of Pakistan may use these analyses to revisit the performance target, staffinL and location of BHUs.

'And they kill me, only because I am a girl'...a review of sex-selective abortions in South Asia.

The low social status of women and the preference for sons determine a high rate of sex-selective abortion or, more specifically, female feticide, in South Asian countries. Although each of them, irrespective of its abortion policy, strictly condemns sex-selective abortion, data suggest high rates of such procedures in India, Nepal, China and Bangladesh. This paper reviews the current situation of sex-selective abortion, the laws related to it and the factors contributing to its occurrence within these countries. Based on this review, it is concluded that sex selective abortion is a public health issue as it contributes to high maternal mortality. Abortion policies of South Asian countries vary greatly and this influences the frequency of reporting of cases. Several socio-economic factors are responsible for sex-selective abortion including gender discriminating cultural practices, irrational national population policies and unethical use of technology. Wide social change promoting women's status in society should be instituted whereby women are offered more opportunities for better health, education and economic participation through gender sensitive policies and programmes. A self-regulation of the practices in the medical profession and among communities must be achieved through behavioural change campaigns.

ICPD to MDGs: Missing links and common grounds.

The ICPD agenda of reproductive health was declared as the most comprehensive one, which had actually broadened the spectrum of reproductive health and drove the states to embark upon initiatives to improve reproductive health status of their populations. However, like all other countries, Pakistan also seems to have shifted focus of its policies and programs towards achieving MDGs. As a result, concepts highlighted in the ICPD got dropped eventually. In spite of specific goals on maternal and child mortalities in MDGs and all the investment and policy shift, Pakistan has still one of the highest maternal mortality ratios among developing countries. Lack of synchronized efforts, sector wide approaches, inter-sectoral collaboration, and moreover, the unmet need for family planning, unsafe abortions, low literacy rate and dearth of women empowerment are the main reasons. Being a signatory of both of the international agendas (ICPD and MDGs), Pakistan needed to articulate its policies to keep the balance between the two agendas. There are, however, certainly some common grounds which have been experimented by various countries and we can learn lessons from those best practices. An inter-sectoral cooperation and sector wide approaches would be required to achieve such ambitious goals set out in ICPD-Program of Action while working towards MDGs. There is a need of increasing resource allocation, strengthening primary health care services and emergency obstetric care and motivating the human resource employed in health sector by good governance. These endeavors should lead to formulate evidence based national policies, reproductive health services which are affordable, accessible and culturally acceptable and finally a responsive health system.

Social health insurance: can we ever make a case for Pakistan?

Social Health Insurance has been used as an approach to increase efficiency of healthcare system and consumer satisfaction in provision of healthcare services. Many developed countries have successfully planned and implemented insurance models which provide almost universal coverage and addresses issues of equity. The phenomenon is established however, developing countries especially Eastern Mediterranean region is still struggling to present one successful model of social health insurance which can be compared with European or Scandinavian countries. Pakistan likewise faces huge challenges in public sector healthcare provision and considerable proportion of population prefers to go to private sector. Quality of care, access and rising costs make healthcare, somehow, a luxury. Rising national economy, political will to carry out health sector reforms and the creation of district health system after devolution presents an opportunity to launch at least some pilot initiatives of social health insurance. This will give us some food for thought to further up scale and replicate the model all over the country.