The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data.

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed-effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life-threatening complications of childbirth.

Introducing client-centered reproductive health services in a Pakistani setting.

Pakistan is a high-fertility country with elevated levels of maternal mortality and unmet need for family planning. Limited access to and poor quality of reproductive health services and gender-related problems comprise the major explanations for these poor indicators. The authors designed an intervention to address some of these issues and implemented it on a quasi-experimental basis in Bhalwal Tehsil of the Sargodha district of Punjab. The intervention introduced a client-centered approach to providing reproductive health services, including family planning and infant, child, and maternal health care. The intervention consisted of training health-care providers based in fixed-location clinics and in communities. It introduced the concept of SAHR (an acronym for salutation, assessment, help, and reassurance), to inculcate a client-centered approach to care that acknowledges explicitly and addresses a client's gender and power relations within her family and household. Results of the intervention indicate significant effects on providers' behavior related to SAHR elements. The changes provide demonstrable evidence that the public sector can shift toward client-centered services in reproductive health care in a challenging setting.