Pakistan: The Faisalabad Obstetric Flying Squada Michele M. Andinab & Fariyal F. Fikreec Introduction Objective of the evaluation Providing access to obstetric emergency services is To evaluate the functioning, organizational mech., a major obstacle to reducing maternal mortality. anisms, impact and community response to the Whereas rural areas suffer from lack of transport, Faisalabad Obstetric Flying Squad. in urban areas the problem tends to be financial barriers to effective use of transport especially Materials and methods among the poor. In Faisalabad in Pakistan an ini­ A tencday evaluation of the organization of FOFS tiative of the Mother and Child Welfare Associa­ was carried out in late 1993. The evaluation con­ tion of Faisalabad (MCWAF) seeks to overcome sisted of: such problems among the urban poor. This repre­ (i) a review of documents and reports; sents a good example of providing outreach ser­ (ii) a review of project records and logs; vices, bringing together traditional birth atten­ (iii) unstructured interviews with project staff; dants (dais), lady health visitors and hospital (iv) participant observation of two FOFS calls; obstetric staff as a team. The Maternal Health and (v) focus group discussions with users, lady health Safe Motherhood Programme considered that the visitors and dais; initiative merited attention with a view to replica­ (vi) open-ended interviews with the general public tion in other developing country settings. In order and staff of six of the twenty MCH health to assess the likely costs and impact of such an centres; approach, an evaluation of the functioning of the (vii) attendance at a session of the community flying squad was commissioned. health education programme and a hospital The Faisalabad Obstetric Flying Squad (FOFS) staff meeting. is one component in a series of activities undertak­ en by the MCWAF to combat maternal and child Description of MCWAF's activities mortality in the city. Created in 1988 under the leadership of Professor Mrs. Altaf Bashir of Allied The Faisalabad Obstetric Flying Squad Hospital in connection with Punjab Medical Col­ The Faisalabad Obstetric Flying Squad was created lege, FOFS is one part of MCWAF's integrated in 1988 in response to high levels of maternal approaches to the provision of improved maternity morbidity and mortality in the city. It aims to pro­ services to the community. The programme activi­ vide free ambulance services to poor mothers in ties ofMCWAF include: cases of obstetric emergency. The ambulance ser­ (i) training and refresher courses for traditional vice is directly linked to the Allied Hospital and is birth attendants (dais); composed of trained health care providers able to (ii) establishment of maternal and child health carry out life-saving procedures such as resuscita­ (MCH) centres including family planning ser­ tion. The Allied Hospital serves as the referral cen­ vices; tre for obstetric emergencies in the area. At the (iii) free maternity services at the Allied Hospital; beginning of the project the hospital provided the (iv) extensive programmes of public health educa­ ambulance for the flying squad but FOFS recently tion through use of media and "mobile acquired its own, fully equipped vehicle. Between health camps"; 1989 and 1992 FOFS received 394 emergency calls, (v) improved liaison between dais, lady health vis­ representing 2%-5% of all obstetric hospital" itors, hospital staff and patients. admissions.d Dai training and refresher courses The Association provides training for dais in order to improve the quality of maternal and child health a Summary of an evaluation report submitted to the Safe Motherhood Research Programme, \VtIO, Geneva, 1993. b Project Consultant, Mother Child International, Geneva, Switzerland. d The reason this range of percentages is given is that there was C Senior Instructor, The Aga Khan University, Karachi, Pakistan. inadequate data on the total number of obstetric admissions. 50 Rapp. trimest. statist. sanit. mond., 48 (1995) services. The training courses are of three months In addition to the health education sessions, duration and include how to conduct a normal the Association has its own newsletter and has pro­ delivery, detection of high risk and abnormal cases, duced videos for more widespread information dis­ timely referral, asepsis and sterilization, antenatal semination. care, neonatal resuscitation, and family planning. A 50-bed maternity hospital is currently under In addition the Association offers an extended construction next door to MCWAF headquarters. one-year training programme for dais. At the Asso­ This has been built with the aid of donations from ciation's health centres lady health visitors con­ Baitul Mal Government of Pakistan and through duct one-day refresher courses. local fund-rasing activities. A Public Health School has been created to address the shortage of trained lady health visitors and midwives. It will be based at Mother and child health centres the maternity hospital. The Association is also ad­ The Association runs 20 health centres, each dressing the issue of women's health and devel­ staffed by a lady health visitor, a family planning opment from a broader perspective. For example, monitor, and a trained dai. The centres are super­ in order to reduce gender discrepancies in access vised by the Association's doctor. Deliveries are to education the Association has opened three pri­ conducted both at the centre and at home by dais mary schools for girls. They are housed at health and by lady health visitors. centres in the Faisalabad slum area. A programme to strengthen the skills of women in embroidery and sewing techniques and thus create opportuni­ Community education programme and mobile health ties to generate income has also been developed. camps The Association follows up maternal deaths and uses the case histories as the basis for community Evaluation of the FOFS education through mobile health education ses­ At the the start of its operation in 1989 and due to sions. These are set up in the neighbourhood telephone congestion it was often difficult to relay where a maternal death has occurred and include telephone calls through to the labour ward. The presentations to community members on the im­ flying squad did nQt have its own transport. The portance of maternal health, the prevention of situation improved considerably in 1993 when an maternal deaths and the availability and function­ ambulance was donated, the Association hired its ing of the Faisalabad Obstetric Flying Squad. Dur­ own driver and telephone connections were im­ ing the mobile education sessions health services proved. The evaluation team participated in two (immunization, vitamin supplementation) are pro­ obstetric emergency missions of the "Flying vided free of charge to mothers and children. Al­ Squad". In both cases it took around one hour to lied Hospital medical students and health centre travel from the hospital to the patient and back, a staff participate actively in such sessions. reasonable time given the traffic conditions. How­ ever, it was not possible to assess delays on the basis of records as the log books were not maintained Survey of maternal deaths in the community with a sufficient degree of accuracy. Since 1980 efforts have been made to documen tall maternal deaths in the municipality of Faisalabad, whether occurring in government or private hospi­ Knowledge of FDFS tals, health centres or at home. This has resulted in Users learn about FOFS mainly during pregnancy the identification of significantly more maternal or during a difficult delivery when a dai or lady deaths than those officially registered. A special health visitor requests relatives or friends to call the effort is made to investigate the circumstances service. Discussions with the users indicated a de­ leading to these deaths by talking with health gree of resistance to summoning assistance from workers and family members of the deceased the hospital. It is a common belief that "people go Woman. At the same time the neighbours of the to the hospital to die". Furthermore, husbands and dead woman are informed about risk factors for mothers-in-law play an important role in determin­ maternal mortality and how to avoid them. ing whether or not medical help is sought. The Association is attempting to overcome such resis­ tance through its educational campaigns. Mobile service unit and other activities The Association's dais and lady health visitors Two mobile service units provide outreach services were well informed about the role and functions of for family planning in the rural areas. Each service the flying squad which they learn about during unit covers 10-12 villages and visits are conducted training and refresher courses. Untrained dais on a daily basis. A registered nurse or midwife working in the community knew very little about supervises the activities of trained field workers. the service. Community members learn about the Community education sessions are also held in the flying squad during community education sessions villages. as well as by word of mouth. Wid hlth statist. quart., 48 (1995) 51 FOFS staffing, equipment, recording mechanisms, hospital though such information is collected dur­ costs ing record keeping. The flying squad differs from ordinary ambulance setvices in that it is staffed by highly trained obstet­ Complications handled by FOFS and outcomes ric personnel. Close collaboration between the Among the most common indications for FOFS hospital administration and FOFS exists, and the calls were labour pains, abortion, eclampsia and hospital cooperates in providing essential staff. postpartum haemorrhage (Table 3). However, due Emergency and resuscitation equipment including to a lack of comparable hospital admission data for oxygen is kept in the ambulance. similar conditions it is not possible to evaluate the All calls to the flying squad are recorded at impact of the setvice on handling obstetric compli­ Allied Hospital and travel details are kept in the cations. A key indicator for appropriate and effi­ ambulance log book.