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(Made-In and Made-For) Methodology for Estimating MMR in Punjab

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(Made-In and Made-For) Methodology for Estimating MMR in Punjab sampling Ali Mohammad Mir Saleem Shaikh Mumraiz Khan Irfan Masood Using the Community Informant Based (Made-in and Made-for) Methodology for Estimating MMR in Punjab A Study Funded by The Maternal and Newborn Health Programme Research and Advocacy Fund (RAF) ALI MOHAMMAD MIR, SALEEM SHAIKH, MUMRAIZ KHAN, AND IRFAN MASOOD Implemented by The Population Council February 2015 The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutions that lead to more effective policies, programs, and technologies that improve lives. © 2015 The Population Council, Inc. Declaration: “I have read the report titled “Using the Community Informant Based (Made-in and Made-for) Methodology for Estimating MMR in Punjab”, and acknowledge and agree with the information, data and findings contained". Principal Investigator Dr Ali Mohammad Mir Acknowledgment: “Using the Community Informant Based (Made-In And Made-For) Methodology for Estimating MMR in Punjab” is a project funded by the Maternal and Newborn Health Programme-Research and Advocacy Fund (RAF), and is implemented by the Population Council, Pakistan. Disclaimer: This document is an output from a project funded by the UK Department for International Development (DFID) and the Australian Department of Foreign Affairs and Trade (DFAT) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, DFAT or the Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF), which can accept no responsibility or liability for such views, for completeness or accuracy of the information, or for any reliance placed on them. iv Table of Contents 1. Introduction .................................................................................................................................................... 1 1.1 Maternal Health in Punjab .............................................................................................................. 2 1.2 Approaches to Measuring Maternal Mortality ............................................................................... 2 1.3 Measurement of Maternal Mortality in Pakistan ......................................................................... 10 1.4 Feasibility of the MIMF Method in Pakistan ................................................................................. 12 1.5 Study Objectives ........................................................................................................................... 13 2. Study Design ................................................................................................................................................15 2.1 Sampling ........................................................................................................................................ 15 2.2 Identification of Informant Networks ........................................................................................... 18 2.3 Study Team and Organization of Field Work ................................................................................ 19 2.4 Data Collection .............................................................................................................................. 20 2.5 Data Management and Analysis ................................................................................................... 24 2.6 Quality Assurance ......................................................................................................................... 24 2.7 Ethical Considerations ................................................................................................................... 25 3. Maternal Mortality: Socio-Demographic Features, Incidence, and Causes .......................................27 3.1 Basic Definitions: ........................................................................................................................... 27 3.2 Identification of Pregnancy Related Deaths:................................................................................. 27 3.3 Socio-demographic Characteristics of the Deceased Women ...................................................... 29 3.4 Incidence of Maternal Mortality ................................................................................................... 33 3.5 Direct and Indirect Causes of PRDs ............................................................................................... 38 4. Maternity Care .............................................................................................................................................43 4.1 Antenatal Care .............................................................................................................................. 43 4.2 Delivery Care ................................................................................................................................. 46 4.3 Postnatal Care ............................................................................................................................... 49 5. Circumstances of Death: Time, Place, and Care-Seeking Behaviour .................................................53 5.1 Time of Death ................................................................................................................................ 53 5.2 Place of Death ............................................................................................................................... 54 5.3 Care Seeking Behaviours: The Delays Model ................................................................................ 56 6. Study Limitations ........................................................................................................................................71 7. Discussion ....................................................................................................................................................73 8. Bibliography .................................................................................................................................................77 9. Annexes ........................................................................................................................................................81 9.1 Listing Forms ................................................................................................................................. 83 9.2 Verbal Autopsy Questionnaire ...................................................................................................... 87 9.3 Ethical Approval from National Bioethics Committee of Pakistan and the Institutional Review Board of the Population Council, New York ................................................................... 125 v 9.4 Study Support Letters ................................................................................................................. 127 9.5 Dates of Trainings and Field Activities ........................................................................................ 139 9.6 Pictures of Trainings in Six Districts ............................................................................................ 140 9.7 List of Health Department Staff Who Were Trained ................................................................... 141 9.8 Pictures of Field Activities ........................................................................................................... 144 9.9 Healthcare Structure in Pakistan ................................................................................................ 145 9.10 Indicators for Measuring Maternal Mortality ............................................................................. 147 9.11 Demographic Description of All Study Districts .......................................................................... 148 9.12 Identified networks for data collection ....................................................................................... 151 9.13 Probability of individual network in capturing the case ................... Error! Bookmark not defined. vi List of Tables Table ‎1.1: Various options for measuring maternal mortality in Pakistan ................................................... 8 Table ‎1.2: Previous sources of data used to estimate MMR in Pakistan .................................................. 10 Table 2.1: Distribution of districts by geographical region, population, level of urbanization, and expected number of live births .................................................................................................. 17 Table 2.2: Participation of key informants in listing meetings--Made-In ................................................... 22 Table 2.3: Key reproductive health indicators for all six districts and Punjab .......................................... 24 Table 3.1: Improvement in reporting of deaths through the study ............................................................ 28 Table 3.2: Age of deceased women by district ............................................................................................ 29 Table 3.3: Educational status of deceased by district ................................................................................ 30 Table 3.4: Level of schooling of deceased
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