Providing Maternity Care In Rural : A Way Forward

Original Article

Providing Maternity Care in Rural Pakistan: A Way Forward Rizwana Chaudhri 1, Naheed Bano 2, Humera Noreen 3, Lubna Ejaz 4 1Head of Obs/Gynae Unit I, Family Hospital, Rawalpindi, 2Assistant Professor, Obs/Gynae Unit I, Holy Family Hospital, Rawal- pindi , 3 Assistant Professor, Obs/Gynae, Benazir Bhutto Hospital, Rawalpindi, 4Professor, Obs/Gynae, Dera Ghazi Khan Medi- cal College (now). Correspondence: Dr. Naheed Bano , Assistant Professor, Obs/Gynae Unit I, Holy Family Hospital, Rawalpindi Email: [email protected] Abstract Objective: Analysis of a low cost intervention project on maternal and neonatal care in rural set- up and to present it as a model for low resource countries. Study design: Quasi-experimental design using a before and after approach to compare the im- pact of interventions. Place and Duration: Department of Obstetrics and Gynaecology, Holy Family Hospital (HFH), Rawalpindi from 01-04-07 to 31-03- 2010. Methodology: Pre-and post-intervention out-patients, admissions, deliveries and ultrasound per- formed were compared. Data was collected from the registers maintained at the target sites on monthly basis and compared on yearly basis. Results: Out-patients increased from 20492 to 44953 at , 2518 to 11639 at , 988 to 1960 at rural health centers and 2140 to 2854 at basic health units. Admissions increased from 3814 to 6014 at Chakwal, from 611 to 1364 at Talagang. Ultrasound performed increased from 7821 to 30771 and from none to 3827 at the two sites. Vaginal deliveries increased from 1953 to 3183 and from 451 to 822 respectively. C-sections registered an increase from 446 to 944 and 27 to 160.Admissions, deliveries and C-sections were not performed at rural health centers and ba- sic health units. Record of maternal and neonatal mortality was not available prior to intervention. Conclusion: Developing countries should initiate projects to reduce maternal mortality and mor- bidity considering their unique circumstances. Key words: Maternal mortality, Safe motherhood, Punjab Safe-motherhood Project. Introduction ruptured uterus due to obstructed labour playing an important role. 4,5 Global Safe Motherhood Initiative Pakistan has a maternal mortality rate of 276 per identified 3 key steps in reducing maternal mortality: 100,000 livebirths. 1 Direct causes are still the leading Primary prevention(family planning),Secondary pre- causes as in other developing countries, 2,3 with

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vention (prevention of obstetric complications by medicines and equipment, poor location and providing skilled care at all deliveries) and Tertiary infrastructure. In a study of 16 rural districts of Pakis- prevention(prevention of maternal death once com- tan in Baluchistan and NWFP, only four district hos- plications have arisen by easy access to emergency pitals were capable of providing the full range of obstetric care .6 The 3 delays’(decision to seek care, emergency obstetric care. 11 Therefore, providing access to care, timeliness and quality of care) con- skilled care in rural areas is still a distant dream. In cern tertiary prevention. 7 In a study of maternal low resource settings,expense,distance and time deaths occurring in eight major hospitals of Pakistan, needed to reach a healthcare facility are main it was evident that 73% of women reached these obstacles for utilizing these services. 12 The problem hospitals in critical condition and 8% were dead on is compounded by lack of referral and back-up arrival. 8 Similar trend of increased risk of mortality support in case of any emergency. among referred women as compared to those Due to social and religious beliefs, females are admitted directly is noted in another study from preferred at providing care at the time of delivery. Cameron(odds ratio 3, 95% CI,2.2-4.0). 9 This shows Lack of social network, infra-structure including good that delay in seeking medical care, lack of educational facilities for children and opportunities knowledge of medical problems and delay in for professional development along with security transportation are major factors in persistently high concerns are major factors due to which female maternal mortality rates. doctors are not willing to serve in rural areas on Healthcare system in Pakistan consists of private permanent basis. 13,14 Punjab Safe-motherhood and public services. Government run heath care project was planned to overcome these hinderances. system in Pakistan is pyramid-shaped with health Its main aims were to provide highly skilled maternity houses,basic health units and rural health centres as services in rural areas, increase the utilization of the base of pyramid followed by tehsil headquater existing primary healthcare units, set-up a referral hospital, district headquarter hospital and finally network to secondary and tertiary healthcare relatively small number of tertiary teaching hospitals facilities as well as continous education and training occupying the top of the pyramid. 10 Basic health of doctors employed in the project. It was decided units and rural health centres compose the primary that doctors employed in the project will be based at health care units, providing antenatal and postnatal a tertiary care hospital and will be rotated on monthly care along with family planning and immunization basis at various health facilities located in a district. services, with no facilities for conducting deliveries A detailed PC 1 was prepared for initiating the Tehsil and district hospitals have X-rays, laboratory “Punjab Safe Motherhood Initiative Project- Chakwal facilities and specialists of obstetrics and District”. This was approved by the Government of gynaecology, pedeatrics and surgery.They are Punjab. District Chakwal, with population of supposed to provide comprehensive EmOC 1,083,725 , was selected as the target district and sevices.However,their use is sub-optimal because of HFH was the tertiary care hospital selected. Sixteen the lack of trained medical staff, poor supply of healthcare facilities in district Chakwal were selected

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for improved provision of maternity services by Obstetrics and Gynaecology, HFH, Rawalpindi from doctors employed in the project, physical and April 1st 2007 to March 31st 2010. infrastructure improvements,improving referral Data regarding clinical examination carried out on network,training of new and existing healthcare staff antenatal cases, ultrasound scans performed, num- by holding seminars and workshops conducted by ber of out-patients, admissions, vaginal deliveries, consultants of HFH. Activities aimed at creating and C-sections, other major and minor surgeries, community awareness on maternal health issues by referrals and maternal and neonatal deaths before holding community meetings and using mass media and after the implementation of the project was ob- like newspapers and FM radio were also planned. tained from registers kept at target site on monthly HFH is a 850 bedded tertiary care hospital affiliated basis. with Rawalpindi Medical College. It has a well Statistical analysis: The pre-intervention period equipped obstetrics and gynaecology department. was taken as A, first year intervention as B and Ten doctors employed in the project all had post- second year intervention as C. Any change in above graduate fellowship degree from College of parameters was analyzed by using descriptive statis- Physicians and Surgeons, Pakistan. Post-graduate tics like percentages. Percentage increase or de- trainees and house-surgeons were also from this crease was calculated for each year. hospital. Two teams of doctors were constituted Main Outcome Measures each including one from the project staff, and post- • Percentage tests performed for clinical exami- graduate trainees and house-surgeons.These teams nation were deputed to work at district headquaters hospital • Number of out-patients and admissions. chakwal and tehsil headquarters hospital Talagang • Number of vaginal deliveries and C-sections. for one month rotation period. Two project doctors • Number of other major and minor surgeries. provided out-door services to 12 basic health units • Number of referrals. and 2 rural health centres in district Chakwal through • Number of maternal and neonatal deaths. one day trip from HFH once a month. Rest of the The study was approved by hospital ethical commit- project doctors worked at HFH as senior registrars. tee. The aim of this study was to analyze the effect of Punjab Safe-motherhood Initiative Project on various Results maternal and neonatal health parameters so that All parameters of obstetric examination increased as similar projects can be planned in other rural areas is shown in figure 1 especially listening to fetal heart of the country. sounds (increased from 21.4% to 62.4%),ultrasound Methodology performed (increased from 17.9% to 85.9%) and re- The quasi-experimental design using a before and cording weight of the woman( increased from 0% to after approach to compare and assess the impact of 4.8%). interventions was conducted in the department of

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Percentage of tests performed

120 Table II presents an almost similar picture at tehsil 96.6 98.8 100 90.6 85.9 71.4 80 62.4 headquarters hospital Talagang. The number of out- % 60 40 21.4 17.9 patients registered an increase from 2518 to 11639, 20 0 4. 8 0 admissions from 611 to 1364, ultrasound scans per- Blood Pressure Abdominal Fetal Ultrasound Weight of Checked Examin a- Hear t- Performed Pregnant Lady Performed Libeats- formed from none to3827, vaginal deliveries con- tened Before Project After Project ducted from 451 to 822 and C-sections performed Figure 1: Percentage of Tests Performed for Clini- from 27 to160. There were 4 maternal deaths in pre- cal Examination intervention period, whereas none was recorded in the two years post-intervention period. Record of Table I shows the numerical as well as percentage neonatal deaths is not available prior to intervention increase at district headquarters hospital Chakwal in and there were 2 and 6 deaths in the post- out-patients (20,492 to 44953),admissions (3814 to intervention period. Referrals showed a 26% in- 6014),ultrasound performed (7831 to 30771), vaginal crease in the first post-intervention year. deliveries conducted (1953 to 3183) and C-sections Table III shows a significant increase in the number performed (446 to 944).There is no record available of out-patients, ultrasound scans performed and re- of maternal or neonatal mortality prior to intervention. ferrals at targeted rural health centre and basic There were 8 and 7 maternal deaths and 8 and 20 health units. neonatal deaths in the first and second year of inter-

vention. Referrals recorded a 129% and 2.2% in-

crease respectively.

Table I. Increase of various parameters at DHQ Chakwal Indicators Apr 07 - Mar 08 Apr 08 - Mar % I ncrease Apr 09 - Mar % I ncrease from (A) 09 (B) from (A) 10 (C) (B) OPD Patients 20,492 32,497 58.6% 44953 38.3% Indoor Patients 3,814 5,628 47.6% 6014 6.9% Ultrasounds Per- 7,831 16,850 115.2% 30771 82.6% formed Normal Deliveries 1,953 2,825 44.6% 3183 12.7% C. Sections 446 773 73.37% 944 22.1% Other Surgeries Ma- 24 116 383.3% 309 166.4% jor Other Surgeries Mi- 196 234 19.4% 346 47.9% nor D & C - 93 93% 338 263.4% Referral to other 79 181 129.1% 185 2.2% Hospitals Maternal Deaths - 8 - 7 Neonatal Deaths - 8 - 20

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Table II. Increase of various parameters at T HQ Hospital Talagang Indicators Apr 07 – Mar Apr 08 – Mar 09 % I ncrease Apr 09 – Mar 10 © % Increase from 08 (A) (B) from (A) (B) OPD Patients 2,518 10,821 329.7% 11639 7.6% Indoor Patients 611 1460 139.0% 1364 ↓ Ultrasounds Per- 0 2,572 2572% 3827 48.8% formed Normal Deliveries 451 697 54.5% 822 17.9% C. Sections 27 135 400.0% 160 18.5% Other Major Surge------ries Minor Surgeries - 51 100% 24 ↓ D&C - 51 100% 56 9.8% Maternal Deaths 4 - ↓ - - Neonatal Deaths Record not 2 - 6 - available Referral to other 123 155 26% 128 ↓ Hospitals

Table III. Betterment at Rural Health Centres (Buchal Kalan & ) and Basic Health Units Rural Health Centers Basic Health Units Indicators Apr 07 Apr % I n- Apr 09 % I n- Ap r 07 - Apr 08 - % I n- Apr 09 - % I n- - Mar 08 - crease - Mar crease Mar 08 Mar 09 crease Mar 10 crease 08 (A) Mar from 10 (C) from (A) (B) from (A) (C) from (B) 09 (B) (A) (B) OPD Pa- 988 1234 25% 1960 59% 2140 2457 15% 2854 16% tients Ultrasounds 0 295 295% 1516 414% 0 984 1784 81% Performed Referral to ?? 94 _ 150 60% ?? 56 247 341% other Hos- pitals

Discussion births in rural Peshawar(Capital city of former NWFP). 17

At United Nations Millennium Summit in 2000, the Fifteen percent of pregnancies are expected to have countries agreed on eight millennium development complications requiring emergency obstetric care and 18 goals one of which is improving maternal health. With all such women should have access to such care. 16,500 maternal deaths occurring every year, Pakis- Keeping all this in view this project was launched as a tan’s progress in terms of achieving MDG 4 and 5 is not pilot project with the aim of extending it to other prov- satisfactory. 15 In a study of 16 rural inces if it is successful. in Baluchistan and NWFP(two major provinces of Pa- Data pattern consistently indicates that in the post- kistan), only 20.4% of women gave birth under the su- intervention period of the project there was a significant pervision of a skilled attendant. 16 This forms the basis of increase in the number of patients availing antenatal a maternal mortality ratio of 433 per 100,000 live and obstetric services at target health facilities. Com- parison of various indicators during pre and post inter-

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vention period shows a tremendous increase in all clin- terialize as the project had to be stopped pre-maturely ical examinations performed . Free of cost ultrasound due to shortage of funds after the massive floods that scans were carried out. The number of out-patients devastated whole of the country in 2010.Telephone increased at all target facilities. Admissions and delive- help-lines were made available at these facilities due to ries including c-sections increased at district and tehsil which doctors could easily communicate with consul- hospitals. This was due to increased confidence of the tants at HFH. However, these help-lines could not be people to utilize government provided services due to extended to lady health visitors and traditional birth at- availability of 24 hours services of well trained and tendants again due to shortage of funds. competent doctors who were rotated from HFH. Deficiency of human resources is a major hindrance in Better record keeping helps in future planning. There almost all the developing countries in their progress was no record of many of the health indicators at these towards MDG 5. 23 It is impossible to reduce maternal facilities prior to intervention. However, proper record mortality without capacity building. Realizing this, im- was maintained after the intervention. provement in competency and skill of local healthcare Anywhere in the world, referral has significant impact providers was another aim of the project so that by the on the patients ,the healthcare system and healthcare time of completion of project, the women would contin- costs. 19 In a study by Hafeez et al the referral rate was ue to get emergency obstetric services. Three medical 8% from primary healthcare to specialist treatment officers working in district headquarters hospital, (population was general population based in Afghan Chakwal were trained in anesthesia services. Seminars refugee camps). 20 Maternal mortality still remains high and workshops were organized under the supervision in tertiary healthcare centers ,primarily due to high per- of consultants from HFH attended by doctors of these centage of referred cases from the periphery in very health facilities, general practitioners, and lady health serious condition. 21 There was an increase in quantity workers. and quality of referrals from the targeted facilities. A Providing neonatal services was an important part of referral system was developed to streamline the flow of the program. However, this could not materialize due to patients from all targeted healthcare facilities to tertiary shortage of staff and funds. services. The patients were referred after providing Conclusion emergency resuscitation and receiving facility was tele- Strategies to increase antenatal care, trained personnel phonically informed in advance. In a study by Bailey et at childbirth, provision of timely emergency obstetric al 22 up gradations of seven strategically situated health care are required to reduce maternal mortality and facilities improved the referral network to 80%. This morbidity. 24 With limited resources to achieve health was further improved by providing vehicles and com- targets, cost-effective and sustainable projects like munication capability to 90%. As a result majority of these are feasible and can save a number of lives. It population could be transferred from midlevel facilities has shown that only ten trained doctors can make a to those having facilities of obstetric surgery within two huge difference in the district health care system and hours. In our project it was planned that patients will be integration of tertiary care hospitals with district and provided with project vehicles for transportation at a tehsil level healthcare facilities’ can be achieved at rela- later stage of implementation; however, it could not ma- tively low cost .The presence of a trained obstetrician

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provided local staff with opportunities to acquire further new focus on implementa- skills. However, political will and support is needed to tion.Lancet.2007;370(9595):1383-1391. make such projects successful. 25 Furthermore, im- 7 Burchett HE, Mayhew IH. Maternal mortality in provement in essential newborn care and wider com- low-income countries: What interventions have munity involvement should also be a part of any such been evaluated and how should evidence base be programs in future. It was distressing to all those in- developed further? Int J of Gynaecol Ob- volved that it had to be stopped before its stipulated stet.2009;105(1):78-81. time as the funds had to be diverted in the aftermath of 8 Bano N, Chaudhri R, Yasmeen L, Shafi F, Ejaz L. floods that inundated major areas of the country. A study of maternal mortality in 8 principal hospit- als in Pakistan in 2009.Int J Gynaecol Obstet DISCLOSURE: The authors have no personal or financial interests in the 2011;114(3):255-259. topic involved in this work. The project itself was funded by Government of 9 Mbass SM, Mbu R, Bouvier-colle MH. Use of rou- Punjab and approximately 2.9 million rupees were spent during the years of study. tinely collected data to assess maternal mortality in seven tertiary maternity centers in Cameroon. References Int J Gynaecol Obstet 2011;115(3):240-243.

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