Providing Maternity Care in Rural Pakistan a Way
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Providing Maternity Care In Rural Pakistan: 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 Chakwal, 2518 to 11639 at Talagang, 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 JSOGP 2013, Vol.3, No.3 150 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 151 JSOGP 2013, Vol.3, No.3 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 JSOGP 2013, Vol.3, No.3 152 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.