UON Network - Tackling Unmet Need for Major Obstetric Interventions 1 2 .. 4 .. 23 .... 3 ..... 11 ...... 24 ...... 3 ...... 14 ...... 29 AKISTAN P IN UON CONTENTS ...... 28 ...... 25 ...... 23 hod ...... 8 icy...... 7 ORMATION QUESTIONNAIRE th pol ...... 3 nd Met F ...... 24 ...... rmation ...... EXERCISE base...... tion ...... OMEN QUESTIONNAIREOMEN EALTH IST OF MAIN DOCUMENTS PUBLISHED BY BY THE PUBLISHED DOCUMENTS OF MAIN IST UON 2 H 3 L 1 W Tackling Unmet Obstetric Needs: Needs: Obstetric Unmet Tackling ONCLUSION TILISATION OF RESULTS ONTEXT HE HE NTRODUCTION Retro-info Equipment a The data Results...... Percep General ...... Maternal heal NNEX NNEX NNEX BBREVIATIONS A A A 1. I 2. C 4. U A Case studies Pakistan Tackling Unmet Needs for Major Obstetric Interventions Obstetric for Major Needs Unmet Tackling 3. T 5. C UON Network - Tackling Unmet Need for Major Obstetric Interventions 2 man Co-operation) sammenarbeit/ Strengthening of Health Services sammenarbeit/ Strengthening sammenarbeit (Ger opical Medicine, Antwerp Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling BBREVIATIONS A GTZ/SHAIP: Gesellschaft für Technische Zu GTZ/SHAIP: Gesellschaft Project. Academy, HSA: Health Services Academy Tr ITM-A: Institute of IUD: Intra-uterine device IUD: Intra-uterine LB: Live births MOI: Major Obstetric Intervention NGO: Non-governmental organisation Package RHSP: Reproductive Health Services STD: Sexually transmitted diseases TBA: Traditional birth attendant THQ: Tehsil headquarters UNDP: United Nations Development Programme Fund UNFPA: United Nations Population Fund UNICEF: United Nations Children's UON: Unmet obstetric needs WFP: World Food Programme WHO: World Health Organisation AMI: Absolute Maternal Indication AMI: Absolute team and management CAM: Co-ordination DHQ: District headquarters EB: Expected births für Technische Zu GTZ: Gesellschaft UON Network - Tackling Unmet Need for Major Obstetric Interventions 3 ss, the interviewing of ident was displaced by and a war with in ysisresults of the of the ce of President Ali Bhutto, ially and agriculturally. But 1993, to be succeeded in etc.) and also demographic ble to study the impact of the dership of the study is usually dership of es, particularly the Gulf states, er Indian Empire. Under the er here has not yet been any retro- networks providing care – public, networks providing he active involvement of regional he active involvement more systemic approach involving systemic more ed the financial costs and the time ed the financial costs ss of collection and analysis of data and analysis ss of collection coups d’état th Iskander Mirzâ as its first President. For th Iskander Mirzâ as its first President. e. Since then two parties have shared the of population. A high proportion of the male daughter Benazirprime Bhutto to power as ant phase of the proce ons in Pakistan is unusual in the approach is unusual ons in Pakistan ll not be possible certain to take into account did not wish to return to after the al troubles, and the Pres the Pakistani context and health policy, we shall the Pakistani context and health policy, of women. The influx of more than 3.2 million consequence it did not give rise to so much consequence it did relatively independent even if it depends on the if it depends on independent even relatively also had considerable social and environmental ed in providing emergency obstetric services. This ed in providing emergency prime minister again in and ruled the country with an iron hand until 1988. to whichever network they belonged, agreed to to whichever network oliferation of weapons, adesh. During the term of offi in South- (area 800,000 sq.km), became in South-Central Asia (area 800,000 ideration of the study as a ideration of the study the towns or to foreign countri he partition of Britain’s form fectly defined. Nor will it be possi ation supported by India, its eastern province broke away to ation supported by India, its eastern pating countries, in which the lea in which the pating countries, ed many months ago, since t and the methodology used. The anal rmation; but it did not permit t rmation; but it did e in Pakistan is the variety of e in Pakistan is the story, with a succession of ospered and began to develop industr Health, in that the whole proce Health, in ght have been an obstacle to carrying out an exhaustive study, but obstacle to carrying out an exhaustive ght have been an ion had the advantage that it reduc ion had the advantage female head of government in a Muslim country. She was deposed in 1990, female head of government in a Muslim country. She was deposed in Pakistan is a country with much migration Pakistan, a large country The study of Major Obstetric Interventi of Major Obstetric The study Another important featur Another important In this case study, after a brief survey of In this case study, after a brief survey Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling ONTEXT NTRODUCTION conflict with the former Soviet Union. accused of corruption, nepotism and incompetenc minister – the first political chessboard. Benazir Bhutto became to find work, leaving their families in the care effects, since just under half of these refugees After his death an election brought Ali Bhutto’s Afghan refugees, mainly into the , has a military leader, who introduced military law 1997 by Nawaz Sharif and in 1999 by General Pervez. population of rural areas migrates to impacts (inflation, jobs lost to refugees, pr once again its progress was interrupted by politic constitution of 1956 it became an Islamic republic, wi constitution of 1956 it became an Islamic many years it had a troubled hi 1965. In 1975, after a war of liber become the independent state of Bangl elected in 1971, the region pr General adopted. It differs from other partici It differs from other adopted. independent in 1947, following t 1. I in the hands of the Ministry of of the Ministry in the hands is institute which out by a research was carried This opt Ministry of Health. of info required for the collection decision-makers and workers in the field. In decision-makers and in cons enthusiasm and participation has not been carried out in Pakistan. those concerned in maternal health, 2. C all those concerned at different levels of the health pyramid. all those concerned religious, all actively involvprivate, military and study, even though it was complet an import information process, and also because diversity of care systems mi diversity of care systems very fortunately all the major structures, very fortunately participate in the collection of data. describe the process of the study since it wi study itself, however, will be difficult, variables which poorly or imper are UON Network - Tackling Unmet Need for Major Obstetric Interventions 4 a family planning a family years the essential ide these local units the numbers of private ity of Provincial Health on planning programme on planning st be added the negative re for maternal and infantile re for maternal and edical or paramedical schools. rnal health and the control of 1960 onwards both private and both private 1960 onwards oduce, there will still be major . was 19.8. In 1992 the rate of use edicine. In parallel there has been 1 l health centres prov ted at almost 150 million. The annual150 million. almost ted at rate igned to encourage couples to limit their igned to encourage couples to limit nurses trained in Pakistan, who are fewer tally effective. In the early seventies a tally effective. In the early seventies ed in 1960. For many had begun in 1952 with had begun is based on units of care responsible for is based on units of care responsible of a new strategy based on community of a new strategy the women’s movements, lies in improving two types of structure are expected to refer two types of structure are expected th care for the populations of rural areas. th care for the populations of rural Bank, Pakistan launched a major programme, the training of female paramedical personnel en living in towns had antenatal care and 70% To these problems mu Pakistani women have at least one child before ite of a public populati a public ite of uring adequate medical personnel in rural clinics, uring adequate medical personnel in welfare centres and reproductive health centres welfare centres and e has been a steady increase in s in 1988 to achieve better ca s in 1988 to achieve icy with a series of different types of project and political types of project a series of different icy with Welfare Division of Planning and Economic to the Ministry ernmental organisation. From ernmental for the improvement of mate events women from entering m en. So long as their status is determined by their “reproductive en. So long as their status is determined he number of boys they can pr opment of an elitist system of m modern contraceptive means; modern contraceptive lic health services. In 1992 there was one doctor for more than 2000 lic health services. In 1992 there was the management and organisation capac The average age of marriage between 1980 and 1990 Since the 1980s, however, ther The key to controlling growth, in the view of The key to controlling growth, in the develop Pakistan’s first health policies were In the 1990s, with the support of the World These attempts to control population growth to control These attempts In 1998 the population of Pakistan was estima was of Pakistan the population In 1998 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling health, coupled with educational campaigns des health, coupled with educational campaigns families to two children. promotion of intra-uterine devices; promotion of intra-uterine to improvement of access Population the transfer of the Development in 1977, and the introduction Development in participation, in co-operation with family participation, in co-operation involved in sterilisation(which became more programmes); programme the reorientation of

Ministry of Health, 1996. Ministry “Progress toward better health”. discrimination which frequently pr institutions, leading to the devel a distinct deterioration in pub people and one hospital for over 130,000 people. This has an important consequence on the number of in number than doctors (with one nurse for every three doctors) Departments. health policy Maternal of contraceptives was only 12%, and almost half patients to rural hospitals. their 20th birthday. In 1990 70% of pregnant wom 1 programme supported by a non-gov supported by a programme this pol followed up public sectors measures: • • • socio- economic status of wom capacity”, and particularly by t programmes of birth control. obstacles to the success of the various to heal basis of these policies was accessibility from being to however, prevented these projects introduced. It programme of decentralisation was and 10,000. Rura covering populations of between 6000 services. These with support and a wider range of with a budget of US$140 million, Administrative problems and the difficulty of ens Administrative problems and the difficulty • launched in 1960 with the object of reducing the rate. of reducing in 1960 with the object launched epidemic diseases. This programme is based on and the strengthening of of increase remains high at around 3%, in sp 3%, at around high remains of increase UON Network - Tackling Unmet Need for Major Obstetric Interventions 5 4

3 kistani government. In personnel, who in any personnel, who in e only small numbers of e only small e management of health e management of han 40,000 traditional birth ented towards the training of th maternal mortality remaining w rate of attendance at health w rate of to go to a health structure, even in the to go to a health a priority of the Pa red delay because of the country’s recent have an escort to go to a health structure. have an escort to unctioning of the health system, a lack of unctioning of the ous levels of the health pyramid – at the by a man, and there ar by a man, of safe motherhood and the care of abortions of safe motherhood and the care of ors make a major contribution to the poor quality ors make a major oductive Health Services Package (RHSP) has ined, as well as inadequat maternal and child health, the situation still gives ng of doctors and more t and Perinatal Health (Zaisdi Sh, ed.). TWFL Publ, , tric emergencies and the lack of a structured system tric emergencies and are absenteeism among health are absenteeism among he referral structures on the second level. gh, at 340/100,000 LB in 1990 according to UNICEF ), policies were then reori 2 an important part in the lo part in the an important failure of these strategies, wi health centres were built. Later, in the seventies and eighties, health centres were built. Later, in ied medical personnel; in rural areas, however, less than a fifth of than a less however, in rural areas, personnel; ied medical women. For example : women. For As a result of the relative Since 1960 maternal and child health has been Since 1960 maternal and child health To these factors must be added the malf To these factors All these services are offered at the vari Socio-cultural barriers play Socio-cultural This ambitious programme, however, has suffe Although progress has been made in Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling female medical staff, particularly in rural areas; staff, particularly female medical get their husband’s permission women must often problem ; case of a life-threatening not go out alone, and must women can frequently and their complications; child health care; health problems; the care of adolescent's reproductive problems; the care of women’s reproductive health prevention and care of sexually transmitted diseases and AIDS; the care of infertility problems; detection of cancers of the breasts and cervix; the care of men’s reproductive health problems. it is unacceptable for women to be examined to be examined for women it is unacceptable and men; a family planning service for women maternal health care, including a programme

The state of the world’s children 1996, http://www.unicef.org. S, Maternal Jafarey Mortality in Pakistan. In: Maternal The state of the world’s children 1998, http://www.unicef.org 1991: 21-32. services and a lack of supervision. All these fact services and a lack attendants (TBAs). high (500/100,000 LB in 1980–92 of care in general. 2 3 4 event are insufficient in number and poorly tra event are insufficient that year 400 maternal and child the traini programmes were directed rather to • • • • • • • • • structures by pregnant structures • able to deal with obste structures of referral Other problems of referral and evacuation. the Repr specialised midwives. More recently been put in place. It comprises: • • pregnant women had such care. had such women pregnant community level, at health centres and at t of births were attended by qualif attended were of births political troubles. cause for concern. Maternal mortality is hi UON Network - Tackling Unmet Need for Major Obstetric Interventions 6 rding to UNICEF and 84 to UNICEF rding to the Directorate of Health of the of of Health Directorate to the (95 per 1000 in 1996 acco in 1996 per 1000 (95 ). 5 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling UNDP Human development report 2001, http://www.undp.org. 5 and between 600 and 800/100,000 LB in 1994–45 according according in 1994–45 LB 800/100,000 600 and between and Punjab. Infantile mortality is equally dramatic is equally mortality Infantile Punjab. per 1000 according to UNDP per 1000 UON Network - Tackling Unmet Need for Major Obstetric Interventions 7 CAM team visit Preparatory visit CAM team & GTZ AKISTAN P Almost half the population are the population Almost half EXERCISE IN cts in the Punjab which were relatively Punjab which were cts in the UON e of the poor soil. Although there is some poor soil. Although e of the HRONOGRAM OF THE HRONOGRAM OF THE fairly good road and rail network. road and rail network. fairly good . C 1

Data collection and analysis Protocol elaboration Preliminary discussions with Pr De Muynck Preliminary discussions Regional meeting in Islamabad Final report First results analysis Feasibility study and HSA involvement confirmation Official agreement with GTZ Figure EXERCISE 11 12 01 02 03 04 05 06 07 08 09 10 03 04 05 06 07 08 09 10 11 12 05 06 07 08 09 10 11 12 01 02 01 02 03 04 2 0 0 0 1 9 9 9 1 9 9 8 UON The UON study was carried out in two distri study was carried The UON Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling HE engaged in agriculture, but production is low becaus production is low in agriculture, but engaged 3. T lives in a state of endemic poverty. industry the population undeveloped, in spite of having a in spite of having undeveloped, UON Network - Tackling Unmet Need for Major Obstetric Interventions 8 s of expected births nce the study covers deficits in MOIs. The , 1998 and their indications, to and the reduction in cost. and the reduction in surveys of this kind. The in surveys AKISTAN ctures are considered to have , P mum rate suggested in the UON elaborate planning of the various elaborate planning local teams and practitioners were and practitioners local teams Expected births (1/1/98 – 30/6/99) a team from the HSA and necessitated in and necessitated the HSA from a team culty of defining a reference rate adapted to s in the Punjab, and . The s in the Punjab, Jhelum and Attock. stetric Interventions ions, which provide an inventory of the human ions, which provide an inventory of entary parts. One, based on questionnaires for entary parts. One, population and housing. Si and child and to calculate 30 June 1999), the number r the collection of data r the collection of (1998) in terms of the availability of local staffs, who, given their in terms of the availability basis of a crude birth rate of 30 per 1000. basis of a crude birth rate of 30 per Jand 228.349 10.275 rate of 1.6% was calculated on the basis of the results of the Total 2.211.892 99.534 Attock 500.770 22.535 Jehlum 516.942 23.262 part of the study to “professionals” part of the um district, whose health stru 156.400 11.862 involved in the study only after involved in the study P.D.Khan 263.615 7.038 EFERENCE POPULATION BY DISTRICT Pindi Gheb 195.704 8.806 214.256 9.642 the study team opted for the mini Total Attock 1.274.935 57.372 Hasanabdal 135.856 6.114 Total Jehlum 936.957 42.162 ys’ work (between 29 June and 11 December 1999) and in Jhelum, and 11 December (between 29 June ys’ work . R District Population 1

eam based the non-involvement of the non-involvement eam based Table The study was carried out in two district The study was carried out in two At the beginning of the study, given the diffi The UON study consists of two complem The UON study consists The collection of data was carried out by out was carried of data collection The Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling analyse the outcome of interventions for mother analyse the outcome of interventions health format other is based on questionnaires for of each health structure. and material resources and the activities Populations studied census of population figures came from the 1998 1998 to a period of 18 months (from 1 January were calculated for that period on the daily work load, could have been daily work load, could the circumstances of Pakistan, Reference rate essentially the reduction in the time required fo essentially the reduction have been constraints There would also stages in the process. Method Equipment and Introduction Major Ob women, makes it possible to analyse modules, or 1%. Finally, however, a study for the of Jhel satisfactory accessibility. Attock, for 23 hospitals, 35 da 23 hospitals, 35 Attock, for study team in January 2000). The June 1999 and 31 (between 29 28 days’ work for 21 hospitals, this thus chose to entrust Pakistan on which the t arguments Approach to the collection of data in hospitals of data collection to the Approach UON Network - Tackling Unmet Need for Major Obstetric Interventions 9 ngs of obstetricians in ngs of obstetricians during the post-partum during the ted in the UON modules, structure, and altogether 68 udy in which Major Obstetric which treat some women from and antibiotics instituted during and antibiotics instituted Also included were women who were women Also included s provided by the Pakistani study the post-partum period in a health period in a the post-partum the questionnaire the most important truct a “women” file which provided the rmed Major Obstetric Interventions during rmed Major Obstetric Interventions t. In spite of some reservations by private t. In spite of some reservations by ctures in childbirth or ctures in to account were as proposed in the UON to account were he districts of Attock and Jhelum who in the who in Jhelum Attock and of he districts discussed at the meeti the study. Among them were hospitals situated the study. Among them were hospitals considered is as sugges en from Jhelum and 23 for women from Attock. en from Jhelum and 23 for women from rformed following abortions or ectopic pregnancies,rformed following o districts covered by the st veal deficits in each tehsil. The questionnaires were completed women operated on in this type of t of indications considered is as suggested in the UON protocol, 30 June 1999 had undergone a Major Obstetric Intervention a Major Obstetric 1999 had undergone 30 June ned but lying conveniently near ent by oxytocics, haemostatics ent by oxytocics, ban or rural. No information wa the study, the study team had no difficulty in gaining access to all the study, the study team had no difficulty e, military, parastatal, NGO. one of the neighbouring districts. neighbouring districts. one of the their pregnancy and the 42nd day of and the 42nd their pregnancy the HSA. Of the variables covered in These questionnaires made it possible to cons There are several categories of health formation in Pakistan: There are several All health structures in the tw The study covered all women resident in t resident women all study covered The The interventions and indicationsThe interventions in taken had perfo Of the 68 formations visited only 44 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling profit-making hospitals and private clinics; profit-making hospitals military hospitals, with varying scopeby the ordinary population; for access by NGOs); privately run non-profit hospitals (supported public district and tehsil hospitals.

for the purposes of the analysis are the following: Name of health formation and also includes indications 1). regarded as non-absolute (see Annex Type of intervention: The list of interventions and also includes as non-major (see Annex 1 for an exhaustive list of interventions regarded these). Indication for intervention: The lis Tehsil (sub-district) in which the formation is situated. Type of formation: public, privat Area of origin of the mother: ur team on the definition of urban and rural area. Mother’s tehsil of origin. basis of an analysis designed to re by the study team from Questionnaire for women structure in these districts or in these districts structure the regions concerned. • • • • period from 1 January 1998 to 1 January 1998 period from the 6th month of between treatm episiotomies or medical Criteria for inclusion Criteria during the same period had died in one of these stru died in one of these same period had during the were interventions pe period. Not included delivery. Maternal Indications were modules. The Absolute into accoun Interventions are performed were taken Attock and Jhelum. hospitals in the early stages of necessary information about the for wom the period covered by the study – 21 Variables studied formations were visited for the purposes of formations were visited for the purposes outside the two districts concer UON Network - Tackling Unmet Need for Major Obstetric Interventions 10 er of the operating he problem of maternal he problem the register of the operating died within 24 hours, stillborn, hours, within 24 died addition the data-collecting team -governmental, other. but not in the regist truct a “health formation” file, were also truct a “health formation” ster of admissions to the hospital. – time and cause of mother’s death, type cause of mother’s – time and strict of Attock has not been supplied to us, strict of Attock has not been supplied Other cases admitted to the emergency he various registers were encountered. The not appear in the file received from Pakistan. not appear in the file received from analyse in any detail t analyse in ire the most important for the analysis are: ire the most important kes it possible to analyse the human and material kes it possible to analyse ation as possible on problem cases, and they also this information with the “women” file. this information with ill be possible only at an aggregated level. It will be only if they were recorded in the register of births and the gynaecology and obstetrics department; y, paramilitary, semi the questionnaire for health formations – the number of the questionnaire for health formations Pakistani team’s report on the study. rnity unit, health centre, clinic, other. ng to report, died, complication. report, died, ng to e not included in the questionnaire. e not included al register of admissions. In the register of admissions to the gynaecology and obstetrics t, and the few cases not recorded in nothing to report, born living and living and born to report, nothing he operating theatre; he operating theatre or the general regi On individual cases the sources of information were: Some information included in in the di Since data on the health formations Some admissions recorded in the labour ward Few difficulties due to the maintenance of t These questionnaires, which were used to cons These questionnaires, by this questionna Of the variables covered Some variables proposedSome variables protocol in the UON It will thus not be possible in this paper not be possible It will thus to Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling the register of births; the register of t the general register of admissions to the general register of admissions to the hospital.

the analysis of work load in that district w the analysis of work load in that district based on information available in the Material used in collection of data • • maternal deaths and the number of stillbirths – does maternal deaths and the number of • • theatre have been excluded from the analysis. department but not recorded in department have been taken into account register of births was well kep theatre were traced in the gener resources of each health formation and to link resources of each Number of dystocic births Number of caesareans in the register of t Type of structure: public, private, militar working in the health formation. Number of gynaecologists and surgeons in the formation. Number of midwives and maternity nurses Total number of births completed by the HSA team. This data base ma completed by the formation is situated. Tehsil in which the Category of structure: hospital, mate made a special effort to obtain as much inform Questionnaire for health formations Questionnaire for State of child on discharge: on discharge: of child State maceration. stillborn with Name of health formation State of mother on discharge: nothi on discharge: of mother State of post-operative complication – ar complication of post-operative deaths in hospital. UON Network - Tackling Unmet Need for Major Obstetric Interventions 11 codified, and it is not codified, and it is the results in terms of eas suggested in the r Obstetric Intervention r Obstetric ore necessary to compile was not documented. The ems was the area of origin of ems was the area It is not possible to correct this It is not possible aphy (there are around 1750 place- aphy (there are around does not seem to have been followed does not seem to purpose, since the exact situation of purpose, since the 6 n by Pakistan for each tehsil seem to n by Pakistan for each tehsil seem performed for uterine ruptures became given in the file are not given in the file are r intervention, while there was an MOI in one cases the selection was more difficult, either cases the selection was more difficult, ed very difficult because of the lack of ed very difficult on of the file, which rvention. It was theref women whose address explicitly includes the women whose address preferable not to analyse difficult, when only one of the interventions districts are within an urban area. It would be districts are within ly graded under three variables (MAJ1, MAJ2 ly graded under three variables (MAJ1, MOI, or because the first variable (theoretically sources of information to confirm their accuracy. to confirm of information sources erion used here was an administrative one, taking erion used here was an administrative ne the most important Majo rds, 1080 for Attock and 1123 for Jhelum. No rds, 1080 for Attock and 1123 for tion to the documents mentioned above, patients’ above, mentioned to the documents tion ructure are regarded in an urban area, as living those beyond on, unspecified” became version/extractions; ng between urban and rural ar Certain corrections were therefore made: erine breach became a laparotomy; upplied. One of the main probl upplied. One of the forceps became a laparotomy; absence of a functional hospital. by the study team is not explained. by the study team knowledge of the local geogr knowledge of the suggested in the UON protocol suggested in the UON each became laparotomies. h has a district hospital. ; but this correction would serve no ; but this correction 7 In addition 6 cases recorded as caesareans It was necessary to carry out a reconstructi The original file contains 2203 reco In face of so many uncertainties, it seems In face of so many uncertainties, it seems Analysis data in Pakistan prov of the give Nor do the urban and rural populations Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling 4 caesareans and hysterectomies became 4 hysterectomies; 1 application of vacuum extractor and internal version became a version/extraction; 2 internal versions and “other interventi 1 blood transfusion and repair of ut 1 repair of uterine breach and 6 repairs of uterine br

Women living within 5 or 15 km of 5 Women living within st a functional health Such as Pindi Gheb, whic of the other two variables (MAJ1 or MAJ2). • • • • • obstetric interventions performed were apparent obstetric interventions performed were of the inte and MAJ3) according to the seriousness the main intervention, MAJ1) mentioned a non-majo • laparotomies. because several of the variables mentioned an 6 7 names in the file) to determine which villages or names in the file) name of a town duplicate was found. to determi lists of these three variables in order usually not for each woman. Although this was mentioned was included the list of MOIs, in some in possible to include within an urban area certain possible to include The “women” file the mothers. The criterion the mothers. The used here, and the criterion of the file, since the addresses variable on the basis detailed possible without a the mother’s area of origin. individual the different cross-check and to files, no account of the presence or sometimes found it useful to consult, in addi in to consult, it useful found sometimes The data base The data of data used Description the data bases s documentation on functional hospitals is not known. correspond to the criterion for discriminati that the crit UON protocol. It may be supposed that radius as in a rural area. UON Network - Tackling Unmet Need for Major Obstetric Interventions 12 Table 2 Table uniform distribution of aggregated data (usually , 1/1/98-30/6/99 he 18 health structures in eport explains the absence on the number of caesareans rage of the district in terms of will be impossible to establish obtain information about births mplementary information (type of mplementary information AKISTAN 81 , P Total 2.122 FILE he final file according to the type of he final file according to the type " contains (for the same hospitals) a much AMI cases) cases) xcept by postulating a the case of the “women” questionnaire. This have available only the health formation have available only the health the “health formations” questionnaire). The study, which was a year in the case of the , 1/1/98-30/6/99 Number % 774 WOMEN 774 " ade only on the basis of 2,203 um. These cover 13 of t 774 1.348 rventions were performed in them during the study rventions were performed in them during Yes No and the Pakistani study r covered by the study of individual cases. rventions can be performed. The heads of three rventions can be performed. The AKISTAN , P No birth for the child is the most poorly documented. Nor, as the most poorly documented. Nor, birth for the child is Yes type of indication (AMI or non-AMI). Whole file ( Total 781 1.422 2.203 MOI for AMI ( MOI for AMI pital activities difficult, since it been desirable to visit them to te picture of the effective cove he data in the two questionnaires Results for child 54 7% Results for child 188 8.5% than the “health formations” questionnaire (321 more in the her, does the file contain any co her, does the file contain MOI Results for mother 5 0.6% Results for mother 41 1.8% Variables Not noted INDICATION ATA MISSING FROM THE . D 2

shows the distribution of cases in t shows the distribution of cases in ISTRIBUTION OF CASES ACCORDING TO CATEGORY OF INTERVENTION AND CATEGORY OF CATEGORY AND OF INTERVENTION ACCORDING TO CATEGORY OF CASES ISTRIBUTION Table 3 . D 3

ABLE The analysis for can be m Except for one structure, t For the construction of this file we For the construction of this file The data on the outcome of the The data on the outcome T After these corrections the file still lacks information on certain variables. variables. on certain information still lacks the file these corrections After Table Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling the proportion of MOIs among hospital deliveries e of two others by the fact that no obstetric inte of two others by the fact that no obstetric in them in order to have a comple maternity care. by type of structure) given in the Pakistani study report. interventions performed over the 18 months institutions refused to take part in the study, institutions refused to take part in the period. It would nevertheless have will make the further analysis of hos the district in which Major Obstetric Inte the district in which Major Obstetric “health formation” questionnaires Reconciliation of data from “women” and performed does not match. The “women” questionnaire “health formations” questionnaire and 18 months in The “health formations” file of Jhel questionnaires completed for the district larger number of caesareans “women” questionnaire, or 40% more than in explanation of this difference lies in the period of summarises the missing information. missing the summarises for the mot regards the outcome of death, time of death). complication, cause intervention (MOI or non-MOI) and the intervention (MOI or non-MOI) and the UON Network - Tackling Unmet Need for Major Obstetric Interventions 13 ing, and are ing, and ted births are over- to rectify these errors ute in private than in that some mothers go r the period of treatment and treat few maternity he study team estimates e probably unreliable. In e probably unreliable. in the district of Jhelum to ion in cases of delay in the ion in cases of delay ble to bring out disparities ble to bring rent sources of information rmation on the indications for of justification, it appears that of justification, it appears l. Most of these addresses are eserve these documents, it has equired by law to sign a form of population and hous population this problem, and the study team sing the terms used for Absolute sult from the fact ity of the indications recorded in the ity of the indications therefore, that expec nancial reasons, some interventions are not nancial reasons, some interventions ssible for the study team which seems more ac for women are sometimes wrongly recorded or hat a mother may have two types of residence, hat a mother may have two types of ulation of expected births. But since these are expected births. ulation of rare in the Punjab, and t criterion, and some ar criterion, and some tals, however, are small, “delay in progress of labour”, “foeto-pelvic “delay in progress he patient is registered fo gynaecologists in health structures had been arranged gynaecologists in health structures team the validity of the info ient’s real address should not exceed 5%. ient’s real address should not exceed om the refusal by three hospitals from the 1998 census of from the . Since the decisions on intervent . Since the decisions l in a neighbouring district also refused to take part in the of such under-notifications. in Jhelum and Attock are confined in health structures outside ude birth rate it will not be possi rate it will not be ude birth ed by a partogram or other type ed by a partogram and hospitals are required to pr a, with the object of standardi tal near their father’s home, which may be outside the districts ers. However since women are r ar attention has been given to ary address while she is in hospita ing each of them clearly. ed out cross-checks between the diffe regard this bias as negligible. . a posteriori According to the Pakistani study Another factor leading to under-recording may re A final source of bias results fr One problem which may lead to biases is t One problem which may lead to biases A major problem was presented by the valid A major problem Since some variables in the questionnaire The population figures come figures come The population It appears that in private structures, for fi It appears that in private structures, Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Maternal Indications and defin a problem Major Obstetric Interventions presents it was not po public health structures. Unfortunately available. for their confinement to a hospi covered by the study. This practice seems to be that biases so created ought not to exceed 2–3%. take part in the collection of data. These hospi patients. Another important hospita study; but since few women living their district the study team Biases in collection of data registers. Some indications were given as registers. Some caesarean” disproportion” or “earlier minimise this bias meetings of order to well before the collection of dat of diagnosis her normal home and a tempor consent, before each intervention been possible to minimise the scale omitted, the study team carri Biases due to inexact diagnosis Biases due to inexact Demographic biases Demographic recorded in the hospital’s regist Discussionbiases of progress of labour are not support progress of labour taken without any explicit these decisions were where t notified by the police office for the area thus the most reliable possiblethus the basis the calc for the cr on the basis of calculated rural areas. It is very probable, between urban and areas. areas and under-estimated in rural estimated in urban (a temporary address). Particul pat estimates that errors concerning the UON Network - Tackling Unmet Need for Major Obstetric Interventions 14 ations” file concerning ations” file paid to Major Obstetric ormed for a problem of and infantile mortality in and infantile es, the cause and time of es, the cause stribution of interventions, of stribution It appears that caesareans rate in Jhelum is 2.6 per 100 rate in Jhelum is 2.6 al death, etc.) in which a less ) is more difficult to understand. ) is of laparotomies and hysterectomies, ). Indications there are 35 toxaemias or ted in accordance with the categories of ted in accordance ” of Pakistani hospitals is high, and that rventions recorded in the various hospitals rventions recorded out any further analysis in this direction. The analysis in out any further caesareans. As will be seen below, the very Table 6 retentions. The interventions performed were is the preferred intervention in the event of a , 1/1/98-30/6/99 Maternal Indications (30% for antecedents of try to assess maternal try to assess not include two variabl not include tions are post-partum haemorrhages which were he data in the “health form he data in ties of the various health structures. ties of the various . Particular attention will be . Particular attention y) could be performed. rs (39 cases) and blood transfusions (32 cases). ies, only one having been perf AKISTAN , P Table 3 NTERVENTIONS ACCORDING TO TYPE OF INTERVENTION AND OF INTERVENTION TO TYPE ACCORDING NTERVENTIONS I Attock Jehlum Total ng the global results on the di on the results global ng the indication. The small number of version/extractions (in spite indication. The small number of version/extractions rate of MOI/100 EB is 2.13. The rate of MOI/100 EB practitioners in Pakistani hospitals; and in addition almost 40% Number % Number % Number % than in Attock (1.8 per 100 EB). than in Attock (1.8 DISTRICT presentations led to 17 cases of stillbirth. ions (abnormal presentations, foet BSTETRIC together 75 transverse presentations O Total 1,006 100% 1,116 100% 2,122 100% ruptures explains the small numbers ruptures explains the small numbers AJOR Caesarean 977 97.1% 1,105 99% 2,082 98.1% Craniotomy 2 0.2% 3 0.3% 5 0.2% Laparotomy 5 0.5% 5 0.4% 10 0.5% Hysterectomy 9 0.9% 3 0.3% 12 0.6% . M 4

Version-extraction 13 1.3% 13 0.6% Table It is very probable that the medical “level The 7 cases of Absolute Maternal Indica Among the 74 cases of non-Absolute Maternal Almost all the interventions performed were Almost all the interventions performed We shall begin by describi shall begin We The tables and figures presented are construc The tables and figures 2122 Major Obstetric Inte The file contains Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling problem in childbirth, in situat accordingly, as in western countries, a caesarean which are usually performed for this of the fact that there are al This is true, to a lesser extent, of craniotom presentation, though abnormal invasive operation (internal version, craniotom frequently decided on by are most of caesareans are performed for non-Absolute caesareans and 20% for breech presentations: see Women who had not had a Major Obstetric Intervention treated medically or for which the type of intervention is not specified. eclampsias, 5 puerperal infections and 30 placental mainly the use of forceps or vacuum extracto small number of uterine indications and deficits then by tehsil. We shall Results hospital. Since the file supplied by PakistanSince the file supplied hospital. does carry been possible to death, it has not a maternal then be linked “women” file will data in the t with resources and the activi the human and material indications in and interventions shown for AMI or non-AMI. Interventions, whether Major Obstetric Interventions The average covered by the study. times higher per 100 EB, or 1.4 UON Network - Tackling Unmet Need for Major Obstetric Interventions 15 , 1/1/98-30/6/99 , 1/1/98-30/6/99 o-pelvic disproportions AKISTAN AKISTAN , P , P arean (88% in Attock and 98% in in the majority, accounting for 68% of in the majority, would appear that a disproportion is often would appear that a disproportion in the frequency of foet Attock Jehlum Total stricts (Jhelum 75%, Attock 60%); ante-partum stricts (Jhelum 75%, for cases presenting a hypertensive pathology, notedfor as below these two designations will be reclassified to permit twice as frequent and post-partum haemorrhages twice as frequent 44 11.4% 37 9.4% 81 10.4% NDICATIONS BY DISTRICT BY NDICATIONS Attock Jehlum Total rventions are antecedents of caesareans, breech rventions are antecedents of caesareans, I NDICATIONS BY DISTRICT BY NDICATIONS I Number % Number % Number % Table 7 Number % Number % Number % ATERNAL Total 693 100% 729 100% 1,422 100% operly conducted directed dynamic trial of labour), particularly operly conducted directed dynamic M ATERNAL ATERNAL Total 387 100% 394 100% 781 100% Sub total 376 100% 454 100% 830 100% M Éclampsia* 0.0 59 13.0 59 7.1 Other cause 309 44.6 263 36.1 572 40.2 e twice as numerous in Jhelum. Non specified 8 1.2 12 1.6 20 1.4 of these women have had a caes presentation Stationary labor 1 0.3 6 1.3 7 0.8 BSOLUTE Uterine rupture 4 1% 4 1% 8 1% Dynamic dystocia 15 4.0 25 5.5 40 4.8 Puerperal infection 6 1.6 0.0 6 0.7 -A Breach presentation 70 18.6 106 23.3 176 21.2 BSOLUTE Genital malformation 4 1.1 2 0.4 6 0.7 Vaginal haemorrhage 3 0.8 1 0.2 4 0.5 ON . A Antecedent of C-section 107 28.5 152 33.5 259 31.2 5 Toxaemia, pre-eclampsia 89 23.7 1 0.2 90 10.8

Mother's medical problem 13 3.5 6 1.3 19 2.3 Other obstetric antecedent 15 4.0 14 3.1 29 3.5 . N below shows the frequency of non-Absolute Maternal Indications in the two below shows the frequency of non-Absolute 6 Foeto-pelvic disproportion 231 59.7% 296 75.1% 527 67.5%

Transverse, facial and front Transverse, facial and Post-partum haemorrhages 16 4.1% 5 1.3% 21 2.7% Ante-partum haemorrhages 92 23.8% 52 13.2% 144 18.4% Table Obstructed labour for other causeObstructed labour for other 31 8.2 38 8.4 69 8.3 Complications connected with cord 0.0 9 2.0 9 1.1 Table Premature rupture of the membranesPremature 8 2.1 18 4.0 26 3.1 Foeto-pelvic disproportions are very much Foeto-pelvic disproportions Table 6 One possible explanation of this difference Obstructed labor for other presentationObstructed labor for other 14 3.7 17 3.7 31 3.7 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling *There seems to be a problem of naming (or coding) toxaemia in Attock and eclampsia in Jhelum. In comparison between the two districts. indications, between di with a marked disparity diagnosis. It is, as noted above, a problem of diagnosed too hastily (without a pr in private structures, which ar Non-Absolute Maternal Indications districts. The great majority inte Jhelum). The main reasons for these eclampsias in Jhelum. presentations, toxaemias in Attock and haemorrhages, on the other hand, are almost haemorrhages, on three times as frequent in Attock. Absolute Maternal Indications Maternal Absolute UON Network - Tackling Unmet Need for Major Obstetric Interventions 16 , Total AKISTAN , P tomy Cranio NDICATIONS BY NDICATIONS I Ratio A/J s, brought out more out s, brought eans, which are twice as Version ATERNAL Extraction ation is given in the file (marginal M re frequently performed in the Jehlum rate tomy Laparo BSOLUTE A the rates of incidence of non-absolute RATIOS OF RATES BY DISTRICT BY OF RATES RATIOS : ween the two district the two ween (‰EB) (‰EB) have been reclassified in order to permit tervention recorded in the file seems wrong, but no Attock rate tomy , 1/1/98-30/6/99 Hysterec s connected with hypertension during pregnancy. s connected with hypertension during in Attock and 0.9% in Jhelum. NDICATIONS the antecedents of caesar I AKISTAN 1/1/98-30/6/99 C- , P ation about the intervention actually performed. NTERVENTIONS FOR NTERVENTIONS Section I Stationary labor 0.02 0.14 0.1 ATERNAL Dynamic dystocia 0.26 0.59 0.4 M Puerperal infection 0.10 0.00 DISTRICT Breach presentation 1.22 2.51 0.5 r Absolute Maternal Indications Total 363 6 3 6 2 380 cases of ante-partum haemorrhage no justific noted above, caesareans are mo Genital malformation 0.07 0.05 1.5 Toxaemia, eclampsia 1.55 1.4 1.1 Vaginal haemorrhage 0.05 0.02 2.2 BSTETRIC Antecedent of C-section 1.87 3.61 0.5 O Mother's medical problem 0.23 0.14 1.6 Other obstetric antecedent 0.26 0.33 0.8 BSOLUTE Uterine rupture 2 2 4 -A AJOR Obstructed labor for other causeObstructed labor for other 0.54 0.90 0.6 on and pre-rupture 228 1 2 231 ON Complications connected with cord 0.00 0.21 0.0 . M 8 , which shows the ratios between rates per 100 EB in the two districts. in the two 100 EB rates per between the ratios shows , which Premature rupture of the membranesPremature 0.14 0.43 0.3

. N Obstructed labor for other presentationObstructed labor for other 0.24 0.40 0.6 . 7

Post-partum haemorrhages 2** 3 4** 9 Ante-partum haemorrhages 89 1 2* 92 Table Table 7 Table Table In this table toxaemias and eclampsias In this table toxaemias and eclampsias The differences between Attock and Jhelum in The differences between Attock and Once again there is a marked disparity bet disparity a marked is again there Once The MOI/AMI rate per 100 EB is 0.7% Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Transverse, facial and front presentation 44 44 Foeto-pelvic disproporti *For these two version/extractions in District of Attock placenta,…) **For these six cases of post-partum haemorrhage the in correction is possible, since we have no inform clearly in clearly of problem comparison between the two districts indications are not very great, except for frequent in Jhelum (where, as case of problems in childbirth). Major Obstetric Interventions fo UON Network - Tackling Unmet Need for Major Obstetric Interventions 17 Total NDICATIONS I tomy Cranio in which most of the ATERNAL M to the hospital run by a not been specified, and it not been specified, ion of an urban area used ion of an urban area have no population figures have no population go, in the event of problems, Version used, since in the district of used, since in the Extraction live in urban areas, there are t, went to private structures in 92% in Pindi Gheb. Altogether BSOLUTE the hospital run by a religious The remainder go to the military A ivate hospital and 20% to the DHQ , 1/1/98-30/6/99 tomy Laparo structures capable of dealing with obstetric structures capable of dealing with AKISTAN MOI for AMI Deficits an urban area live in the tehsil of Attock, an urban area live in the tehsil of rict (Attock and Jhelum), a public (THQ) hospital which was not fully , P t, while 16% prefer to go pe of area, since we pe of area, since Expected Performed Number % tomy r health formations has r health formations es. Moreover, the definit es. Moreover, the Hysterec NTERVENTIONS FOR NTERVENTIONS I TTOCK A women who had a caesarean (though for non-Absolute women who had a caesarean (though 37 37 295 1 296 C- the only means of saving their life. he small tehsil of lpindi, almost all of them to BSTETRIC Section ch of the population seems to ons for Absolute Maternal Indications ons for Absolute Maternal ouring district of . O Attock go to the Al Janat pr ranging from 64% in Fateh Jang to DISTRICT OF DISTRICT a priori (1/1/98-30/6/99) 1600 expected with a serious complication in childbirth did not have , tals in other tehsils. AJOR of the study for lack of an anaesthetis Total 388 1 4 1 394 M suggested in the UON protocol was not suggested in the rupture Total 57.372 918 380 538 58,6% presentation BY TEHSIL Uterine rupture 4 4 District Expected births EFICITS IN . D 9

123 Hasan Abdal4 Attock5 Gheb Pindi Fateh Jang 6.114 Jand 22.535 8.806 9.642 98 361 141 10.275 154 272 42 164 11 35 89 56 130 24,6% 57,1% 20 92,2% 119 77,3% 144 87,8% Transverse, facial and front Transverse, Post-partum haemorrhages 5 5 N° Ante-partum haemorrhages 51 1 52 Almost 90% of women from t Women from Pindi Gheb, where there is Women from Pindi Gheb, where there It is not possible to analyseIt is not possible to deficits by ty dist Except in the two largest tehsils in each health The tehsil of Attock has 8 functional Table Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Foeto-pelvic disproportion and pre- Foeto-pelvic to the neighbouring district of Rawa organisation in , which is quite close and easily accessible by road. functional during the period hospitals are concentrated and mu very large deficits everywhere, around 800 women out of the a Major Obstetric Intervention, religious organisation in the neighb in the district. hospital (5%) and other private hospitals 8 Attock in the event of a problem. Only Maternal Indications) went to the Pindi Gheb hospital. Deficits in Major Obstetric Interventi Deficits in Major Obstetric although there are also hospi Deficits in Attock District of for the towns in which there are health structur for the towns in which criterion appears that the as belonging to Attock the only women mentioned emergencies. 37.5% of women in for the distric hospital, which is the public hospital in the collection of data in the questionnaires fo in the collection of UON Network - Tackling Unmet Need for Major Obstetric Interventions 18 and quite close 8 ccessibility of the Table 9 NTERVENTIONS FOR I partly due to the limited , 1/1/98-30/6/99 2 pital or the Al Janat private or the Al pital ary hospitals if they have a la. This is a Christian hospital, them prefer to go to the DHQ than 10% to the Tajpuri private ate hospitals in to admit AKISTAN BSTETRIC BSTETRIC s) and Fateh Jang (64% deficits) O , P 1 AJOR TTOCK go to the Taxila hospital, which is also which hospital, the Taxila go to M 3 A oblems of geographical a dealing with obstetric emergencies. More IN is farther from Rawalpindi, go to the Attock is farther from Rawalpindi, go to the , The numbering of tehsil refer to ich is 97% Muslim. The private hospitals, whichich is 97% Muslim. The private hospitals, he tehsil of Attock, who if, as noted above, they e immediately referred to the DHQ hospital in e immediately referred to the DHQ seem – apart from the one in Al Janat to a small it observed here may be Although there is a good road network linking this Although there is a good road network 54 ISTRICT OF ISTRICT OF , D nce these two districts are small in area sq.km; district of Attock 6867 sq.km. er to go to one of the two milit er to go er to go to the Attock military hos Attock go to the er to rict hospital, and rather more ing the religious hospital in Taxi t and to the refusal of the priv private hospital, and only 30% of se of Hassan Abdal (73% deficit IN ABSOLUTE NUMBERS NDICATIONS I , private structures in Jhelum. go to the military hospital. EFICITS ATERNAL . D M 25 to 75 25 to 76 to125 126 to 175 2

Deficits in Attock Deficits Absolute numbers Absolute Figure BSOLUTE BSOLUTE A The deficits observed may be partly due to pr The deficits observed may be partly Women living in the district of Jand, which Women living in the district of Jand, In Jhelum there are 10 hospitals capable of Similarly, 76% of the women of Fateh Jang of Fateh women of the 76% Similarly, Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Hassan Abdal 350 sq.km, Fateh Jang 1249 women with serious obstetric problems (who ar women with serious obstetric problems Kohat). health structures; but in the ca this explanation is certainly insufficient, si 8 availability of means of transpor a country wh and its attractiveness is surprising in are frequently more difficult of access financially, extent – to be little used by women living outside t military hospital or the Al Janat of Kohat. hospital in the neighbouring district large defic district with Attock and Kohat, the to the Rawalpindi hospitals, includ do not go to Taxila, prefer to Deficits in Jhelum than half of the women (54%) pref problem; 28% go to the public dist hospital. The rest go to other conveniently close. The others pref others close. The conveniently hospital. UON Network - Tackling Unmet Need for Major Obstetric Interventions 19 Table 10 ATERNAL M s of Rawalpindi or l of PD Khan, which 20% of the women of ing districts mentioned NTERVENTIONS FOR ehsils distant from the the women of Sohawa, I BSOLUTE , 1/1/98-30/6/99 6 A pital. The private structures in medical staff (gynaecologists AKISTAN BSTETRIC BSTETRIC O only 2 women seem to have gone , P , 1/1/98-30/6/99 The numbering of tehsil refer to 8 AJOR HELUM M J AKISTAN the neighbouring district IN AMI in the tehsil hospita NTERVENTIONS FOR NTERVENTIONS MOI for AMI Deficits , I , P er plays a part here and that the military and er plays a part here and that the military rcely be due to problems of geographical y for women living in t hospitals is found among Expected Performed Number % EHLUM ill farther from the neighbour ISTRICT OF J han and Sohawa, and less than BSTETRIC , D O to one of the military hospitals or, less frequently, to the hospitals or, less frequently, to to one of the military pitals or the public district hos makes it possible to get quickly to Rawalpindi makes it possible to get quickly to or Islamabad. AJOR ISTRICT OF ISTRICT OF M he year because of shortages of he year because tal is at , but , D IN ABSOLUTE NUMBERS NDICATIONS 7 I (1/1/98-30/6/99) , 25 to 75 25 to 125 76 to 126 to 175 one of the military hospitals. Abolute numbers Deficits in Jehlum Deficits EFICITS IN EFICITS Total 41.982 675 394 281 41,6% ATERNAL . D NDICATIONS . D I M 10 3

District Expected births 678 Jehlum Sohawa Khan PD 23.262 7.038 11.682 372 113 190 345 23 26 27 7,3% 164 90 86,3 79,6 Table N° Figure BSOLUTE BSOLUTE A The women of PD Khan also goThe women of PD The same distribution in the choice of Very few women in these three tehsils go to Very few women in these three tehsils The large deficit in Sohawa can sca The large deficit in Sohawa can Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Jhelum DHQ hospital. Only 2 women had a MOI for Jhelum DHQ hospital. for much of t was non-functional and anaesthetists). almost 60% of whom prefer , preferring the military hos during the study period. to that hospital for an obstetric problem public structures are more affordable, particularl public structures are more affordable, Jhelum attract few or no women from PD K Jhelum attract few or no women from financial barri Jhelum. It may be supposed that the district’s main centre. above. The nearest district hospi accessibility, since the road system and st PD Khan is fairly distant from Jhelum UON Network - Tackling Unmet Need for Major Obstetric Interventions 20 , 1/1/98-30/6/99 m the tehsils of Attock m the tehsils s. It appears, therefore, care was a major factor in AKISTAN In view of the large deficits In view of he women who go to health he women who go , P bers of stillbirths, which are 3.6 mother unknown mother unknown result most frequently from a problem of district, almost all fro district, almost of early perinatal deaths. Once again this an AMI (foeto-pelvic disproportion). All of the hat in these cases the time which elapsed possible explanation of this is a delay in the these 11 deaths took place in hospitals in ngly low in both district in utero partum period. While for deaths within 24 hours helum this type of indication accounts for only 25% ls is good, and that t ls is good, and that Maternal deaths Results for the Maternal deaths Results for the Number % Number Number % Number time and died without receiving emergency care. time and died without ATERNAL DEATHS BY DISTRICT M chief tehsil in each district it is reasonable to suppose that a it is reasonable to in each district chief tehsil em and the woman’s admission to nal deaths in any of the cases. in any of the cases. nal deaths for obstetric emergencies, since this almost always makes it r various reasons (geographical or financial accessibility, socio- (geographical or financial accessibility, r various reasons of cases of cases milar, they differ markedly in num tric problems do so in time to avoid grave complications such as in time to avoid grave complications tric problems do so HOSPITAL - Jand 53 1 1.9% Total 1,079* 8 0.74% 40 Total 1.123 3 0,27% 1 Attock 764 1 0.1% 25 Jehlum 993 3 0,3% 1 Sohawa 64 NTRA PD Khan 66 Tehsil Number . I Tehsil Number Pindi Gheb 51 9 Fateh Jang 104 2 1.9% 5 Hasan Abdal 107 4 3.7% 1 11

Jehlum Attock *Not including one case in which the mother’s tehsil of origin is not known Table Of the 8 deaths in Attock 2 originated from Of Stillbirths for the majority were responsible Maternal mortality in hospital is astonishi Maternal mortality There were only 8 uterine ruptures (4 in each (4 in each only 8 uterine ruptures There were Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling neighbouring districts, and it may be supposed t between the detection of the probl obstructed labour (41% of stillbirths), while in J of stillbirths. structures in the event of obste structures in the event uterine ruptures. 3 deaths in Jhelum were non-AMI. Eight of reducing her chances of survival. Child deaths points to a good quality of care possible to avoid infant deaths during the post- the pattern in both districts is si times as high in Attock as in Jhelum tehsil. One decision to seek hospital care: in Attock deaths observed everywhere except in the everywhere except observed were unable fo number of women to reach a hospital in cultural barriers, etc.) hospital Maternal deaths in care in the various hospita that the quality of Uterine ruptures or Jhelum). There were no mater There were no or Jhelum). UON Network - Tackling Unmet Need for Major Obstetric Interventions 21 4.5 , AMONG ) S 4.0 Jehlum ival of infants. The AMI. In the tehsil of 100 MOI 3.5 , 1/1/98-30/6/99 not certain that an ils (caesarean rate < rates between the chief HOURS BY DISTRICT BY HOURS PER ( 24 3.0 AKISTAN the small number of tehsils tehsils half the stillbirths follow Attock , P HOURS HOURS residence, go to the same health 24 2.5 are stillbirths, it is 24 hours result from an ther to rapidity of access to health structures ther 2.0 able influence on the surv disparity in caesarean , 1/1/98-30/6/99 100 EB) and peripheral tehs 1.5 Stillborn< 24 h Deaths deaths of Total Stillborn< 24 h Deaths deaths of Total AKISTAN Caesarean rate (for 100 Expected Births) Number % Number % Number % P 1.0 Number % Number % Number % ACCORDING TO CAESAREAN RATE below is difficult because of after an AMI, while in the other women, whatever their place of MOI, .5 Figure 4 cases cases UMBER OF CHILDREN STILLBORN AND DYING WITHIN DYING AND STILLBORN OF CHILDREN UMBER . N TILLBIRTHS AND NEONATAL MORTALITY MORTALITY WITHIN NEONATAL TILLBIRTHS AND 0.0 12

. S 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0

4

Jand 53 2 3,8% 1 1,9% 3 5,7%

Total 1079* 49 4,5% 4 0,4% 53 4,9% Total 1123 20 1,8% 2 0,2% 22 2% MOI 100 / mortality perinatal Early Attock 764 33 4,3% 3 0,4% 36 4,7% Jehlum 993 12 1,2% 2 0,2% 14 1,4% Sohawa 64 4 6,3% 4 6,3% Table PD Khan 66 4 6,1% 4 6,1% Tehsil of Number Tehsil of Number Pindi Gheb 51 2 3,9% 2 3,9% Fateh Jang 104 6 5,8% 6 5,8% Hasan Abdal 107 6 5,6% 6 5,6% Figure In Attock half the stillbirths and deaths within In Attock half the stillbirths and deaths Attock Jehlum Interpretation of Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling WOMEN WHO HAVE HAD HAD AN WOMEN WHO HAVE Jhelum there are only 2 stillbirths an AMI. included in the analysis. is, however, a clear There tehsils in the districts (caesarean rate > 3/ tehsils in the districts (caesarean most infant deaths 1.5/100 EB). Nevertheless, since have a favour increase in the caesarean rate would difference observed here is likely to be attributable ra difference observed here is likely to than to quality of care, since the structures. UON Network - Tackling Unmet Need for Major Obstetric Interventions 22 (c) MOI/AMI Number of % a not insignificant (b) that the distribution of that the distribution during the study period, in the women go for their a on health formations a on health ore be made in order to ore be made rresponding to the period rresponding (28%) go to neighbouring ses – the explanation for he number of births in the he number of births (c) MOI place over a period of 18 period over a place , 1/1/98-30/6/99 liveries place in which took surgical facilities, nor those, only 38% of cases – a similar ed here, therefore, on the one ed here, therefore, ary structures, however, perform Number of % in which deliveries are performed. t, therefore, that her hand, the proportion of MOIs in AKISTAN (a) , P districts of Attock and Jhelum, hospital districts of Attock the district. As an example, cases which in the “women” file, taking all indications and tal deliveries requiring a Major Obstetric the collection of dat the collection cared for in hospitals outside the district of . Over all, only 19% of it possible to calculate the number of hospital it possible to calculate that many patients link the two types of information it is necessary types of information link the two be practically non-functional with private hospitals performing proportionately assumptions must theref assumptions 2.009 4% 369 18% 83 22% 2.123 5% 467 22% 179 38% period of 18 months co period of deliveries (b) Intra-hospital of problem obstetric ca which, on the ot Number of % 30 June 1999 by multiplying t 30 June 1999 by a (for the “women” file) took file) the “women” a (for even for a perfectly normal delivery. 57.372 42.162 the table does not include de (6%). Over all, only 11% of expected births take place in was collected. It will be assum was collected. It existence of other structures Absolute Maternal Indications in e of dealing with obstetric emergencies. This may seem a rather e of dealing with obstetric emergencies. y structures (22%). These milit births(a) second-level structures without Expected hospitals in neighbouring districts. e between 1998 and 1999e between 1998 and and on the other OSPITAL ACTIVITIES TEHSIL BY . H he study period (18 months). he study period (18 13

problems. It may legitimately be though hospital Number of Number Table below presents, for hospitals in the below presents, for Private 6 3.521 6% 208 6% 147 71% Private 13** 2.037 5% 238 12% 64 27% Military 2 Military 2 status In Jhelum most births are in public hospitals In Attock the situation is rather different, The collection of individualcollection The dat Table 13 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Sub total 6.426 11% 712 11% 270 38% Sub total 8.044 19% 1088 14% 385 35% Total 28 99.534 14.470 15% 1800 12% 655*** 36% Attock Public 2* 896 2% 135 15% 40 30% Jehlum Public 3 3.884 9% 383 10% 142 37% Tehsil Hospital primary-level structures or in probably few in number, which took place outside required a Major Obstetric Intervention and were Jhelum account for less than 3% of cases recorded interventions together. The proportions of hospi Major Obstetric Interventions for Intervention are highest in militar confinement to a structure capabl inadequate level of coverage, but situation to what occurs in public hospitals, in *Not including the THQ hospital in Fateh Jang, reported to including *Not which only 2 caesareans were performed, both for non-AMI. for which only 2 caesareans were performed, both Obstetric Interventions. **Of these 13 structures only 8 performed Major ***Not including MOI/AMI performed in hospital deliveries is much lower (10% of hospital deliveries). the highest number of deliveries hospitals with facilities for surgical treatment which, as in Jhelum, may be the Moreover, analysing the “women” file, we observe districts in the event of number of women go to these hospitals Work load and resources load and Work months, from January 1998 to June 1999, while to June 1999, from January 1998 months, to In order to be able the year 1999. covered only they relate, and the periods to which to equate stabl hand that fertility remained activities reported during t activities reported assess the number of hospital deliveries for a deliveries for number of hospital assess the during which the individual data the year. This makes births was linear throughout deliveries 1998 and between 1 January of 1.5. year 1999 by a factor UON Network - Tackling Unmet Need for Major Obstetric Interventions 23 , 1/1/98- MOIs, i.e. a MOIs, AKISTAN r action at the local , P more doctors with ory of resources. The objectives of the study ternal mortality and morbidity represent 71% of ing data, this retro-information e permanently on duty. rmation, makes it possible for aims being to supply them with a carried out, by its modest cost, and regional decision-makers and ), and teams of gynaecologists and to plan strategies fo he process of retro-information, the Attock Jehlum udy is the final report analysing the data, ss high, over all, than in Jhelum, particularly Figure 5 r one small private hospital, all functional r one small private hospital, all ause one of the original document effectively meets one of the original e are also midwives in all hospitals except in addition there are one or h MOI/Gynaecologist/month rms of deficits and an invent 30/6/99 unqualified midwives ar eries are performed by unqualified birth attendants. eries are performed by unqualified birth ologist qualified to deal with obstetric emergencies effectively ologist qualified to deal with obstetric ic or military structures. not at all at the stage of collect for district teams – one of the understanding of the causes of ma volved in the study. In Pakistan, since these field workers were t are that the type of study ons but also to workers in the field, the practitioners and the study not only to national lutions appropriate to each situation. the national system of health info hese private hospitals, however, AMIs Public Private Military Public Private Military Deliveries/midwife/mont ONTHLY WORKLOAD OF MEDICALAND PARAMEDICAL PERSONNEL . M 5

8 6 4 2 0

20 18 16 14 12 10

Charge de travail de Charge fo In terms of human resources, except Another key phase of the UON study is t So far the only documented product of the st The proportion of births involving an MOI is le The proportion of births involving an Over all, work loads are nowhere excessive ( Over all, work loads are nowhere excessive

Figure Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling Workload TILISATION OF RESULTS TILISATION and to find, at the local level, so decision-makers to gain a better international partner organisati paramedicals in the structures in involved to only a small extent or could be seen as being all the more important bec was to provide technical support methodology for their work and a data base enabling them main conclusions of this repor particularly by its inclusion in objectives, a description of the situation in te in private structures (6%). In t much higher proportion than in publ structures have at least one gynaec the year. In present at the hospital throughout Retro-information communication of the results of level and to follow up their effects. published in October 2000. This very descriptive obstetric skills in the majority of hospitals. Ther obstetric skills in the majority of hospitals. deliv private structures in Attock, in which and surgeons, and, for deliveries, qualified 4. U UON Network - Tackling Unmet Need for Major Obstetric Interventions 24 , private, military experiences of all he file of data is so l gain will be “lost” if ng or not, is difficult to y out interviews with key rk was held in Islamabad in Islamabad held in rk was ant persons – representatives – ant persons isse, British High Commission, isse, British thus impossible to ascertain how ich other countries in the network ich other countries consider an approach to planning consider an approach workers in each phase of the study, is workers in each phase of the study, for example if the study is extended to danger of being lost. T ssimilation of the results, and even of the ssimilation of the results, and even th system, including public ture continuation of the study, for once the the Ministry of Health either at the national or the Ministry of Health either at the national r attention by health planners, for, as we have ings at departmental and/or local level lies in ings at departmental heir perception of the problem of dealing with heir perception of the problem of dealing consideration by those who every day must consideration by those who every through in common, will have a chance to lead through in common, future, and that the financia ures, whether profit-maki with obstetric problems, and it is not possible in yses, the thoughts and the yses, the thoughts , departmental and district level, members of the level, members and district , departmental leading international bodies (WHO, World Bank, (WHO, World international bodies leading Medical Association Medical and directors of public and the has, in the view of those involved, proved effective in ile health. Unfortunately the methodology adopted by ile health. Unfortunately the methodology countries in the UON netwo in the countries hat planners and field workers can develop in common hat planners and field a strong point of the health system. it is difficult to believe that it can be used again in future. UON study it is planned to carr presented to numerous import numerous to presented lopment Bank, Coopération Su Coopération lopment Bank, rking at the HSA, it has been very difficult for us to analyse the studied, and certainly not to studied, and certainly herefore, that the a ing of this kind, however, at wh ing of this kind, however, on and analysis of data was carried out by an organisation of on and analysis of data was carried he time required for carrying out the study. However one of the he time required for carrying out the ant phase into account, and it is vered by the study. The meeting could thus serve as a process of as a process could thus serve the study. The meeting vered by forward programmes intended only for the public sector. The iding emergency obstetric care. cher, the only person who can fully comprehend the various be still more difficult if in future, ss, the direct involvement of field For the “research” part of the The approach adopted by Pakistan The existence in Pakistan of a complex heal A regional meeting of anglophone of anglophone meeting A regional The fact that the collecti Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling ONCLUSION Pakistan did not take this import obstetric emergencies or possible solutions. 5. C workers in the field of maternal and infant workers in the field of maternal and an impact on t far the study has had or will have involved. of concertation t It is by this type they have beenstrategies which, because thought action. to real and effective Perception UNICEF, UNFPA,UNICEF, Asian Deve PAM, of the Pakistani editor of the journal etc.), the co in the areas military hospitals A meet national retro-information. concrete discuss in a structured way the does not make it possible to were also present, in eachproblems revealed district The value of local meet adapted to each context. the results but also the anal sharing not only Institute of Public Health, representatives of of Public Health, Institute February 2000, and the results were results and the 2000, February Health at national Ministry of of the Pakistani limiting the financial costs and t strong points of the proce lacking here. It may be feared, t effective in technique, by field workers will not be not taken into the positive results hoped for are complex and so poorly documented that Since the principal resear codifications used, is no longer wo data collected, and it will other districts, the file has to be used again. and religious structures, needs to be given particula seen, each sector is actively involved in dealing these circumstances to put cohabitation of public hospitals with private struct manage, but ought to be able to become confront the problems of prov involvement of research professionals without direct even departmental level poses for the fu a problem study has been completed the data base created is in UON Network - Tackling Unmet Need for Major Obstetric Interventions 25 JAND UNKNOWN SPECIFY YEAR NGO YEAR URBAN RURAL DAY MONTH TEHSILS DAY MONTH PARASTATAL RUPTURED UTERUS OTHERS SOHAWA KHAN D. P. PROLONGED LABOUR DATE OF ADMISSION OF DATE PARA SETTING ANOTHER FACILITYANOTHER ELSEWHERE JHELUM ATTOCK H. ABDAL FATEHJANG STILL BORN STILL HEALTH SERVICES ACADEMY, SERVICES ACADEMY, ISLAMABAD HEALTH GRAVIDA RETROSPECTIVE DATA COLLECTION INSTRUMENT COLLECTION DATA RETROSPECTIVE SINGLETON MULTIPLE UNMET OBSTETRIC NEEDS STUDY 1998-2000 STUDY NEEDS OBSTETRIC UNMET PUBLIC PRIVATE MILITARY PUNJAB ICTJHELUM NWFP ATTOCK ECLAMPSIA YEARS PERMANENT TEMPORARY OMEN QUESTIONNAIREOMEN 1 W QUESTIONNAIRENO: DATE: SVD TWINS C-SECTION CPD AGE HOSPITAL ID NO: HOME THIS FACILITY NAME Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling FACILITY TYPE FACILITY ADDRESS: FACILITY NAME FACILITY PROVINCE DISTRICT PRE- ECLAMPSIA NNEX 4. TYPE OF PREGNANCY OF 4.TYPE 5. OBSTETRICALPAST HISTORY 3. DELIVERED AT 3. DELIVERED 2.IDENTIFICATION WOMAN OF 1.IDENTIFICATION OF HEALTH FACILITY A UON Network - Tackling Unmet Need for Major Obstetric Interventions 26 BLOOD TRANSFUSION BLOOD ANTIBIOTIC THERAPY ANTIBIOTIC CRANIOTOMY SYMPHYSIOTOMY SPECIFY * LAPAROTOMY MANUAL PLACENTAL REMOVALMANUAL VERSION INTERNAL MATERNAL EXHAUSTION RUPTURED UTERUS C-SECTION PREVIOUS H/O HISTORY OBSTETRICAL BAD OTHER PRESENTATION BREECH LIE TRANSVERSE BY OBSTRUCTED LABOR BROW BY OBSTRUCTED LABOR PRESENTATION PRESENTATION OTHER BY OBSTRUCTED LABOR CONTRACTIONS POOR UTERINE BY LABOR PROLONGED CPD BY LABOR OBSTRUCTED CAUSES OTHER BY LABOR OBSTRUCTED APH DUE TO PLACENTA PRAEVIA / ECLAMPSIA PRE-ECLAMPSIA / PIH PPH PLACENTA RETAINED UTERUS PRE-RUPTURED CERVIX THE OF TEAR LACERATION (VAGINAL, VULVAL, PERINEAL TEAR) INFECTION PUERPERAL DIC PRECIOUS PREGNANCY OTHERS CERVICAL TEAR REPAIR TEAR CERVICAL REPAIR TEAR PERINEAL ** Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling OTHERS VACUUMFORCEPS UTERINE REPAIR UTERINE C-SECTION HYSTERECTOMY * = ONLY FOR UTERINE BREECH, ** = ONLY FOR RUPTURED UTERUS UTERUS RUPTURED FOR ONLY = ** BREECH, UTERINE FOR ONLY * = UON QUESTI ONNAI PAGE RE 2 7. INDICATIONS 6. MAJOR OBSTETRICALINTERVENTION (CURRENT PREGNANCY) UON Network - Tackling Unmet Need for Major Obstetric Interventions 27 Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling UON Network - Tackling Unmet Need for Major Obstetric Interventions 28 Available (day, night & weekends) during the last 30 days Not EOC Comprehensive EOC Comprehensive Basic EOC

(From………..To……….) Findings of Facility’s EOC Status EOC of Facility’s Findings • • • c) Military c) Health center Health c) FLCF LHW maternity Private

c) d) a) Community(Dai) b) No. Posted No. Present Present a) Yes b) No a) Hospital b) Maternity a) Hospital b) Maternity a) Government b) Private No. ofPosts sanctioned d) Clinic e) Others (specify) d) Clinic (specify) e) Others d) Others______Para-military f) e) Semi-govt. ORMATION QUESTIONNAIRE F EALTH EALTH Service profile during the last 12 period month Total deliveries deliveries Normal If ALL of 16 a-h = Yes, check:AND If ALL of 16 a-f = Yes 16 g or 16 h = NO, check:If ANY of 16 a-f = No check: EOC ______COMPREHENSIVE ______BASIC EOC ______NOT EOC 2 H Staffing profile Description of health facility Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling

• • • Nameof facility: Location/Addressof facility: area: Catchment

9. 10. section Caesarean 11. in) (referred referrals obstetric of No. III. 8. 6. Is the facility open 24 hrs a hrs 24 open facility Is the 6. day 4.Type of 4.Type facility: of operating 5.Type of agency: NNEX h. LHV h. i.Dai d. Woman medical Woman d. officer Mid-wife / Nurse e. wife Mid f. technician Lab g. a. Gynecologist a. Anesthetist b. Surgeons General c. II. 7. on staffing Check-list I. 1. 2. 3. A UON Network - Tackling Unmet Need for Major Obstetric Interventions 29 AKISTAN P IN UON UON ting the Unmet Obstetric Need at districts ting the Unmet Obstetric on to Islamabad, Pakistan, 15-20.11.99, 5 p. Pakistan, on to Islamabad, Report of a preparatory visit to Pakistan, 17 p. Report of a preparatory Collection at District Jehlum, 2 p. at District Jehlum, Collection & al. Unmet Obstetrical Needs in the Districts of Attock & of in the Districts Needs Unmet Obstetrical & al. IST OF MAIN DOCUMENTS MAIN IST OF PUBLISHED BY THE 3 L Tackling Unmet Obstetric Needs: Pakistan Needs: Obstetric Unmet Tackling NNEX Jehlum, Punjab Province, Pakistan, 79 p. Province, Pakistan, Jehlum, Punjab missi on the UON 1999, Jahn A., Report November Report of Data Tassadaq Farook, July 1999, F., Zaidi, Sahela A.R., Estima May 1999, Tassadaq the Punjab provinceAttock & Jehlum in 31 p. of Pakistan, A., Litt V., De Brouwere V., December 1998, Jahn October 2000, Saleha Abdur Rehman Abdur Rehman Saleha 2000, October A