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MMR) in Districts Haripur and Nowshera, Khyber Pakhtunkhwa

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MMR) in Districts Haripur and Nowshera, Khyber Pakhtunkhwa Using the Community Informant Based (Made-in and Made-for) Methodology for Estimating Maternal Mortality Ratio (MMR) in districts Haripur and Nowshera, Khyber Pakhtunkhwa Implemented by The Population Council February 2016 The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutions that lead to more effective policies, programs, and technologies that improve lives. © 2016 The Population Council, Inc. Declaration: “I have read the report titled “Using the Community Informant Based (Made-in and Made-for) Methodology for Estimating MMR in districts Haripur and Nowshera, KP”, and acknowledge and agree with the information, data and findings contained". Principal Investigator Dr Ali Mohammad Mir: _________________ Acknowledgment: “Using the Community Informant Based (Made-In and Made-For) Methodology for Estimating MMR in districts Haripur and Nowshera, Khyber Pakhtunkhwa” is a project funded by GIZ and implemented by the Population Council, Pakistan. Disclaimer: The Reproductive, Maternal and Newborn Health Project (RMNHP) implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Development and Cooperation (BMZ) aims to strengthen the health system and to improve the quality of healthcare for mothers and children. At the dissemination seminar for the Punjab Maternal Mortality study in February 2015 GIZ committed to support replication of the community-based methodology for estimating maternal mortality (MADE-IN MADE-FOR) in Khyber Pakhtunkhwa province as this initiative is supposed to contribute to the overall RMNHP objective. While funding this particular initiative, the GIZ hereby declares that the responsibility and mandate for the study design, data collection, data analysis, and interpretation of results lies solely with the principle investigator and the Population Council and will not be influenced at any stage by the GIZ. The content of any publication arising from the research does not necessarily reflect the official views of GIZ. We declare no conflict of interest. ii Table of Contents Abbreviations and Acronyms ...............................................................................................................................vii Executive Summary ............................................................................................................................................... 1 Introduction.. ........................................................................................................................................................... 5 Maternal Health in Khyber Pakhtunkhwa ................................................................................................. 7 Approaches to Measuring Maternal Mortality........................................................................................... 8 Measurement of Maternal Mortality in Pakistan ...................................................................................15 Feasibility of the Made-In/Made-For Method in Pakistan .....................................................................16 Study Objectives ..........................................................................................................................................18 Study Design .........................................................................................................................................................21 Site and Coverage .......................................................................................................................................21 Identification of Informant Networks .......................................................................................................22 Study Team and Organization of Field Work...........................................................................................23 Data Collection .............................................................................................................................................24 Qualitative Component ...............................................................................................................................26 Data Management and Analysis ...............................................................................................................26 Quality Assurance ........................................................................................................................................26 Ethical Considerations ................................................................................................................................27 Maternal and Pregnancy Related Deaths: Socio-Demographic Features and Causes .............................29 Basic Definitions ..........................................................................................................................................29 Identification of Pregnancy-related Deaths .............................................................................................29 Socio-Demographic Characteristics of Deceased Women ...................................................................31 Maternal Mortality .......................................................................................................................................34 Direct and Indirect Causes of Pregnancy-related Deaths .....................................................................38 Maternity Care ......................................................................................................................................................43 Antenatal Care .............................................................................................................................................43 Delivery Care ................................................................................................................................................45 Postnatal Care .............................................................................................................................................47 Circumstances of Death: Time, Place and Care-Seeking Behavior ..............................................................49 Time of Death ...............................................................................................................................................49 Place of Death ..............................................................................................................................................50 Care Seeking Behaviors: The Delays Model ............................................................................................52 The First Delay: The Decision to Seek Care .............................................................................................52 Study Limitations .................................................................................................................................................58 Discussion……………….. .........................................................................................................................................59 Bibliography…………………………………………………………………………………………………………………………………...62 iii List of Tables Table ‎1.1: Various options for measuring maternal mortality in Pakistan .............................................13 Table ‎1.2: Previous sources of data used to estimate MMR in Pakistan ................................................15 Table 2.1: Key reproductive health indicators for the two study districts and KP province .................21 Table 2.2: Participation of key informants in listing meetings—Made-In ................................................21 Table 3.1: Ages of deceased women by district ..........................................................................................31 Table 3.2: Education of deceased women, by district ................................................................................32 Table 3.3: Education of deceased women’s husbands ..............................................................................33 Table 3.4: Socioeconomic status of households, by district......................................................................33 Table 3.5: Death rates of women of reproductive age per 100,000 (excluding women aged <15 or >49 years) .......................................................................................................................................34 Table 3.6: Adjusted Estimation of PRDs after Capture-Recapture Analysis ...........................................36 Table 3.7: MMR Estimation by District ..........................................................................................................36 Table 3.8: Age-specific unadjusted MMR by district ...................................................................................37 Table 3.9: Comparison of direct and indirect causes of maternal deaths, by district…………………..…35 Table 3.10: Direct Causes of Maternal Deaths (n=181) ...............................................................................36 Table 3.11: Indirect causes of maternal deaths (n=97) ...............................................................................41 Table ‎4.1: Percentage of ANC visits by district ............................................................................................43
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