Birth Centre Management and Business Skill Training for Community Midwives of Pakistan

The Community Midwifery program was introduced in 2007 across Pakistan with the idea that the trained Community Midwives (CMWs) will be deployed back to their ‘native’ rural communities. Hence, they are not employed by government rather they must earn their income by charging fees for their services. It is expected from them to attract clients, establish birth clinics and operate as a small business to support and sustain them financially. However, the CMW training program only teaches students about antenatal, intranatal, postnatal and newborn care, family planning services and awareness of community dynamics and does not include content about setting up a ‘birth station’ and how to market and sustain a small business. We encountered comments from CMWs in a variety of forums that many of them were unable to sustain a birthing station and financially support themselves. Hence a research intervention was designed for them known as ‘Business Skills Training (BST)’ with the objective of enhancing the business skills of CMWs to increase their likelihood of establishing financially sustainable birthing clinics. This article is the description of BST intervention and the process of this training

Smoking practices and nicotine dependence among adolescents in Pakistan

Objective: To find out the smoking prevalence and associated factors among in-school and out-of-school adolescents and their nicotine dependence.METHOD: The cross-sectional study was conducted from April to June 2008 comprising 1014 adolescents aged 12-18 years residing in two rural districts of Sindh and Punjab. Trained interviewers collected information from the adolescents regarding age, ethnicity, religion, occupation and education of parents, smoking behaviour, smoking history of family/friend, type of family system, number of siblings and place of residence. Statistical package Epi-Info version 6 was used to enter the data and analysis was performed by using SPSS version 12.Results: Overall smoking prevalence among the 1014 adolescents was 15.2%, with significant gender stratification (7.9% among girls versus 20.2% among boys). Of these, 50% were moderately nicotine dependent. However, the prevalence among in-school adolescents (14.6%) was not significantly different from out-of-school adolescents (16.1%). The factors associated with adolescents\u27 smoking were father\u27s illiteracy (adjusted odds ratio [OR] = 8.2), friend\u27s smoking (adjusted OR = 6.8), father\u27s smoking (adjusted OR = 5.4) and nuclear family setup (adjusted OR = 3.6). When explored for the first place of smoking, friends\u27 home was mentioned by majority of adolescents boys and girls.CONCLUSION: Although there was a significant difference found between the prevalence of smoking among adolescent males and females, but any difference among in-school and out-of-school adolescents smoking prevalence could not be established

Can CMWs sustain quality services and high coverage as private providers in Chitral? A three-year prospective qualitative study

Background: The maternal and neonatal mortality ratesof Chitral district of Pakistan are among the highest in the country. One of the factors that found to havepositive impact on maternal and newborn health indicators is the availability ofquality skill birth attendance because the majority of the poor women cannot access facility-based maternity care. Therefore, in 2006, the Government of Pakistan (GOP) has initiated a program to train and deploy Community Midwives (CMWs) to support safe pregnancies and births. The Aga Khan Health Service’ Pakistan, initiated the Chitral Child Survival Program (CCSP) in partnership with the National Maternal Neonatal and Child Health program. The CCSP was an intervention package deploying 28 CMWs in remote villages of the district and supported by several strategies to ensure successful transition of these CMWs in remote settings. Aim: This study aims to assess the effectiveness of CCSP’s package of interventions and to identify the push (facilitating) and pull (hindering) factors that may have an impact on the CMW’s service utilization. Methods: A three-year longitudinal prospective qualitative design, using individual in-depth CMWs and focus group interviews of key informants conducted in Chitral district of Khyber Pakhtunkhwa province, Pakistan in localities where the CMWs were deployed. Using purposive sampling, 27 CMWs (all part of CCSP), key informants and other stakeholders were recruited. Data analysis was done concurrently with data collection by the researcher, using Creswell’s six steps. Findings: The major themes emerging from this study are: Safe and competent care in isolated villages, community’s support and satisfaction from the CMW work, Supportive supervision, dynamics of CMWs with other healthcare professionals, CMW’s referral systems and its challenges, CMW remuneration and fee for service , and Sustainability of the CMW services Recommendations: Continued support, ongoing in-service education of CMWs and constant engagement of the community, certainly plays a crucial role. TheGoP could consider incorporating CMWs in the service structure with a salary based on their scope of practice. This may ensure the sustainability of the CMW model and would allowcommunity to access the MNCH services provided by them

Patterns, control and complications of diabetes from a hospital based registry established in a low income country.

Background: Diabetes registry enables practitioners to measure the characteristics and patterns of diabetes across their patient population. They also provide insight into practice patterns which can be very effective in improving care and preventing complications. The aim of this study was to assess the patterns, control levels and complications at the baseline of the patients attending clinic at the large tertiary care hospital in Karachi, Pakistan with the help of the registry. This can be used as a reference to monitor the control and also for a comparison between peer groups. Methods: This was a cross sectional study with the data obtained from diabetes registry collected with the help of pre-designed questionnaire. HbA1c was used as a central diabetes measure and other related factors and complications were assessed with it. Results: Only 16.6% of the participants had optimal HbA1c≤7.0%. 52.9% of the patients were classified as having poor control defined by HbA1c of \u3e8%. Three fourth of the study population were obese according to Asian specific BMI cutoffs and majority had type 2 diabetes with duration of diabetes ranging from less than one to about 35 years, mean(SD) duration being 7.6 years (7.1). Overall only 4% of the patients were on combine target of HbA1c, LDL and BP.Results of multivariable logistic regression showed that the odds of having optimal glycemic control increased by 3% with every one year increase in age. In addition, having longer duration of diabetes was associated with 56% lower odds of having good glycemic control. Moreover, having higher triglyceride levels was associated with 1% lower odds of having good glycemic control. Conclusion: This highlights the large burden of sub optimally controlled people with diabetes in Pakistani population, a low income country with huge diabetes prevalence and ineffective primary health care system creating enormous health and economic burden

Challenges identified in the management of patients with inherited metabolic disorders – A five year experience from Pakistan

Background: Pakistan is the sixth most populous country in the World. High rates of consanguinity and inter caste marriages have resulted in a substantial burden of inherited metabolic disorders (IMDs). Despite this load, there is a dearth of both medical genetic and clinical metabolic services in Pakistan. There are inadequate numbers of appropriately trained clinicians, ill-equipped laboratories, lack of scientists and technologists equipped with skills to deal with the challenging laboratory investigations involved in IMD and a health care infra-structure unable to support a service. Aim: We present the first five year experience of the first established metabolic unit at a tertiary care hospital in Pakistan and present the case for screening of parents, parents’ siblings and antenatal diagnostic testing in subsequent pregnancies in order that families can make informed choices in preventing recurrence. Subjects and methods: This retrospective observational study comprising of patients’ chart review was conducted in the Department of Paediatrics, AKUH Karachi in Pakistan for patients who presented to the Clinical Genetics unit from January 2008 to December 2012 seeking diagnosis and treatment for the underlying IMD. Results: We evaluated 426 children, of which, 333 (78%) had consanguineous parents. Most patients, 151 (35%). evaluated for IMD were between 1 year and 5 years of age. Developmental delay, seizures, hypotonia, microcephaly, neuroregression, dystonia, ataxia and encephalopathy were the most common reasons for referrals. Only 155 (36%) patients underwent metabolic biochemical testing. Among the investigated group of patients, diagnoses were established for 85 (55%) patients equivalent to only 19.8% of the total. Conclusion: Neonatal screening for IMDs and their treatment in the current situation is an unaffordable practical option in Pakistan. Screening parents, siblings and subsequent pregnancies, however, is likely to provide a cost effective and acceptable alternative in reducing the burden and enabling early, effective detection of affected progeny before the stage when neurometabolic changes become irreversible in developing countries like Pakistan with very limited resources

Prospective Assessment of the Prevalence of Enter Hyperoxalosis in Kidney Transplant Candidates

UNLABELLED: Enteric hyperoxalosis (EH) is an emerging cause of kidney transplantation (KT) dysfunction. We sought to determine the prevalence of EH and factors that affect plasma oxalate (POx) among at-risk KT candidates. METHODS: We prospectively measured POx among KT candidates evaluated at our center from 2017 to 2020 with risk factors for EH namely bariatric surgery, inflammatory bowel disease, or cystic fibrosis. EH was defined by a POx ≥10 μmol/L. Period-prevalence of EH was calculated. We compared mean POx across 5 factors: underlying condition, chronic kidney disease (CKD) stage, dialysis modality, phosphate binder type, and body mass index. RESULTS: Of 40 KT candidates screened, 23 had EH for a 4-y period prevalence of 58%. Mean POx was 21.6 ± 23.5 μmol/L ranging from 0 to 109.6 μmol/L. 40% of screened had POx \u3e20 μmol/L. Sleeve gastrectomy was the most common underlying condition associated with EH. Mean POx did not differ by underlying condition ( = 0.27), CKD stage ( = 0.17), dialysis modality ( = 0.68), phosphate binder ( = 0.58), and body mass index ( = 0.56). CONCLUSIONS: Bariatric surgery and inflammatory bowel disease were associated with a high prevalence of EH among KT candidates. Contrary to prior studies, sleeve gastrectomy was also associated with hyperoxalosis in advanced CKD. POx concentrations observed in EH reached levels associated with tissue and potentially allograft deposition. Concentrations can be as high as that seen in primary hyperoxaluria. More studies are needed to assess if POx is indeed a modifiable factor affecting allograft function in patients with EH

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The COVID-19 pandemic led to the closure of educational campuses and the suspension of conventional classroom teaching globally and locally, and many switched overnight to an online modality. The change was experienced differently by varied audiences, given the availability of resources. The study aimed to examine stakeholders’ experiences of emergency remote instructions in the Post-RN Baccalaureate Nursing Program during the COVID-19 pandemic. A qualitative descriptive exploratory design with a purposive sampling technique was used at a private nursing university in Karachi, Pakistan. Focus group discussions with students and faculty were conducted separately, while in-depth interviews with key informants were held using semi-structured interview guides. The focus group discussions and in-depth interviews were recorded electronically and transcribed and translated, coded, and analysed manually. Findings uncovered two major themes. (a) Remote teaching and learning—a paradigm shift; and (b) Remote learning ecosystem—a challenging team sport. The first theme denotes a major shift in pedagogical approach migrating from blended learning model to a complete online modality. Theme two uncovers the efforts and teamwork of the various stakeholders who assisted in mitigating the challenges collaboratively when migrating to virtual learning environment. Findings suggest that to continue to thrive in the post-COVID world, faculty, students, and key informants must collegially enhance the teaching, learning, and assessment strategies and student-teacher interaction, capitalising on evidence-based practices, trial and error, multi-level support mechanisms, and partnerships. The study recommends building resilience in instructional and administrative infrastructure to prepare for future events like pandemics and suggests development of evidence-informed blended and online nursing programmes in the region.</div

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The COVID-19 pandemic led to the closure of educational campuses and the suspension of conventional classroom teaching globally and locally, and many switched overnight to an online modality. The change was experienced differently by varied audiences, given the availability of resources. The study aimed to examine stakeholders’ experiences of emergency remote instructions in the Post-RN Baccalaureate Nursing Program during the COVID-19 pandemic. A qualitative descriptive exploratory design with a purposive sampling technique was used at a private nursing university in Karachi, Pakistan. Focus group discussions with students and faculty were conducted separately, while in-depth interviews with key informants were held using semi-structured interview guides. The focus group discussions and in-depth interviews were recorded electronically and transcribed and translated, coded, and analysed manually. Findings uncovered two major themes. (a) Remote teaching and learning—a paradigm shift; and (b) Remote learning ecosystem—a challenging team sport. The first theme denotes a major shift in pedagogical approach migrating from blended learning model to a complete online modality. Theme two uncovers the efforts and teamwork of the various stakeholders who assisted in mitigating the challenges collaboratively when migrating to virtual learning environment. Findings suggest that to continue to thrive in the post-COVID world, faculty, students, and key informants must collegially enhance the teaching, learning, and assessment strategies and student-teacher interaction, capitalising on evidence-based practices, trial and error, multi-level support mechanisms, and partnerships. The study recommends building resilience in instructional and administrative infrastructure to prepare for future events like pandemics and suggests development of evidence-informed blended and online nursing programmes in the region.</div