Clean birth kits to improve birth practices: development and testing of a country level decision support tool

Background: Clean birth practices can prevent sepsis, one of the leading causes of both maternal and newborn mortality. Evidence suggests that clean birth kits (CBKs), as part of package that includes education, are associated with a reduction in newborn mortality, omphalitis, and puerperal sepsis. However, questions remain about how best to approach the introduction of CBKs in country. We set out to develop a practical decision support tool for programme managers of public health systems who are considering the potential role of CBKs in their strategy for care at birth. Methods: Development and testing of the decision support tool was a three-stage process involving an international expert group and country level testing. Stage 1, the development of the tool was undertaken by the Birth Kit Working Group and involved a review of the evidence, a consensus meeting, drafting of the proposed tool and expert review. In Stage 2 the tool was tested with users through interviews (9) and a focus group, with federal and provincial level decision makers in Pakistan. In Stage 3 the findings from the country level testing were reviewed by the expert group. Results: The decision support tool comprised three separate algorithms to guide the policy maker or programme manager through the specific steps required in making the country level decision about whether to use CBKs. The algorithms were supported by a series of questions (that could be administered by interview, focus group or questionnaire) to help the decision maker identify the information needed. The country level testing revealed that the decision support tool was easy to follow and helpful in making decisions about the potential role of CBKs. Minor modifications were made and the final algorithms are presented. Conclusion: Testing of the tool with users in Pakistan suggests that the tool facilitates discussion and aids decision making. However, testing in other countries is needed to determine whether these results can be replicated and to identify how the tool can be adapted to meet country specific needs

Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan

<p>Abstract</p> <p>Background</p> <p>Only 39% of deliveries in Pakistan are attended by skilled birth attendants, while Pakistan's target for skilled birth attendance by 2015 is > 90%.</p> <p>Methods</p> <p>A 12-month maternal health voucher intervention was implemented in Dera Ghazi Khan City, located in Southern Punjab, Pakistan in 2009. A pre-test/post-test non-experimental study was conducted to assess the impact of the intervention. Household interviews were conducted with randomly selected women who delivered in 2008 (the year prior to the voucher intervention), and with randomly selected women who delivered in 2009. A strong outreach model was used and voucher booklets valued at $50, containing redeemable coupons for three antenatal care (ANC) visits, a postnatal care (PNC) visit and institutional delivery, were sold for$1.25 to low-income women targeted by project workers. Regression analysis was conducted to determine the impact of the voucher scheme on ANC, PNC, and institutional delivery. Marginal effects estimated from logistic regression analyses were used to assess the magnitude of the impact of the intervention.</p> <p>Results</p> <p>The women targeted by voucher outreach workers were poorer, less educated, and at higher parity. After adjusting for these differences, women who delivered in 2009 and were sold voucher booklets were significantly more likely than women who delivered in 2008 to make at least three ANC visits, deliver in a health facility, and make a postnatal visit. Purchase of a voucher booklet was associated with a 22 percentage point increase in ANC use, a 22 percentage point increase in institutional delivery, and a 35 percentage point increase in PNC use.</p> <p>Conclusions</p> <p>A voucher intervention implemented for 12 months was associated with a substantial increase in institutional delivery. A substantial scale-up of maternal health vouchers that focus on institutional delivery is likely to bring Pakistan closer to achieving its 2015 target for institutional delivery.</p

Evaluating quality of contraceptive counseling: An analysis of the method information index

The Method Information Index (MII) is calculated from contraceptive users\u27 responses to questions regarding counseling content-whether they were informed about methods other than the one they received, told about method-specific side effects, and advised what to do if they experienced side effects. The MII is increasingly reported in national surveys and used to track program performance, but little is known about its properties. Using additional questions, we assessed the consistency between responses and the method received in a prospective, multicountry study. We employed two definitions of consistency: (1) presence of any concordant response, and (2) absence of discordant responses. Consistency was high when asking whether users were informed about other methods and what to do about side effects. Responses were least consistent when asking whether side effects were mentioned. Adjusting for inconsistency, scores were up to 50 percent and 30 percent lower in Pakistan and Uganda, respectively, compared to unadjusted MII scores. Additional questions facilitated better understanding of counseling quality

Security lies in obedience - Voices of young women of a slum in Pakistan

<p>Abstract</p> <p>Background</p> <p>Existing literature shows that young people, especially women, have poor knowledge about sexuality and reproductive health. Many of the difficulties young women experience are related to beliefs and expectations in society making them more vulnerable to reproductive ill health. The objective of this study was to explore how young women living in a slum in Islamabad are prepared for marriage and how they understand and perceive their transition to marriage and the start of sexual and childbearing activity.</p> <p>Methods</p> <p>Twenty qualitative interviews and three focus group discussions were conducted with young women residing in a slum of Islamabad. Content analysis was used to explore how the participants represented and explained their situation and how decisions about their marriage were made.</p> <p>Results</p> <p>The main theme identified was <it>security lies in obedience</it>. The two sub-themes contributing to the main theme were <it>socialization into submissiveness </it>and <it>transition into adulthood in silence</it>. The theme and the sub-themes illustrate the situation of young women in a poor setting in Pakistan.</p> <p>Conclusion</p> <p>The study demonstrates how, in a culture of silence around sexuality, young women's socialization into submissiveness lays the foundation for the lack of control over the future reproductive health that they experience.</p

Estimate of vertical transmission of Hepatitis C virus in Pakistan in 2007 and 2012 birth cohorts.

Despite a combination of high Hepatitis C virus (HCV) prevalence, a large adult population and high fertility, no published estimates of the scale and contribution of vertical transmission to HCV incidence in Pakistan exist. The objective of this study was to estimate the number of new HCV infections occurring in Pakistan as a result of vertical transmission. We adapted a published mathematical model based on HCV antibody and viraemia prevalence, fertility rates, risk of HCV vertical transmission and children mortality rates to estimate the number of infections in the 2007 and 2012 birth cohorts nationally and in four subnational regions. We estimated that 19 708 (95% uncertainty interval [UI]: 15 941-23 819) children were vertically infected by HCV in 2007 and 21 676 (95% UI: 17 498-26 126) in 2012. The majority of these cases (72.9% and 72.5% in 2007 and 2012, respectively) occurred in Punjab. We estimated that vertical transmission as a mode of exposure accounted for a quarter of HCV infections among children under 5 years of age (25.2% in 2007 and 24.0% in 2012). CONCLUSION: Our results showed that one in 260 children born in Pakistan in 2007 and 2012 acquired HCV vertically. While currently no interventions during pregnancy and childbirth are recommended to reduce this risk, prevention, testing and treatment strategies should be considered to reduce the burden of vertical HCV infections among young children. Other routes of transmission appear to contribute the majority of HCV infections among children and must also be clarified and urgently addressed

Reproductive and sexual health in the Maldives: analysis of data from two cross-sectional surveys

<p>Abstract</p> <p>Background</p> <p>The Maldives faces challenges in the provision of health services to its population scattered across many small islands. The government commissioned two separate reproductive health surveys, in 1999 and 2004, to inform their efforts to improve reproductive and sexual health services.</p> <p>Methods</p> <p>A stratified random sample of islands provided the study base for a cluster survey in 1999 and a follow-up of the same clusters in 2004. In 1999 the household survey enquired about relevant knowledge, attitudes and practices and views and experience of available reproductive health services, with a focus on women aged 15-49 years. The 2004 household survey included some of the same questions as in 1999, and also sought views of men aged 15-64 years. A separate survey about sexual and reproductive health covered 1141 unmarried youth aged 15-24 years.</p> <p>Results</p> <p>There were 4087 household respondents in 1999 and 4102 in 2004. The contraceptive prevalence rate (CPR) for modern methods was 33% in 1999 and 34% in 2004. Antenatal care improved: more women in 2004 than in 1999 had at least four antenatal care visits (90.0% v 65.1%) and took iron supplements (86.7% v 49.6%) during their last pregnancy. The response rate for the youth survey was only 42% (varying from 100% in some islands to 12% in sites in the capital). The youth respondents had some knowledge gaps (one third did not know if people with HIV could look healthy and less than half thought condoms could protect against HIV), and some unhelpful attitudes about gender and reproductive health.</p> <p>Conclusions</p> <p>The two household surveys were commissioned as separate entities, with different priorities and data capture methods, rather than being undertaken as a specific research study. The direct comparisons we could make indicated an unchanged CPR and improvements in antenatal care, with the Maldives ahead of the South Asia region for antenatal care. The low response rate in the youth survey limited interpretation of the findings. But the survey highlighted areas requiring attention. Surveys not undertaken primarily for research purposes have important limitations but can provide useful information.</p

Estimate of vertical transmission of Hepatitis C virus in Pakistan in 2007 and 2012 birth cohorts.

Despite a combination of high Hepatitis C virus (HCV) prevalence, a large adult population and high fertility, no published estimates of the scale and contribution of vertical transmission to HCV incidence in Pakistan exist. The objective of this study was to estimate the number of new HCV infections occurring in Pakistan as a result of vertical transmission. We adapted a published mathematical model based on HCV antibody and viraemia prevalence, fertility rates, risk of HCV vertical transmission and children mortality rates to estimate the number of infections in the 2007 and 2012 birth cohorts nationally and in four subnational regions. We estimated that 19 708 (95% uncertainty interval [UI]: 15 941-23 819) children were vertically infected by HCV in 2007 and 21 676 (95% UI: 17 498-26 126) in 2012. The majority of these cases (72.9% and 72.5% in 2007 and 2012, respectively) occurred in Punjab. We estimated that vertical transmission as a mode of exposure accounted for a quarter of HCV infections among children under 5 years of age (25.2% in 2007 and 24.0% in 2012). CONCLUSION: Our results showed that one in 260 children born in Pakistan in 2007 and 2012 acquired HCV vertically. While currently no interventions during pregnancy and childbirth are recommended to reduce this risk, prevention, testing and treatment strategies should be considered to reduce the burden of vertical HCV infections among young children. Other routes of transmission appear to contribute the majority of HCV infections among children and must also be clarified and urgently addressed

Clinical training alone is not sufficient for reducing barriers to IUD provision among private providers in Pakistan

<p>Abstract</p> <p>Background</p> <p>IUD uptake remains low in Pakistan, in spite of three major efforts to introduce the IUD since the 1960s, the most recent of these being through the private sector. This study examines barriers to IUD recommendation and provision among private providers in Pakistan.</p> <p>Methods</p> <p>A facility-based survey was conducted among randomly selected private providers who were members of the Greenstar network and among similar providers located within 2 Kilometers. In total, 566 providers were interviewed in 54 districts of Pakistan.</p> <p>Logistic regression analysis was conducted to determine whether correct knowledge regarding the IUD, self-confidence in being able to insert the IUD, attitudes towards suitability of candidates for the IUD and medical safety concerns were influenced by provider type (physician vs. Lady Health Visitor), whether the provider had received clinical training in IUD insertion in the last three years, membership of the Greenstar network and experience in IUD insertion. OLS regression was used to identify predictors of provider productivity (measured by IUD insertions conducted in the month before the survey).</p> <p>Results</p> <p>Private providers consider women with children and in their peak reproductive years to be ideal candidates for the IUD. Women below age 19, above age 40 and nulliparous women are not considered suitable IUD candidates. Provider concerns about medical safety, side-effects and client satisfaction associated with the IUD are substantial. Providers' experience in terms of the number of IUDs inserted in their careers, appears to improve knowledge, self-confidence in the ability provide the IUD and to lower age-related attitudinal barriers towards IUD recommendation. Physicians have greater medical safety concerns about the IUD than Lady Health Visitors. Clinical training does not have a consistent positive effect on lowering barriers to IUD recommendation. Membership of the Greenstar network also has little effect on lowering these barriers. Providers' barriers to IUD recommendation significantly lower their monthly IUD insertions.</p> <p>Conclusions</p> <p>Technical training interventions do not reduce providers' attitudinal barriers towards IUD provision. Formative research is needed to better understand reasons for the high levels of provider barriers to IUD provision. "Non-training" interventions should be designed to lower these barriers.</p

Does improving maternal knowledge of vaccines impact infant immunization rates? A community-based randomized-controlled trial in Karachi, Pakistan

<p>Abstract</p> <p>Background</p> <p>In Pakistan, only 59-73% of children 12-23 months of age are fully immunized. This randomized, controlled trial was conducted to assess the impact of a low-literacy immunization promotion educational intervention for mothers living in low-income communities of Karachi on infant immunization completion rates.</p> <p>Methods</p> <p>Three hundred and sixty-six mother-infant pairs, with infants aged <b>≤ </b>6 weeks, were enrolled and randomized into either the intervention or control arm between August - November 2008. The intervention, administered by trained community health workers, consisted of three targeted pictorial messages regarding vaccines. The control group received general health promotion messages based on Pakistan's Lady Health Worker program curriculum. Assessment of DPT/Hepatitis B vaccine completion (3 doses) was conducted 4-months after enrollment. A Poisson regression model was used to estimate effect of the intervention. The multivariable Poisson regression model included maternal education, paternal occupation, ownership of home, cooking fuel used at home, place of residence, the child's immunization status at enrollment, and mother's perception about the impact of immunization on child's health.</p> <p>Results</p> <p>Baseline characteristics among the two groups were similar. At 4 month assessment, among 179 mother-infant pairs in the intervention group, 129 (72.1%) had received all 3 doses of DPT/Hepatitis B vaccine, whereas in the control group 92/178 (51.7%) had received all 3 doses. Multivariable analysis revealed a significant improvement of 39% (adjusted RR = 1.39; 95% CI: 1.06-1.81) in DPT-3/Hepatitis B completion rates in the intervention group.</p> <p>Conclusion</p> <p>A simple educational intervention designed for low-literate populations, improved DPT-3/Hepatitis B vaccine completion rates by 39%. These findings have important implications for improving routine immunization rates in Pakistan.</p