RAF-RSPN Endline Report

1Addressing Delays for Access to EmONCin Non-LHW Areas of Pakistan

Removing the Three Delays in Access to

Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker

Programme

A RESEARCH REPORT

MAY 2014

2 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Co-InvestigatorDr. Muhammad Sarwat Mirza

May 2014 Rural support Programmes Network (RSPN). All rights reserved.

DECLARATION:

We have read the report titled ‘Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme’, and acknowledge and agree with the information, data and findings contained.

Principal InvestigatorBashir Anjum

Edited By: Umme-laila Hussain (RSPN Communications)

Design & PrintDOT Advertising

ACKNOWLEDGMENT STATEMENT:

‘Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme is a research project funded by the Maternal and Newborn Health Programme - Research and Advocacy Fund (RAF), and is implemented by the Rural Support Programmes Network (RSPN).

DISCLAIMER:

This document is an output from a project funded by the UK Department for International Development (DFID) and the Australian Department of Foreign Affairs and Trade (DFAT) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, DFAT or the Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF), which can accept no responsibility or liability for such views, for completeness or accuracy of the information, or for any reliance placed on them.

IMPLEMENTING PARTNERS:


Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan

not Covered by the Lady Health Worker Programme

A RESEARCH REPORT


ACKNOWLEDGEMENTS

We are thankful to our partners, the Thardeep Rural Development Programme (TRDP) and the Health

and Nutrition Development Society (HANDS), who were an integral part of this research project. The

programme staff of both these organisations deserves due appreciation. In addition, the People’s Primary

Healthcare Initiative, the District Health Departments and the management at the District Headquarter

hospital of Dadu made valuable contributions to the project. At the provincial level, the Director General of

Health Services, Department of Health, Sindh also extended support in overseeing the research project and

coordinating with health personnel at the district level, for which we are deeply grateful.

We were fortunate to have inputs from experienced health professionals and researchers; Dr. Shireen

Bhutta, from JPMC Karachi, Dr. Shaikh Tanveer Ahmed, CEO of HANDS, Mr. Zaffar Junejo, CEO of TRDP,

Dr. Huma Quraishi, Director of Pakistan Medical and Research Council, Dr. Zarifuddin Khan, National

Coordinator MNCH- WHO, General (Rtd.) Usmani, Professor of Reproductive Health at Sarhad University

Institute of Information Technology and Dr. Yasmeen Qazi, Senior Country Advisor to the David and Lucile

Packard Foundation, who were part of the Project Advisory Committee.

We would also like to acknowledge the efforts of our field team and research officers without whom we

would not have been able to complete the daunting task of data collection, documentation and analysis.

Apart from the authors, Ms. Shandana Khan, the Chief Executive Officer RSPN and Mr. Khaleel Ahmed

Tetlay, the Chief Operating Officer of RSPN enriched this research project and report with their valuable

input.

We thank the National Programme for Family Planning and Primary Healthcare and the Maternal, Neonatal

and Child Healthcare (MNCH) Programme for providing valuable input and coordination support at the

district and provincial levels.

Most of all we would like to express extreme gratitude to all the women and men of Khudabad and Kamal

Khan, Dadu, who participated in the project, spared their time and shared their experiences with us. A

research study like this is heavily indebted to the openness and honesty of the research participants as

their experiences make way for learning and policy change.


CONTENTS

1. Executive Summary 1

2. Introduction and Literature Review 7

2.1 Outline of this Research 8

2.2 Aims, Objectives and Outcomes 9

2.3 Research questions 9

3. Study Design and Methodology 11

3.1 Target Population 11

3.2 Sampling Methodology and Sample size 12

4. Results and Findings 17

4.1 Demographic and Household Characteristics 17

4.2 OBJECTIVE 1: Community Resource Persons - Awareness about

Health-seeking and EmONC 21

4.3 OBJECTIVE 2: Knowledge and involvement in decision

making and access to health facilities 28

4.4 OBJECTIVE 4 & 5: Village Health Committees – VHC, Community

based financing and Access to EmONC Services and Facilities 46

4.5 OBJECTIVE 6: Readiness of staff and supplies and uptake of services 53

4.6 Health Facility Audit 54

4.7 Predictors of Facility Based Deliveries 62

5. Summary, Discussion and Conclusions 65

5.1 Key Findings 65

5.2 Limitations 67

5.3 Lessons Learned 68

5.4 Recommendations 69

6. References 71

7. Appendices 74

7.1 Geographical location (Map of the area, highlighting project districts) 74

7.2 Women’s questionnaire (Quantitative Survey) 75

7.3 Birth audit questionnaire 99

7.4 Check list of Focus Group Discussions and Indepth Interviews 116

7.5 Focus Group Discussions and Indepth Interviews 117

7.6 CRP Model 119


LIST OF FIGURES

Figure 1: Inter-spousal communication for place of Delivery (Reported by Women) 30

Figure 2: Perceived Impact of Post-partum Danger Signs on a Woman’s Life (Reported by Wives) 34

Figure 3: Perceived Risks to the Life of a Newborn (Reported by Wives) 35

Figure 4: Comparison of place of delivery at baseline with program women (Khudabad) 41

Figure 5: Who conducted delivery 42

Figure 6: Comparison of outcome of delivery for women in baseline study with program women 42

Figure 7: CRP Visited (Reported by Women- Birth audit) 43

Figure 8: Received IEC Material (Reported by Women- Birth audit) 43

Figure 9: Information Gained from IEC Material (Reported by Women-birth audit) 43

Figure 10: Mechanism to Provide Financial Support (End line) 46

Figure 11: Knowledge of Community Mechanism to Provide Transport Support 47

Figure 12: Receive Community Support for EmONC Services 48

Figure 13: Avail VHC fund – Birth Audit (Reported by Women) 49

Figure 14: Mode of Transport – Birth Audit (Reported by Women) 50

Figure 15: Did you go to a Health Facility for a Post-partum Check-up (Reported by Wives) 50

Figure 16: Physical Examination within 24 Hours of Delivery (Reported by Women) 51

Figure 17: Women Who Were Examined Within the First Week (Reported by Women) 52

Figure 18: Display of Management and Clinical Protocols at BHU Aminani 56

Figure 19: Medicine supply and their storage in BHU Kamal Khan and Aminani respectively 57

Figure 20: Infant Weighing Scale at BHU Kamal Khan 58

Figure 21: Medical equipment at MCH Centre Khudabad 58

Figure 22: Record of supervisory visit by District Manager PPHI at BHU Aminani 58

Table 1: Sample Size – Quantitative Survey with Men and Women 12

Table 2: Sample Size – Qualitative Component 13

Table 3: Sample Size – Birth Audit 13

Table 4: Mean Age of the respondents 17

Table 5: Household Characteristics across the intervention and control arm at baseline and endline 18

Table 6: Distance to Health Care- across the intervention and control arm at baseline and endline 18

Table 7: Age and Reproductive History of Program Women (N=846) 17

Table 8: Poor outcome of last pregnancy (Abortion, still birth, neonatal death, physical & mental abnormalities etc) 19

Table 9: Mean Age and Income of recent mothers 19

Table 10: Education Level and Employment Status 20

LIST OF TABLES


LIST OF TABLES

Table 11: Reproductive History of Women (Birth Audit) 20

Table 12: Number of ANC Visits a Pregnant Woman Should Make - Wife and Husband – Endline 21

Table 13: Number of Antenatal Care Visits a Pregnant Woman Should Make (Reported by wives) 21

Table 14: Sources of Information Regarding Antenatal Care – Wives 22

Table 15: Sources of Information Regarding Antenatal Care: Husbands 22

Table 16: Important Components of ANC – Husbands’ and Wives’ Opinion 23

Table 17: Antenatal care visits (Reported by Women, Quantitative survey) 24

Table 18: Antenatal care Visits (Reported by Program women) 24

Table 19: Type of provider for antenatal care (Reported by Wives) 24

Table 20: Practice for Birth Preparedness (Reported by Wives) 25

Table 21: Source of Knowledge of Respondents Regarding Birth Preparedness – Wives 28

Table 22: Knowledge of Birth Preparedness (Reported by Wives) 29

Table 23: Preferred Place for Giving Birth (Reported by Wives) 29

Table 24: Number of Pregnancy Related Complications Known 30

Table 25: What Pregnancy Related Complications Wives Know About 31

Table 26: Source of Information for Complications during Delivery (Reported by Women) 32

Table 27: Knowledge of Complications that Can Occur During Delivery 33

Table 28: Recognition of danger signs for post-partum period – Wives 34

Table 29: Sources of Information about Danger Signs during the Post-partum Period (Reported by Wives) 35

Table 30: Most Important Things to do with a Newborn – Wives 36

Table 31: Danger Signs for a Neonate (Reported by Women) 36

Table 32: Understanding of Exclusive breastfeeding (Reported by Women) 37

Table 33: Source of Information about New-borns (Reported by Wives) 37

Table 34: Decision-makers to Seek Treatment (Reported by Women) 38

Table 35: Did not Seek Treatment (Reported by Women) 38

Table 36: Time Taken to Seek Healthcare (Reported by Wives) 39

Table 37: Reasons for Delay (Reported by Women) 39

Table 38: Where was Treatment Sought (Reported by Women) 40

Table 39: What Prompted to Seek Healthcare? (Reported by Wives) 40

Table 40: Reason for delivery at selected place (Reported by Women) 43

Table 41: Source of Information for Financial Support Mechanisms (End line) 47

Table 42: Type of Support from Community for EmONC Services (Reported by women, End line) 48

Table 43: Source of Funds – Wives 49

Table 44: Who Examined the Woman immediately after birth (Reported by Wives) 51

Table 45: Who Were They Examined By (Reported by Women) 52

Table 46: Time Taken to be Seen at a Health Facility (Reported by Women) 54

Table 47: Summary table for Health facility audit 55

Table 48: Predictors of Having Facility Based Deliveries – Program Data 62


LIST OF ABBREVIATIONS

ANC Antenatal Care

BHU Basic Health Unit

CMO Community Mobilisation Officers

CMW Community Midwives

CRP Community Resource Persons

CPR Contraceptive Prevalence Rate

DHQ District Health Quarter

DSM District Support Manager

EmONC Emergency Obstetric and Neonatal Care

FGD Focus Group Discussions

FMO Female Medical Officer

FP Family Planning

HANDS Health and Nutrition Development Society

IDI In Depth Interviews

IEC Information, Education and Communication

KAP Knowledge, Attitude and Practices

LHW Lady Health Workers

LSO Local Support Organisation

MDG Millennium Development Goals

MNH Maternal and Neonatal Health

MCH Maternal and Child Health

MWRA Married Women of Reproductive Age

NGO Non-Governmental Organisations

PNC Postnatal Care

PPHI People’s Primary Care Health Initiative

RAF Research and Advocacy Fund

RH Reproductive Health

RSPN Rural Support Programme Network

TBA Traditional Birth Attendant

THQ Tehsil/ Taluqa Health Quarter

TRDP Thardeep Rural Development Programme

UC Union Council

UCHC Union Council Health Committee

VHC Village Health Committee

WHO World Health Organisation


DEFINITIONS

ANTENATAL CARE

Antenatal refers to the period of pregnancy for a woman. Antenatal care includes medical check-ups to assess pregnant woman’s health status, identification of any maternal or child health risks; and counselling during pregnancy and for delivery. Important components of ANC include monitoring blood pressure, ultrasound, weight and examining for any other conditions that may put the mother and/or child at risk. The World Health Organization recommends a minimum of 4 ANC visits.

BIRTH PREPAREDNESS

Birth preparedness refers to the planning and management of maternal and child health from the beginning of the pregnancy till the child is born, as well as post-partum care for the mother and child. It involves making specific decisions regarding health seeking measures, finances, travel arrangements and any other unforeseen contingencies.

INFANT MORTALITY RATE (IMR)

Infant mortality rate is the number of deaths of children less than one year of age, per 1000 live births. The rate for a given region is the number of children dying under one year of age, divided by the number of live births during the year, multiplied by 1000.

NEONATAL

The neonatal period refers to the first 28 days of a child’s life after birth. During this period, the child is at risk and therefore requires extreme care.

NEONATAL MORTALITY RATE (NMR)

Number of deaths during the first 28 days of life per 1000 live births in a given year or period.

Neonatal deaths may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before the 28th day of life.

MATERNAL MORTALITY RATIO (MMR)

Maternal mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births

POSTNATAL / POST-PARTUM

Postnatal refers to the period after childbirth. Postnatal care includes care for both the mother and child after birth. Postnatal care is defined as the first 6 weeks after childbirth; and is considered critical for maternal and child health.

Early post-partum care is defined as health care provided to the woman within 48 hours of giving birth. In Pakistan, women hardly receive early post-partum care – the percentage being particularly low among poor and rural populations. Early post-partum care can save the lives of many women; while improving health of others.

STILLBIRTH

The definition recommended by WHO is a baby born with no signs of life at or after 28 weeks’ gestation.


1. EXECUTIVE SUMMARY

BACKGROUND

Pakistan with its current population of more than 180 million is the sixth most populous country in the world and fourth in Asia. Approximately two-thirds (65%) of the population is located in rural areas. Demographic trends indicate a continuously increasing growth in population. Presently the population growth rate is 1.9 per cent per annum. Pakistan’s population growth rate is thus very high as compared to 0.1 per cent for more developed countries. The Maternal Mortality Ratio (MMR) is 276 per 100,000 live births. The under 5 mortality rate is 89 per thousand live births, infant mortality rate is 72 per thousand live births and neonatal mortality rate is 54 per thousand live births. These figures are far higher in rural than in urban locations. Despite the deployment of a very large work force of Lady Health Workers (LHWs), 35% of the rural areas across the country remain un-served. The non-availability of LHWs in these areas is compounded by extreme poverty which further limits the access to essential health services.

METHODS

RSPN in collaboration with HANDS and TRDP implemented a one year intervention in a non-Lady Health Worker covered area by attempting to reduce the delays in utilising emergency obstetric care that are known to contribute towards maternal mortality. The main interventions were community mobilisation through Community Resource Persons (CRPs) to address the first delay (male CRPs for male segments of the population and female CRPs for women), formation of Village Health Committees (VHCs) and the establishment of a transport fund and arrangement of vehicular transport for complicated delivery cases to address the second delay. The training and equipping existing public sector health facilities to address the third delay was a common component in both intervention and control areas. The intervention commenced in May 2012 (with the exception of the transport fund that was operationalised in November 2012) and continued until June 2013. The project research utilised mixed research methodologies to achieve the project objectives. The various approaches used for this project included

1. Baseline and end line quantitative surveys of MWRAs and their husbands to compare project intervention areas with non-intervention areas.

2. Pre-post quasi experimental design in the intervention areas with follow-up of enrolled participants. The participants were enrolled during pregnancy and follow-up was completed till the time of delivery and first post-natal and neonatal check-up during the first week postpartum.

3. A birth-audit survey for a subset of women (who had given birth during the last one year) as a mid-term assessment of project interventions in the intervention and non-intervention area.

4. Health facility audit to ascertain the functionality with reference to staff, infrastructure, services, equipment and materials, reporting and recording mechanism and facilities/amenities availability.

Qualitative focus group discussions and in-depth interviews were conducted with MWRAs, husbands, TBAs, VHCs, village influencers and elders in the family. Two union councils in Dadu were selected – UC Khudabad and UC Kamal Khan. The intervention area was the non-LHW covered rural population of UC Khudabad of district Dadu which had an estimated population of 27,188. The non-intervention UC Kamal Khan was also located in district Dadu and has an estimated 32,452 non-LHW covered population. The project compared two socio-demographically similar communities to see if the interventions increased skilled birth attendance through facility based deliveries or improved the uptake of EmONC in the intervention community (Khudabad) as compared to the non-intervention community.


RESULTS

CRPs and Knowledge Enhancement

CRPs were effective in raising the knowledge of communities regarding antenatal care. When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). Regarding the components of antenatal care, husbands in Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed. Regarding the number of antenatal care visits, the base line and end line data comparison revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The programme data revealed that 92% of the program women had one antenatal check-up; 86%, 73% and 57% had a second, third and fourth antenatal visit. The CRPs visited nearly 91% of the households and were cited as the main source of information in intervention UC at the end line for antenatal care by 41% of the women and 35% of the husbands. The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to base line. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The CRPs helped to increase awareness regarding complications during pregnancy among husbands from 36% to 79% (an increase of 43%) and from 83% to 94% among women. With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications such as severe bleeding, convulsions, high fever, loss of consciousness, labour period longer than 12 hours and un-delivered placenta when compared to base line. When the women were inquired about the source of information for complications during delivery it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by trained health care providers (11%).

Wives in Khudabad demonstrated an increase in their ability to recognise danger signs such as bleeding, blurred vision, convulsions, difficulty in breathing, severe weakness, severe abdominal pain and difficulty in breathing during the post-partum period. The perceived impact of post-partum danger signs on women’s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad. The most common sources of information regarding danger signs during the post-partum period in Khudabad was family elders at base line, however, CRPs emerged as an important source of information at the end line. The perceived risk to the life of newborn increased from 76% at base line to 94% at end line among women in Khudabad. The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination; avoid feeding food, initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth. The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessively crying were correctly identified as signs of danger. The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% at end line, suggesting that children should only be breastfed for first six months of life.

CRPs and Health Care Use

As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. With regards to the decision makers to seek treatment, there was considerable increase in the proportion of women in Khudabad who were engaged in decision making at end


line (10% at base line to 39% end line). The time taken to seek health care showed improvement for women in Khudabad with almost three-fifths seeking health care immediately (59%) at end line compared with 50% at base line. The utilisation of public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/clinic remained the most sought health providers both at base line and end line. The place of delivery for last pregnancy among women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at public sector health facility. Comparing with programme data, a higher proportion of women (24%) gave birth at a public sector health facility while 28% delivered at home. The programme data for women revealed that for around 66% women, delivery was conducted by skilled health provider. For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed by advice from family, confidence in provider, costs and advice from provider. Around one-fifth of the women (22%) and husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line.

Village Health Committees and Transport Mechanism

A considerably higher proportion of women and their husbands (43% & 47% respectively) had knowledge of the community mechanism to provide transport support in Khudabad at end line compared to the base line (4% & 9%, respectively). A higher proportion of husbands (33%) in Khudabad received community support for EmONC services when compared with base line (23%). Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%). Around 28% of the women at base line in Khudabad went to a health facility for post-partum check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high during end line assessment. The overall trend remained the same for Khudabad at base line and end line with most of the women being examined immediately after birth by lady doctors and TBAs. However, there was an improvement in the proportion of women examined by trained TBAs from 0% at base line to 6% at end line. Regarding postnatal care, around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line.

Health Facility Audit

A third component of the intervention attempted to reduce the delays at health facilities and provided some basic medical equipment to public sector health facilities as well as training paramedical staff and TBAs. The operational hours of the MCH centre were extended from 2 pm to 8 pm. The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as the provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times. However, the qualitative findings repeatedly revealed high absenteeism, vacancies of key paramedical staff and unpleasant staff attitudes, especially towards the poor, as a major deterrent to institutional births. Community members frequently complained of poor treatment, being yelled at or scolded or being asked for a reference before they were treated adequately. The project however had little control over these problems.

Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. It was found that the use of vehicles arranged through the VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery.


CONCLUSIONS AND RECOMMENDATIONS

The project intervention period was very short while significant changes in behaviours require continuous long term efforts and repeated positive reinforcements through success stories and realisation of ‘good’ outcomes. Furthermore, in working with poor communities, the biggest challenge is to provide cost-effective and user-friendly solutions to problems. Going forward, communities should be more integral to the design of such interventions and the duration of interventions that seek to change behaviours should be longer – several years as was seen in the case of the Matlab project in Bangladesh. Another key aspect of the intervention may be to use VHCs as means to provide oversight over public sector facilities that are meant to serve communities. Based on the research findings, the CRP model has shown effectiveness in mobilising communities in non-LHW covered areas to seek institutional healthcare. CRPs are an effective, community based solution for providing EmONC information and referrals to rural communities. As their monthly honorarium is one-sixth of the LHW salaries, the government and donors can use CRPs as an alternate to LHWs in un-covered areas till the government is able to deploy LHWs.


2. INTRODUCTION AND LITERATURE REVIEW

Pakistan has some of the highest maternal and neonatal mortality rates in the world. Despite a considerable investment of resources over the past decades, these rates have not improved sufficiently. While most interventions have been facility based and largely in the public sector, it appears that many of the factors that underlie this high mortality are social and have their roots in communities. It is well known that despite the presence of an extensive network of nearly 15,000 public sector health facilities, women turn to these for fewer than 10% births2.

Maternal and Neonatal Mortality in a Global Context

Worldwide, more than 800 women die daily during pregnancy or childbirth. In fact, the average lifetime risk of a woman from a developing country dying from complications related to pregnancy or childbirth is over 300 times greater than for women from developed countries (State of the World’s Children, UNICEF 2009). Most such deaths would be preventable if critical but often ordinary resources were available. In particular, poverty – which restricts access to health services - adversely impacts maternal and neonatal health. For example, in Pakistan neonatal mortality is about 55% higher for the poorest as compared to the richest quintiles3 and similar inequalities also affect maternal health4.

Beyond poverty, factors such as distance to healthcare facilities, lack of information and poor quality of services, the perception among poor people that they will be treated shabbily at health facilities and cultural barriers to health seeking limit women’s access to health services5;6. Sixty percent of the world’s births still take place without a skilled birth attendant, usually with Traditional Birth Attendants (TBAs), who are a common in rural communities; but also have poorer maternal outcomes due to unhygienic practices, inability to handle complications, lack of professional training and poor medical knowledge7-9. However, the absence of viable options such as quality professional providers and high costs force women in communities to seek these TBAs; and weak referral mechanisms further delay seeking of life saving emergency obstetric and neonatal care (EmONC) until it is too late.

The Situation in Pakistan

In Pakistan maternal mortality is 276 per 100,000 live births and neonatal mortality is 54 per 1,000 live births. This situation is graver for rural areas – that comprise nearly two-thirds of the Pakistan’s population – where the MMR is 319, in contrast to 175 for urban areas1. The effects of rural poverty are further aggravated by socio-cultural norms, lack of female empowerment, male control of key assets and decision-making that limit a woman’s ability to negotiate for better health services or access services without their spouse’s consent10. Pakistan has made insufficient progress in reducing maternal mortality (MDG 5)11. The Lady Health Worker Programme was initially created to promote maternal health and family planning, but over the years has seen an expansion in the tasks assigned to LHWs and simultaneously diminishing efficacy at meeting reproductive health goals. Furthermore, the programme only covers around 65% of the country, and among the population that remains uncovered by the programme are the extremely poor, living in remote rural locations. The government then created a cadre of community midwives to provide skilled birth attendance to rural homes. However, poor planning, management and accountability have led to a largely ineffective programme. Similarly a number of donor funded programmes have also been implemented in various regions across Pakistan; however, there is no evidence that they have impacted maternal or neonatal mortality on the whole.


The Three Delays Model and the need for EmONC

Among women who die during maternity, most do so due to delays in seeking care12. These delays occur 1) in deciding to seek medical care when a woman encounters complications during pregnancy or labour, 2) during transport to a healthcare facility and 3) in receiving adequate and appropriate treatment once at a healthcare facility. These delays are grounded in socio-cultural structures, poverty, political will and institutional capacities of the healthcare system10.

In addition to the three delays it is recognised that once complications arise during pregnancy or labour, in some women they will progress rapidly to become severe and life threatening and that it is often difficult to predict which woman will encounter these complications. Hence, the concept of emergency obstetric and neonatal care (EmONC) services was developed so that these women can receive emergency care by a trained provider as needed and there should be provisions made to transport women to higher level facilities should the need arise13.

Numerous interventions to reduce three delays in access to EmONC have been devised and implemented globally. These interventions range from capacity building initiatives in local communities, improving access to skilled health care and service quality, promoting facility based births, providing transport facilities and scaling up of services. These interventions have included training of TBAs who far outnumber other providers7 and have had a moderately successful record in some developing countries14;15. However other evidence suggests that TBAs perhaps never unlearn their old ways and therefore there has been a shift16

to other cadres such as community midwives (CMWs) who receive more extensive training. Other means to improve maternal mortality have included improved referral systems so that women are transported to facilities on time17;18. This in turn has been one of the best options since improved access – which includes readily available means of transport - to well-equipped hospitals has reduced maternal mortality19-27.

Examples of other Community Based Initiatives

In Pakistan, over the past few years NGO driven initiatives have explored novel ways of improving access to maternal and child health and family planning or birth spacing services in remote rural areas that are not covered by LHWs. In the Marginalised Areas Reproductive Health and Family Planning Viable Initiatives (MARVI), conducted in non-LHW covered areas of district Umerkot by HANDS and the Thardeep Rural Development Programme, community-based MARVI workers mobilised communities and provided subsidised services and referral for reproductive health (RH) and family planning services. It resulted in an increase in Contraceptive Prevalent Rate (CPR) from 7% to 31% in a period of 5 years and a skilled birth attendance rate of 48%. Similarly the Rural Support Programmes Network (RSPN) carried out a project in non-LHW covered areas across 10 districts of Sindh where CRPs created awareness among the men and women of reproductive age about birth preparedness, antenatal care, danger signs during pregnancy and delivery, neonatal care, prevention of diarrhoea and pneumonia, immunisation and birth spacing. In the USAID funded Family Advancement for Life and Health (FALAH), the RSPN used a similar approach to help increase CPR from 14 to 36%. In the USAID funded PRIDE project, Health Management Committees (HMCs) were formed around each health facility in district Mansehra and Bagh; which raised awareness for health issues in the local communities, oversaw the functions of facilities and saw considerable improvements in the quality and uptake of services.

2.1 OUTLINE OF THIS RESEARCH

For this study the research team conducted operational research to address issues related to three delays in


remote rural areas that are not covered by the LHW programme. The intervention was at three levels. First, male and female CRPs were trained to mobilise the communities. This mobilisation included formation of Village Health Committees and the institution of a community financed transport fund. The research team worked with local public sector facilities to upgrade their equipment, train their providers and to open their services for a second shift, i.e. from 8am to 8pm, rather than the customary 8am to 2pm. Finally CRPs worked with the community to provide health messages about recognising dangers during pregnancy and labour and to promote facility births. The team also trained local TBAs to recognise danger signs during pregnancy and to refer women to health facilities. The overall design was a quasi experimental community based study. The union council Khudabad was selected in the district Dadu because of its remoteness. UC Kamal Khan – also from district Dadu - was selected as control as it had similar indicators and health services profile and was not geographically contiguous. It is noted that following selection of the sites, Kamal Khan received a number of NGO interventions and experienced an improvement in its health profile.

2.2 AIMS, OBJECTIVES AND OUTCOMES

The aims of this project were:

• To develop and demonstrate a community based intervention model to remove the three delays in access to EmONC in areas not covered by LHWs.

• To generate robust evidence to push for the scale-up of proven, cost effective community based interventions with a focus on improving EmONC services and access for poor and marginalised communities in non-LHW covered areas.

2.3 RESEARCH QUESTIONS

Q 1. Do training community-level volunteers as Community Resource Persons improve awareness for health-seeking among married couples of reproductive age regarding EmONC?

Q 2. Does the knowledge and awareness of women, husbands and community members improve women’s involvement in decision-making and their mobility to access health facilities?

Q 3. Does the presence of trained Community Resource Persons contribute to timelier referral of complicated deliveries, or at least increase deliveries in facilities?

Q 4. Does a community support mechanism in the form of a Village Health Committee (VHC) increase access to EmONC services/facilities?

Q 5. How effective are community based financing mechanisms (such as community saving schemes to cover cost of transport) in improving access to facilities for complicated deliveries?

Q 6. Do Community Resource Persons help improve neonatal care practices?

The main outcomes of interest was improved skilled birth attendance or facility based deliveries


3. Study Design and Methodology

The present intervention project research utilised mixed research methodologies to achieve the project objectives. The various approaches used for this project included:

1. Base line and end line quantitative surveys of MWRAs and their husbands to compare project intervention areas with non-intervention areas.

2. Pre-post quasi experimental design in the intervention areas with follow-up of enrolled participants. The participants were enrolled during pregnancy and follow-up was completed till the time of delivery and first postnatal and neonatal check-up during the first week postpartum.

3. A birth audit survey for a subset of women (who had given birth during the last one year) as a mid-term assessment of project interventions in the intervention and non-intervention area.

4. Health facility audit to ascertain the functionality with reference to staff, infrastructure, services, equipment and materials, reporting and recording mechanisms and facilities/amenities availability.

Qualitative focus group discussions and in-depth interviews with MWRAs, husbands, TBAs, VHCs, village influencers and elders in the family. Two union councils in Dadu were selected – UC Khudabad and UC Kamal Khan. The intervention area was the non-LHW covered rural population of UC Khudabad of district Dadu which had an estimated population of 27,188. The non-intervention UC Kamal Khan was also located in district Dadu and has an estimated 32,452 non-LHW covered population.

The interventions component of the project had the following key components:

1. Community mobilisation to address the causes of the first delay

2. A community support mechanism in the form of Village Health Committees to ensure transport to health facilities in emergency cases to address the causes of second delay

3. Training of health care providers to ensure delivery of quality EmONC services to address the third delay (common in both areas)

The project compared two socio-demographically similar communities to see if the intervention increased skilled birth attendance through facility based deliveries or improved the uptake of EmONC in the intervention community (Khudabad) as compared to the non-intervention community.

3.1 TARGET POPULATION

The target population were Married Women of Reproductive Ages (MWRAs) residing in the intervention (Khudabad) and non-intervention (Kamal Khan) UCs of district Dadu, located in the province of Sindh. Based on available demographic data, approximately 3,000 MWRAs were anticipated in both the intervention and non-intervention areas. Among these only MWRAs with children under the age of 3 years were recruited in the sampling, to address information accuracy and recall bias. For the birth audit, the target population was MWRAs who had given birth in the past 12 months.

In addition to this, regular programmatic data were collected and validated throughout the intervention period. This was done through referral slips which were given to the Community Resource Persons (CRPs), which they would use to refer pregnant women to health facilities. Each referral slip had three parts; one for the client (i.e., the pregnant woman), the second to be given to the project’s community mobilisation officers (CMOs) and the third to be retained by CRPs. CMOs would collect these slips from each CRP on a weekly basis, after which the project’s research officers would visit the health facilities and meet with healthcare providers to track whether the referred clients had actually visited the facilities. Additionally, the research officers validated 5% of all clients (selected randomly) who availed services from health facilities through an interview and by tallying information with the CRP record.


3.1.1 Census of both Union Councils

To have an updated sampling frame the research team conducted a brief but universal activity in the selected union councils. The census focused on updating information from both union councils of neonates, children under the age of 3 and 5 years, maternal deaths, neonatal deaths and total households in the village/UC.

3.2 SAMPLING METHODOLOGY AND SAMPLE SIZE

There were 4 components in this study. The primary household survey sampling was done to detect a difference in facility births of 5%. Systematic sampling strategy with a simple random start was conducted to identify eligible women for the quantitative survey from a list of all eligible women in each of the union councils (the universe), to give a sample size of 389 women per UC and their respective husbands. We oversampled this number to include 550 women in order to have power for some sub-analyses. The household rosters of the project were used to list all households in each of UC and then divided them with sample size (n=550) to achieve the interval k. The first household was selected through simple random selection approach, and every kth household was approached for recruitment. If more than one eligible woman was encountered within a household, the first one was recruited. If there were no eligible women in that household, the house to its right was approached but the sampling frame resumed with the next kth household on the original list (i.e. the enumerators did not “frame-shift” if they had to resort to an alternative household).

The birth audit was meant to provide supporting, in depth evidence for key variables. Since the research team had maintained a list of all births occurring in the area, every third birth was selected for the birth audit using the random number generator function in Microsoft Excel.

For the qualitative assessment, respondents were recruited based on identification by key informants.

3.2.1 Base line Survey

After receiving the census data, the sampling frame was used to interview at least 550 couples from each union council, i.e. a total of 1100 participants (550 male and 550 female) from each UC.

Table 1: Sample Size – Quantitative Survey with Men and Women

Union Council Interview Category Target Interviews Achieved Target

Khudabad Male 550 475

Female 550 536

Total 1100 1011

Kamal Khan Male 550 526

Female 550 559

Total 1100 1085

The qualitative study set was planned separately to cover those villages where the number of maternal or neonatal deaths was high. For in-depth interviews, at least 5 people were targeted from each group i.e. women, in-laws, health care providers and local influential/political leaders/ social workers.


Table 2: Sample Size – Qualitative Component


Kamal Khan FGDs 14 14

IDIs 30 36

Total 44 50

Khudabad FGDs 14 14

IDIs 30 30

Total 44 44

3.2.2 Birth Audit

As per the given sampling frame, birth audit interviews were only conducted with mothers who had given birth in the past year. Details of the sample are given in Table 3.

3.2.3 Health Facility Audit

An audit was conducted of the BHUs in Kamal Khan, BHU Aminani and the MCH centre from Khudabad, as well as the district headquarters hospital Dadu.

3.2.4 Data Collection Tools

Data collection tools were prepared and finalised with inputs from the donor agency. All tools were pre-tested and changes incorporated. The tools were translated into the local language, which was Sindhi. All interviews were also conducted in the local language except for the health facility audit which was conducted in Urdu.

The quantitative household survey tool included questions on socio-demographics, birth preparedness and antenatal care, skilled care at birth, skilled care for obstetric emergencies, post-partum and neonatal care and community support for obtaining emergency services. The birth audit similarly captured information on household characteristics, knowledge, attitude and practices regarding pregnancy, antenatal care, delivery location and procedures, postnatal care and decision-making.

The qualitative tools gathered detailed and in-depth insight on delivery practices, knowledge about EmONC services, skills of health facility staff and community support mechanisms. Probes were used for each of the identified themes to congregate complete information and achieve saturation.

The health facility audit tool was adapted from an instrument developed by the WHO

Table 3: Sample Size – Birth Audit


Kamal Khan Women only 150 157

Khudabad Women only 150 150

Total 300 307


3.2.5 Data Management

Data for all components of the project were collected on paper based forms. To computerise the quantitative forms, separate study specific data entry programs were developed in Epi Data software for each quantitative component of the project. Data from the paper based forms were computerised through a team of data entry operators. After computerisation, the data was coded, labelled, edited and cleaned by preparing a .dbf format file and exporting it into SPSS version 20 software. Completion of data entry was followed up with logical editing and cleaning of the dataset. This was done through execution of frequencies and cross-tabulations in SPSS version 20 software. Standard data management practices to deal with outliers and missing values were adopted to ensure completeness of the dataset. The same software was used for analysis of data.

The qualitative information was translated into English and transcribed. Transcription was done under identified analysis themes in-line with the project objectives. Matrices were developed for the devised themes and the findings were summarised under each theme.

The quantitative and qualitative data was analysed and triangulated based on key variables that included knowledge and practices regarding ANC, birth preparedness, safe birthing, neonatal care and postnatal care. The role of CRPs and VHCs was particularly assessed for creating awareness and reducing delays in access to EmONC.

3.2.6 Quality Assurance Mechanisms

To ensure the data’s quality, the following steps were taken during the data collection process:

3.2.6.1 Hiring and Training of Enumerators

A total of 22 male and 22 female enumerators and 8 supervisors were hired through an interview process which was conducted by research team in Dadu. This team was then trained over a period of 4 days, where they were oriented on the background and objectives of the research, and the use of the quantitative and qualitative survey tools. During the training, the enumerators conducted practice interviews with each other and then in the field, after which each enumerator was evaluated.

3.2.6.2 Monitoring of the Survey

The data collection process was monitored by two research officers, two monitoring officers and a research quality coordinator, all of whom accompanied the research teams in the field and provided support when needed. In addition, the information on the qualitative and quantitative survey forms was verified by re-visiting respondents on a random basis.


3.2.7 Research Objectives and Methodological Approach

The following tools were used for acquiring information and analysis:

3.2.8 End Line Evaluation

Similar to the base line survey, a detailed quantitative survey was conducted to assess the change in key variables of interest across the intervention and non-intervention areas. The end line survey similar to the base line carried the same sample size and the same quantitative questionnaire and sampling methodology.

3.2.9 Analysis of Qualitative Data

Qualitative data was analysed using qualitative content analysis. The data was transcribed from field notes by interviewers as well as from verbatim transcripts (translated from Sindhi to Urdu by professional translators) and then analysed for significant themes that were identified with particular reference to each of the groups and keeping in mind the overall study objective of identifying information about reproductive health practices in the community. Both ‘manifest content’ (visible, obvious components) and ‘latent content’ (underlying meaning) of the text were analysed.

The transcripts were read several times to understand in depth the respondents’ life experiences, their views on their preparation for and knowledge about RH, MNCH, family planning and child bearing activities. ‘Meaning units’ that mirror statements, were then identified as per topic guides, by highlighting phrases in the transcripts which were ‘condensed’ and thereafter ‘codes’ were identified from the ‘condensed meaning units’ without losing the context.

Research Question Survey Tools of Analysis

1. Does training community-level volunteers as community resource persons improve awareness for health-seeking among married couples of reproductive age regarding EmONC?

Quantitative Household survey

Frequencies; Cross-tabulations

2. Does the knowledge and awareness of women, husbands and community members improve women’s involvement in decision-making and their mobility to access health facilities?

Quantitative Household survey

Birth Audit

Qualitative survey


Thematic analysis

3. Does the presence of trained community resource persons contribute to timelier referral of complicated deliveries, or at least increase deliveries in facilities?

Quantitative

Household survey

Birth Audit


Multivariate Regres-sion Analysis

4. Does a community support mechanism in the form of a Village Health Committee (VHC) increase access to EmONC services/facilities?

Quantitative

Household survey

Birth Audit

Qualitative survey


Thematic analysis

5. How effective are community based financing mechanisms (such as community saving schemes to cover cost of transport) in improving access to facilities for complicated deliveries?

Quantitative

Household survey

Birth Audit

Qualitative survey


Thematic analysis

6. Do community resource persons help improve neonatal care practices?

Quantitative

Household survey

Qualitative survey


Thematic analysis


Finally, the research team reviewed the codes independently and grouped similar codes into sub-categories and categories. From the categories theme and sub-themes were identified after systematically analysing the commonalities, variations and disagreements of the researchers. The data was further analysed with a focus on the description and interpretation of message meaning and concepts30 for a richer perspective of how individuals receive and process information and use it at individual and group level.

3.2.10 Analysis of Quantitative Data

The data analysis for the quantitative component included descriptive and inferential analyses. In descriptive analysis frequencies, proportions and means with standard deviations were derived to understand and describe the survey participants and their characteristics. The second stage of analysis included deriving inferential statistics involved multivariate regression modelling to derive the predictors for main outcome of interest (i.e. skilled birth attendance/institutional deliveries) for key variables in relation to plausibility and objectives of the study.


4. RESULTS AND FINDINGS

The quantitative survey was based on two samples. The primary sample included women and their husbands who had a child in the past three years to record their knowledge, attitudes and practices. The birth audit sample was based on women who had given birth in the past one year to explore the most recent behaviours and birthing practices after the intervention in Khudabad and the comparative performance in Kamal Khan (control UC). Only women who had delivered in the past one year were surveyed to minimise recall bias. The sample size for the birth audit was around 150 women. The end line survey similar to the baseline targeted to interview women and their husbands at end line.

4.1 Demographic and Household Characteristics

4.1.1 Quantitative Household Survey

The base line and end line quantitative surveys included women who gave birth to a child in past 3 years and their husbands. Most respondents were in their early thirties, with mean age difference of 1 year observed between the husband and wife. The overall prevalence of formal schooling was low and commonly up to primary education level among husbands, while it was much lower among women.

Table 5 shows the key household characteristics of both the intervention (Khudabad) and non-intervention (Kamal Khan) UCs when the base line and end line surveys were conducted. The mean monthly income of the respondents in the end line study was PKR 8, 873 and PKR 8,096 in Khudabad and Kamal Khan respectively. Most of the houses in end line study in Khudabad (74%) and Kamal Khan (82%) were made of bricks (un-plastered). The proportion of households with a latrine facility increased from base line in both the intervention and control arm of the study. More than one third of the households in both Khudabad (36%) and Kamal Khan (35%) practiced open defecation. When compared with the base line, the practice of open defecation decreased in both the intervention and control arms of the study.

Base line End line

Khudabad Kamal Khan Total Khudabad Kamal Khan Total

Husband 33.9 35.7 34.8 33.5 32.5 33.0

Wife 28.7 30.4 29.6 31.4 33.0 32.3

Table 4: Mean Age of the respondents


The distance from the health facility at end line decreased in Khudabad compared to base line; a higher proportion of households (58%) reported to be residing within 5 kms of a health facility. A similar pattern was observed for distances to TBA with majority of the respondents (88%) reported to have TBA within a vicinity of 5 kms. In the control UC (Kamal Khan), the distance from the health facility increased compared to base line with 61% of the households reported to have health facility at a distance more than 5 kms. However, the availability of the TBA within 5 km of the household increased from base line.

4.1.2 Demographic and Reproductive History of Programme Women

The mean age of the women enrolled in the intervention program was 28 years ± 5 years. The mothers included in the program had a mean number of 2.5 children and a maximum of 12 children. The mean number of pregnancies was found to be 3.12±2.71. The mean number of abortions was found to be 0.63±1.18.

Base line End line

Khudabad (N=1018)%

Kamal Khan (N=1132)%

Khudabad (N=1013)%

Kamal Khan (N=1090)%

Mean Monthly Income (PKR) 8,147 6,324 8,873 8,096

Houses with Mud Walls 2 4 0 2

Houses with Thatch Walls 1 3 0 0

Houses Made of Wood 34 57 34 54

Brick/Un-plastered Houses 74 76 74 82

Brick and Cement 20 7 25 16

Household ownership 96 97 97 98

Flush/Pit latrine 53 42 64 65

Open Defecation 45 57 36 35

Have a Radio 7 6 8 7

Have a Television 56 36 67 52

Own Livestock 40 66 80 84

Table 5: Household Characteristics across the intervention and control arm at baseline and end line

Base line End line

Khudabad (N=1018)

Kamal Khan (N=1132)

Khudabad (N=1013)

Kamal Khan (1090)

Health Facility<5km 52 46 58 39

>5km 48 54 42 61

TBAs<5km 71 69 88 82

>5km 29 31 12 18

Table 6: Distance to Health Care- across the intervention and control arm at base line and end line


VARIABLE STATISTIC

Age (in Years)

Minimum 17

Maximum 47

Mean (Std. Dev, Confidence Interval (CI) 27.79 (5.367, CI 27.44 to 28.13)

No. of Live Children

Minimum 0

Maximum 12


No. of previous pregnancies

Minimum 0

Maximum 16


No .of Abortions

Minimum 0

Maximum 12


Table 7: Age and Reproductive History of Programme Women (N=846)

With regards to poor pregnancy outcome (abortion, still birth, neonatal death, physical & mental abnormalities) in the past, it was found that almost one-fifth (19.8%) of the programme women had a poor outcome.

4.1.3 Birth Audit

The birth audit was specifically conducted among women who had given birth in the past 12 months. The mean age of women included in the birth audit was around 29.6 years; while the mean age of their husbands was 35 years. Most of these women had been married for 10 years on average. The average household incomes were low, and commonly reported to be hardly enough to cover basic household expenses.

Table 8: Poor outcome of last pregnancy (Abortion, still birth, neonatal death, physical & mental abnormalities etc)

# %

No 567 65.6

Yes 171 19.8

DNK 126 14.6

Total 864 100.0

Khudabad (N=150) Khudabad (N=150)

Mean Std. Dev Median Mean Std. Dev Median

Woman's Age 29.6 6.2 29 29.7 6.5 29

Husband's Age 34.4 7.2 34 34.2 7.6 33

Duration of Marriage 9.7 6.2 9 9.9 6.3 8

Household Income 6,722 4,974 6,000 6,125 6,525 5,000

Table 9: Mean Age and Income of recent mothers


Focus on girls’ education was poor in both UCs. With limited financial resources in the family and the prevailing culture, less than 20% of the women had ever gone to school in both Khudabad and Kamal Khan. More men had attended regular school.

The women in the sub-sample were all housewives; while men generally were labourers, farmers or land owners indicating that the population primarily relied on agricultural income. Agricultural income is by nature unstable and periodic, leading to low average monthly incomes.

The women in the sub-sample were all housewives; while men generally were labourers, farmers or land owners indicating that the population primarily relied on agricultural income. Agricultural income is by nature unstable and periodic, leading to low average monthly incomes.

The birth audit revealed that the women on average had been pregnant at least 3-4 times and had experienced at least one stillbirth in the past. The majority of women in the birth audit indicated full term (i.e. around 37 weeks of gestation) for their last pregnancy and the labour durations were normal (i.e. when considered to be less than 12 hours). ANC visits had declined from 5 to 4 at end line.

Khudabad(N=150) %

Kamal Khan(N=157) %

Regular Schooling - Women 19% 14%

Regular Schooling – Men 59% 44%

Employment Status - Men

Unemployed 2% 6%

Land Owner 13% 17%

Farmer 26% 30%

Office Worker 3% 1%

Government Servant 6% 1%

Small Business Owner 7% 6%

Labourer 37% 37%

Other 7% 3%

Table 10: Education Level and Employment Status

Number of Khudabad Base

line (N=130)

Khudabad End line (N=150)

Kamal Khan Base line (N=128)

Kamal Khan End line (N=156)

Mean(+ St. Dev)

Mean(+ St. Dev)/ Median

Mean(+ St. Dev)

Mean(+ St. Dev)/Median

Number of pregnancies 3.4 (+ 2.5) 3.4 (+ 2.9)/ 3 3.6 (+ 2.7) 3.4 (+ 2.7)/3

Number of stillbirths 1.3 (+ 0.5) 1.4 (+ 0.5)/1 1.6 (+ 0.7) 1.4 (+ 0.8)/1

Number of antenatal/ during pregnancy visits 5.2 (+ 2.9) 4.4 (+ 2.2)/4 5.1 (+ 2.4) 4.1 (+ 2.6)/3

Table 11: Reproductive History of Women (Birth Audit)


4.2 OBJECTIVE 1: Community Resource Persons - Awareness about Health-seeking and EmONC

4.2.1 Knowledge about Antenatal Care

When inquired about the number of antenatal care visits pregnant women should make, it was found that majority of women and their husbands in both intervention and control UCs suggested that pregnant women should go for at least 3-4 visits. As compared to men, more women suggested more than 4 antenatal visits.

When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). The control UC (Kamal Khan) also showed slight improvement in this regard, with proportion of women who suggested to having more than 4 antenatal visit increasing from 23% at base line to 25% at end line.

The base line and end line comparison for Khudabad showed a marked increase in the proportion of women who reported CRPs as a source of information regarding antenatal care (1% at base line and 41% at end line). There was a decrease in proportion of women who had no source of information at end line (4%) compared to base line (19%). The proportion of women who got information from a trained health care provider also

Khudabad Kamal Khan

Husband (N=500)

(N=513) Wife (N=521)

(N=569)Husband Wife

# % # % # % # %

At least One 2 0 4 1 5 1 3 1

At least two 50 10 42 8 49 9 48 8

At least three 139 28 118 23 172 33 170 30

At least four 297 59 339 67 291 56 334 59

Other 1 0 3 1 1 0 6 1

No Answer 4 1 0 0 1 0 3 1

Do not know 7 1 7 1 2 0 5 1

Khudabad Kamal Khan

Base line (N=517) End line (N=513) Base line (N=581) End line (N=569)

# % # % # % # %

At least One 43 8 4 1 17 3 3 1

At least two 83 16 42 8 104 18 48 8

At least three 140 27 118 23 166 29 170 30

At least four 198 38 339 67 251 44 334 59

Other 13 3 3 1 5 1 6 1

No Answer 0 0 0 0 0 0 3 1

Do not know 40 8 7 1 38 7 5 1

Table 12: Number of ANC Visits a Pregnant Woman Should Make - Wife and Husband – End line

Table 13: Number of Antenatal Care Visits a Pregnant Woman Should Make (Reported by wives)


When husbands were inquired, a similar pattern was observed as for women regarding sources of information for antenatal care in both the intervention and control UCs. There was a decrease in proportion of men who had no source of information at end line (6%) compared to base line (27%) in the intervention areas. The proportion of men who got information from CRPs showed a dramatic increase from 1% at base line to 35% at end line.

Table 14: Sources of Information Regarding Antenatal Care – Wives

Khudabad Kamal Khan


# % # % # % # %

No one 99 19 18 4 89 15 22 4

Friend 15 3 9 2 18 3 19 3

Family elders 370 72 218 42 414 71 389 68

Trained health care provider 29 6 55 11 59 10 123 22

LHW 1 0 1 0 1 0 6 1

CRPs 3 1 209 41 0 0 4 1

Radio TV 0 0 0 0 0 0 0 0

Newspaper 0 0 0 0 0 0 2 0

Other 0 0 0 0 0 0 1 0

No Answer 0 0 3 1 0 0 3 1

Table 15: Sources of Information Regarding Antenatal Care - Husbands

Khudabad Kamal Khan


# % # % # % # %

No one 136 27 28 6 102 19 25 5

Friend 22 4 6 1 13 2 21 4

Family elders 222 44 217 43 276 50 384 74

Trained health care 91 18 60 12 153 28 75 14

LHW 11 2 5 1 1 4 1

CRPs 3 1 177 35 0 0 5 1

Radio TV 2 0 0 0 0 3 1

Other 14 3 4 1 6 1 1

No Answer 0 0 3 1 0 0 3 1

increased from 6% at base line to 11% at end line. The data for control UC (Kamal Khan) revealed that only 1% of the women got information from CRPs at end line while the family members were the main source of information regarding antenatal care (68%).


Regarding the components of antenatal care, husbands in Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed.

ANC Visits – Regarding the number of antenatal care visits, the base line and end line data comparisons revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The control UC (Kamal Khan) had a higher proportion of women with one or more antenatal care visits at base line (95%) compared with Khudabad and slightly improved at end line (97%).

Table 16: Important Components of ANC – Husbands’ and Wives’ Opinion

Khudabad Kamal Khan

Husband


# % # % # % # %

Checking for Anaemia 142 28 235 47 180 33 316 61

Measure Blood Pressure 200 40 308 62 231 42 316 61

Weighing 91 18 103 21 100 18 104 20

Immunisation 88 18 139 28 80 15 123 24

Counselling 75 15 119 24 206 37 144 28

Urine test 33 7 94 19 30 5 102 20

Check the foetus position 45 9 86 17 53 10 114 22

Don’t Know 157 31 16 3 88 16 14 3

Wife


# % # % # % # %

Checking for Anaemia 203 39 254 50 233 40 291 51

Measure Blood Pressure 262 51 356 69 288 50 327 57

Weighing 99 19 160 31 115 20 87 15

Immunisation 112 22 186 36 130 22 155 27

Counselling 47 9 139 27 60 10 189 33

Urine test 33 6 95 19 71 12 87 15

Check the foetus position 19 4 103 20 16 3 116 20

Don’t Know 100 19 12 2 83 14 30 5

*= It is important to note that responses were not shared with respondents and were recorded as mentioned.

**=The percentage will be more than 100% if added, due to multiple responses


When the program data was analysed, it was found that 92% of the program women had her first antenatal check-up, however the proportion of women going for antenatal visits progressively decreased in the second, third, forth and more than 4 antenatal visits, with only one quarter (28%) women having more than 4 antenatal visits.

Type of Provider – Regarding the type of provider for antenatal care, a higher proportion of women in Khudabad availed antenatal care from a public sector LHV/doctor at end line (20%) compared to base line (7%). The utilisation of the private sector LHV/doctor for antenatal care in Khudabad slightly decreased at end line (65%) compared to base line (65%). The antenatal care seeking from TBA/Dai in Khudabad decreased at end line (7%) compared with base line (21%).

Table 18: Antenatal Care Visits (Reported by Programme Women)

1st Antenatal Check up (N=864)

2nd Antenatal Check up (N=864)

3rd Antenatal Check up (N=864)

4th Antenatal Check up (N=864)

More than 4 Antenatal Check

ups (N=864)

# % # % # % # % # %

No 70 8 120 14 238 27 374 43 619 72

Yes 794 92 744 86 626 73 490 57 245 28

Table 17: Antenatal Care Visits (Reported by Women, Quantitative survey)

Baseline End line

Khudabad (N=517)

Kamal Khan (N=581)

Khudabad (N=513)

Kamal Khan (N=569)

# % # % # % # %

None 46 9 21 4 16 3 14 2

One or more antenatal visits 462 89 551 95 494 96 553 97

Not Applicable 9 2 9 2 3 1 2 0

Table 19: Type of Provider for Antenatal Care (Reported by Wives)

Base line End line

Khudabad (N=471)

Kamal Khan (N=560)

Khudabad (N=497)

Kamal Khan (N=555)

# % # % # % # %

None 12 3 8 1 3 1 1 0

TBA/Dai 97 21 37 7 70 14 35 6

LHW 7 1 1 0 1 0 1 0

CMW 4 1 0 0 1 0 1 0

Private sector LHV/Doctor 314 67 434 78 322 65 431 77

Public Sector LHV/ Doctor 36 7 74 13 99 20 80 15

Other 1 0 6 1 1 0 6 1


Practice for Birth Preparedness – Regarding the practices for birth preparedness, both the intervention and control UCs showed a decline in the all the measures at end line compared to base line.

4.2.2 Qualitativefindings

4.2.2.1 Awareness about ANC and EmONC

The first step to mitigating the first delay in seeking care is to recognise danger signs during pregnancy. The research findings clearly show higher knowledge levels regarding EmONC in the intervention area at the end line as compared to that at baseline; as well as the recognition of danger signs during pregnancy, at time of birth and after delivery, while little has changed in the non-intervention area. The concept of maternal health during pregnancy was well understood in Khudabad but less so in Kamal Khan. Knowledge about EmONC and pregnancy in Kamal Khan was superficial at best. Awareness about ANC and the ability to realise signs of danger during pregnancy were higher in Khudabad.

Women in Khudabad understood the importance of nutrition for pregnant women and were able to identify signs of danger during pregnancy and childbirth. Clearly this was an improvement over the base line when they had known many of the complications related to nutrition but now came to link them with specific nutrition problems and their solutions. They also acknowledged the importance of breastfeeding in strengthening the baby’s immune system. In Kamal Khan, women had little knowledge of complications; but they understood the need for rest and a healthy diet during pregnancy. Information on neonatal and postnatal care was not demonstrated in Kamal Khan.

Awareness levels among men in Khudabad were decent. They understood women’s need for nutrition and rest and were even able to recognise certain danger signs during pregnancy and early signs of labour. Men in Khudabad claimed to take pregnant women in their households for regular ANC visits and for immunisation, and were aware that if a danger sign appeared they should take the mother and/or the newborn to the hospital immediately. This signals a departure from their prior practices when there was considerable suspicion for institutional care. On the other hand, men in Kamal Khan exhibited no knowledge of EmONC.

The other change from the base line is the presence of community based mechanisms for transport of women either for ANC or for EmONC. In the base line assessment, the lack of these means had been highlighted as a major impediment facility based care for women in Khudabad.

Table 20: Practice for Birth Preparedness (Reported by Wives)

Khudabad Kamal Khan

Base line (517)

End line (513) Base line (581) End line (569)

% % % %

None 18 10 14 8

Saved funds 72 49 81 36

Had ANC visits with CMW, TBA 2 0 0 0

Visited delivery facility 0 1 0 0

Arranged transport 23 15 13 12

Identify blood donor 5 5 4 2

Identified skilled provider 1 1 2 1

Identified place of delivery 3 7 2 6

Procure clean delivery kit 2 0 5 2

We never had information regarding check-ups during pregnancy, but once the project team gave us the information, we started taking care of women during their pregnancy

A FATHER IN-LAW


TBAs in Khudabad exhibited clear awareness of childbirth and recognition of complications; and demonstrated sound knowledge of safe birthing practices. They stated that regular check-ups and a healthy diet are important for pregnant women and were able to identify specific steps in the care of a newborn as opposed to only guesses that were recorded at the base line. TBAs in Kamal Khan were unable to provide any details on the handling of deliveries, care necessary during pregnancy and the importance of ANC and PNC visits. They were only able to provide some basic information on how to handle newborn babies.

Fathers-in-law indicated some basic knowledge about neonates and pregnant women, which is an improvement over the base line. However, as for all other respondents they made no mention of PNC visits or their importance. They had some vague knowledge about childbirth; however their information was weak. Mothers-in-law in Khudabad exhibited sound knowledge of EmONC.

In Khudabad the community understood the need for 2-3 medical check-ups during pregnancy; but was unable to demonstrate an understanding of postnatal care visits. The VHCs were well aware of precautions necessary during pregnancy, required ANC visits and neonatal health. VHCs who received training from the project team were better able to take care of pregnant women; guiding them for regularly spaced ultrasound tests to ascertain the foetus’s health, to ensure that there is no excessive amniotic fluid in the womb, and whether the foetus is correctly positioned. VHC exhibited sound knowledge of nutrition requirements for pregnant women and their immunisation. They advised pregnant women to work less after 3-4 months of pregnancy; to avoid lifting heavy objects and ensure that they are vaccinated. They however were unable to demonstrate knowledge about postnatal care.

4.2.2.2 Recognising Danger Signs for Complicated Pregnancies and Neonatal Health

Overall, women were able to recognise complications during pregnancy and childbirth. They were also convinced of the benefits of colostrum for neonatal health and were keen on BCG vaccines for newborns. Women in the intervention area were aware of signs of neonatal complications including ‘blue baby’, jaundice, breathing asphyxia, and tetanus and knew of common health problems that arise during pregnancy such as weakness, vomiting, swelling, fever, and blood pressure.

Men in Khudabad did have knowledge of danger signs during pregnancy, delivery and post-delivery and were prepared to take women and newborns to the hospital if any of the danger signs appeared. They were aware of complications such as unstable blood pressure after 5-6 months of pregnancy, lower abdominal pain, lethargy, seizures, heavy bleeding, and incomplete discharge of placenta. Their knowledge was slightly higher than at the base line. They also understood the need to take the woman to hospital if the baby is breaching and a C-section is required. In this regard there was a higher level of acceptance of facility births than at the base line.

Regarding neonatal care, men in Khudabad demonstrated less information and only showed understanding of breathing asphyxia. While influential persons did have some knowledge about pregnancy; they could not describe complicated pregnancies. Normal symptoms such as anaemia, lack of Vitamin C, weakness, laziness, backaches, and vomiting were incorrectly suggested as problems related to pregnancy. Most participants depended on women to tell them when they were not feeling well. They exhibited some knowledge of newborn care such as delays in immunisation due to transport issues, and understood that it was a concern if the child did not breast feed, or suffered from seizures.

Most TBAs in Khudabad had adequate knowledge and were able to identify complicated cases and refer women to the hospital in time. The TBAs in Kamal Khan were unable to express their knowledge or experience. A few suggested they were experienced in discerning the difficulty level of the delivery. Most said they could not handle complicated pregnancies.

The health centre has no services, no beds, no personnel, no water or gas, and no bathroom. The doctor only visits for an hour and is never there when he is needed. They cannot solve our health problems; they only have basic medicine

A COMMUNITY

MEMBER

Usually, there is no bed, electricity or other necessary facilities but water is available in most health centres

A MOTHER IN-LAW


In Kamal Khan, knowledge about pregnancy or complications was poor and TBAs were unable to distinguish between normal and complicated pregnancies. The women in the intervention district had sound knowledge of ‘good’ practices for neonatal health. Men in Kamal Khan had very little and inappropriate knowledge of danger signs. They mentioned conditions such as swollen feet and face and chronic disease to be complications of pregnancy.

4.2.2.3 Social Restraints on the Movement of Women When Seeking Healthcare

While neither women nor men describe from either Kamal Khan or Khudabad feel that women are restrained from seeking health care, however there is a strong feeling that they need to be accompanied by a man or an elderly woman. In the absence of a male household member, women can go with another woman or even a young child. They feel that if a woman were to go to the hospital by herself to give birth, she cannot do anything on her own. She cannot buy medicines or find transportation in that situation.

While these restrictions are based on perceived needs – absence of support staff at facilities and the fact that in Pakistan families are often called upon to buy even the most routine of supplies - they can sometimes cause delays in seeking care, particularly during emergencies since a woman must wait for someone to accompany her to the hospital.

In some villages of Kamal Khan, women face restrictions on their movement. They cannot go anywhere without their husband’s permission nor can they travel alone. In cases where the husband is not available, a child or an elderly woman goes with the woman. The head of the household decides about place of childbirth and the woman does not seek health care without his permission. The woman consults the head of the household for place of delivery and the TBA also gives her suggestions when asked.

4.2.3 Summary of Findings – OBJECTIVE 1

CRPs were effective in raising the knowledge of communities regarding Antenatal care. When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). Regarding the components of antenatal care, husbands in the Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed. Regarding the number of antenatal care visits, the base line and end line data comparison revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The programme data revealed that 92% of the programme women had their first antenatal check-up; 86%, 73% and 57% had a second, third and fourth antenatal visit. The CRPs visited nearly 91% of the households and were cited as the main source of information in intervention UC at the end line for antenatal care by 41% of the women and 35% of the husbands. The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to base line. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The CRPs helped to increase awareness regarding complications during pregnancy among husbands from 36% to 79% (an increase of 43%) and from 83% to 94% among women. With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications


such as severe bleeding, convulsions, high fever, loss of consciousness, labour period of longer than 12 hours and un-delivered placenta when compared to base line. When the women were inquired about the source of information for complications during delivery it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by trained health care provider (11%).

4.3 OBJECTIVE 2: Knowledge and Involvement in Decision Making and Access to Health Facilities

4.3.1 Knowledge about Birth Preparedness

Birth preparation and planning is an important process for any family that is about to have a child. Childbirth involves a number of risks to maternal and child health; as well as financial implications that require planning and resource management.

At base line, women from Khudabad largely depended on family elders for information (91%); however, at end line majority of women (64%) did not mention any source of information for knowledge about birth preparedness. It is possible that they learn through observations or experiences. However, these characteristics were not explored in this research study and therefore the evidence is non-conclusive. An increased proportion of women at end line in Khudabad reported to get information from a trained health care provider (6%) and CRPs (9%) compared to base line (trained health care provider = 3%, CRPs= 1%).

Table 21: Source of Knowledge of Respondents Regarding Birth Preparedness – Wives

Khudabad Kamal Khan


# % # % # % # %

No one 10 3 315 64 14 3 301 56

Friend 9 3 23 5 22 5 17 3

Family elders 326 91 79 16 401 86 170 32


LHW 0 0 2 0 0 0 0 0

CRPs 4 1 43 9 0 0 0 0

The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to baseline. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The knowledge of birth preparedness for women in control UC (Kamal Khan) showed a decline in all the preparatory measures except identification of delivery place which increased from 2% at base line to 7% at end line.


Table 22: Knowledge of Birth Preparedness (Reported by Wives)

Khudabad Kamal Khan


# % # % # % # %

Arrange transport 237 46 166 32 182 31 156 27

Save money 459 89 293 57 529 91 259 46

Identify blood donor 31 6 33 6 41 7 24 4

Identify skilled provider 16 3 8 2 8 1 1 0

Identify the place 27 5 37 7 14 2 37 7

Procure clean kits 15 3 19 4 55 9 16 3

4.3.2 Preferred Place for Giving Birth

Regarding the preferred place for giving birth, the base line and end line comparison revealed that home persisted to be most preferred place for giving birth in both the intervention and control UCs. A decline in the preference for public facility was also observed at end line in both intervention and control UCs.

Discussion Regarding Place of Next Delivery – Couples demonstrated maturity in handling pregnancy situations and discussed where to have their next child. A higher proportion of women discussed regarding the place for next delivery in both the intervention and control UCs (Khudabad and Kamal Khan) at end line (83% & 91%, respectively) compared to base line (58% & 64%).

Table 23: Preferred Place for Giving Birth (Reported by Wives)

Khudabad Kamal Khan


# % # % # % # %

Home 149 50 242 57 177 48 244 47

Private facility 108 36 164 38 124 33 255 49

Public facility 39 13 20 5 64 17 17 3

CMW house 4 1 1 0 3 1 0 0

Other 0 0 0 0 4 1 0 0


4.3.3 Knowledge of Pregnancy Related Complications

When the women were inquired about the pregnancy related complications, it was found that a higher proportion of women (94%) in Khudabad knew of at least one complication compared to base line (83%). The mean number of pregnancy related complications also showed improvement from base line (2.7) to end line (3.5) in Khudabad. A similar pattern was observed for husbands in Khudabad. The proportion of husbands who knew of at least one pregnancy related complication increased from 36% at base line to 95% at end line. The mean number of complications known increased from 1.2 to 3.0 at end line.

The proportion of women in the control UC (Kamal Khan) with knowledge of at least one pregnancy related complication showed slight improvement at end line (93%) compared to base line (92%), however, the mean number of complications decreased from 3.4 to 2.9.

0

10

BaselineN=517

Khudabad Kamal Khan

BaselineN=581

EndlineN=513

EndlineN=569

20

30

40

50

60

70

80

90

100

58

64

91

83

Figure 1: Inter-spousal Communication for place of Delivery (Reported by Women)

Table 24: Number of Pregnancy Related Complications Known

Base line End line

WifeKhudabad

(N=517)Kamal Khan

(N=581)Khudabad

(N=513)Kamal Khan

(N=569)

Knew of at least one complication 83% 92% 94% 93%

Number of complications known (Mean) 2.7 3.4 3.5 2.9

Husband (N= 583) (N=536) (N=555) (N=552)

Knew of at least one complication 36% 79% 93% 95%

Number of complications known (Mean) 1.2 2.1 3.0 3.0


Regarding the knowledge about pregnancy related complications, women in Khudabad showed improvement for the complications such as bleeding, severe abdominal pain, convulsions, accelerated/reduced foetal movements, swollen hands/feet and loss of consciousness when compared to base line. This could be attributed to an increased focus by CRPs on creating awareness about complications, which require frequent referrals to health facilities. Bleeding, severe abdominal pain and convulsions are known to be some of the worst complications which require immediate care. The intervention seems to have worked to raise awareness for knowledge about pregnancy related complications. In the control UC Kamal Khan, knowledge of women about some of the complications (convulsions, loss of consciousness, accelerated/reduced foetal movements) showed improvement, while the knowledge of women about other complications declined.

Regarding the respondent’s opinion whether a woman can die from complications during pregnancy, the findings revealed that at the end line a lower proportion of both women and their husbands in Khudabad and Kamal Khan believed that a woman can die from complications during pregnancy.

Source of Information about Complications during Pregnancy – With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. There seems to be a shift from family members as source of information to CRPs. For the control UC Kamal Khan, family members were found to be main source of information both at base line and end line.

Table 25: What Pregnancy Related Complications Wives Know About

Khudabad Kamal Khan

Base line (N=430)

End line (N=481)

Base line (N=533)

End line (N=528)

% % % %

None 1 0 0 0

Bleeding 47 53 42 43

Severe headache 69 68 79 61

Blurred vision 45 45 56 36

Convulsions 6 23 3 18

Swollen Hands/face 23 33 30 21

High fever 35 18 40 27

Loss of conscious 8 12 4 9

Difficulty in breathing 22 34 43 30

Severe weakness 47 50 55 45

Severe abdominal pain 18 25 24 21

Accelerated /reduced foetal movement 5 9 2 5

Water breaks 0 2 1 2


When the women were inquired about the source of information for complications during pregnancy it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by a trained health care provider (11%). For the control UC Kamal Khan, family members were found to be the main source of information (72%) followed by a trained health care provider (20%).

Table 25: Source of Information about Complications During Pregnancy (Reported by Wives)

Khudabad Kamal Khan


# % # % # % # %

No one 29 8 2 1 45 9 5 2

Friend 12 3 11 3 16 3 17 6

Family elders 303 82 127 40 375 76 226 74


LHW 2 1 3 1 0 0 4 1

CRPs 4 1 151 47 3 1 3 1

Radio TV 0 0 1 0 0 0 5 2

Newspaper 0 0 1 0 0 0 2 1

Other 1 0 0 0 0 0 7 2

Table 26: Source of Information for Complications during Delivery (Reported by Women)

Khudabad Kamal Khan


# % # % # % # %

No one 42 10 14 3 55 10 16 3

Friend 15 3 8 2 19 3 19 3

Family elders 354 81 227 46 399 72 396 72


LHW 1 0 1 0 0 0 0 0

CRPs 2 0 189 38 1 0 4 1

Radio TV 0 0 0 0 0 0 0 0

Newspaper 0 0 1 0 0 0 0 0

Other 0 0 1 0 0 0 4 1


Knowledge Regarding Complications during Delivery- The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications such as severe bleeding, convulsions, high fever, loss of consciousness, labour period of longer than 12 hours and un-delivered placenta when compared to base line. The ability of respondents to recognise the three significant complications during delivery, which are severe bleeding, prolonged labour and retention of placenta improved at the end line in Khudabad.

4.3.4 Recognition of Danger Signs for Post-partum Period

Wives in Khudabad demonstrated an increase in their ability to recognise danger signs such as bleeding, blurred vision, convulsions, difficulty in breathing, severe weakness, severe abdominal pain and difficulty in breathing during the post-partum period. In control UC Kamal Khan, a lower proportion of women recognised danger signs at end line.

Table 27: Knowledge of Complications that Can Occur During Delivery

Khudabad Kamal Khan

Base line End line Base line End line

Husband (N=501)

Wife (N=517)

Husband (N=500)

Wife (N=513)

Husband (N=551)

Wife (N=581)

Husband (N=521)

Wife (N=569)

% % % % % % % %

None 17 8 1 0 5 2 1 0

Severe Bleeding 48 55 76 77 54 62 78 64

Severe Headache 30 51 59 44 43 65 54 42

Convulsions 21 26 28 32 19 27 23 25

High fever 44 47 52 49 64 62 53 44

Loss of conscious 8 10 23 27 8 6 20 18

Labour more than 12 hrs

4 8 9 11 3 7 10 11

Placenta not delivered

3 20 16 22 3 30 15 22


Perceived Impact of Post-partum Danger Signs on a Woman’s Life – The perceived impact of post-partum danger signs on women’s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad.

Sources of Information about Danger Signs during the Post-partum Period – The most common sources of information in Khudabad was family elders at base line, however, CRPs emerged as an important source of information regarding danger signs during the post-partum period at the end line. For the control UC Kamal Khan, the family elders remained as the main source of information at end line.

Table 28: Recognition of danger signs for post-partum period – Wives

Base line End line

Khudabad (N-517)

Kamal Khan (N=581)

Khudabad (N=513)

Kamal Khan (N=569)

% % % %

None 6 1 1 1

Bleeding 53 65 73 62

Severe headache 50 58 50 41

Blurred vision 24 20 29 20

Convulsions 19 20 25 18

High fever 46 50 41 33

Loss of conscious 14 10 10 5

Difficulty in breathing 27 48 40 38

Severe weakness 44 55 55 52

Severe abdominal pain 19 27 26 26

Don’t know 6 3 2 3

*= It is important to note that responses were not shared with respondents and were recorded as mentioned.

**=The percentage will be more than 100% if added, due to multiple responses

0

70

BaselineN=454

Khudabad Kamal Khan

BaselineN=558

EndlineN=499

EndlineN=548

75

80

85

90

95

100

82

9697

96

Figure 2: Perceived Impact of Post-partum Danger Signs on a Woman’s Life (Reported by Wives)


Table 29: Sources of Information about Danger Signs during the Post-partum Period (Reported by Wives)

Khudabad Kamal Khan


# % # % # % # %

No one 44 10 1 0 52 9 1 0

Friend 17 4 23 5 23 4 64 12

Family elders 306 69 136 28 401 72 221 41


LHW 6 1 64 13 6 1 4 1

CRPs 4 1 147 30 30 5 16 3

Radio TV 0 0 1 0 0 0 1 0

Newspaper 0 0 0 0 4 1 3 1

Perceived Risks to the Life of a Newborn - The perceived risk to the life of newborn increased from 76% at base line to 94% at end line.

Most Important Things to do with a Newborn – The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination, avoid feeding complimentary foods for the first 6 months, early initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth.

0

50

BaselineN=438

Khudabad Kamal Khan

BaselineN=515

EndlineN=513

EndlineN=569

55

60

65

70

75

85

90

95

100

80

76

92 9394

Figure 3: Perceived Risks to the Life of a Newborn (Reported by Wives)


Danger Signs for a Neonate – The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessively crying were correctly identified as signs of danger.

Understanding of Exclusive Breastfeeding – The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% suggesting at end line that child should only be breastfed for first six months of life.

Table 30: Most Important Things to do with a Newborn – Wives

Khudabad Kamal Khan

Base line (N=517)

End line (N=513)

Base line (N=581)

End line (569)

# % # % # % # %

Immediate Bathing 196 38 171 33 300 52 251 44

Covering in blanket 323 62 361 70 366 63 344 60

Cleaning 325 63 367 72 386 66 390 69

Showing to family 40 8 107 21 51 9 116 20

Feeding complimentary foods 169 33 57 11 169 29 51 9

Vaccination 62 12 147 29 49 8 125 22

Early initiation of breastfeeding 144 28 181 35 150 26 223 39

Don’t know 20 4 3 1 19 3 2 0

Table 31: Danger Signs for a Neonate (Reported by Women)

Khudabad Kamal Khan

Base line (N=517) End line (N=513) Base line (N=581) End line (569)

# % # % # % # %

None 32 6 8 2 18 3 1 0

Turning red 140 27 141 27 207 36 99 17

Turning blue 135 26 177 35 190 33 133 23

Not breathing 257 50 222 43 284 49 179 31

Not feeding 190 37 256 50 234 40 243 43

Excessive crying 187 36 259 50 249 43 244 43

Not moving 84 16 106 21 89 15 98 17


Table 32: Understanding of Exclusive breastfeeding (Reported by Women)

Khudabad Kamal Khan

Base line (N=517)

End line (N=404)

Base line (N=581)

End line (N=451)

# % # % # % # %

Breastfeeding with other milk when mother’s milk is short

355 69 80 20 428 74 58 13

Breastfeeding with other foods when mother’s milk is short

50 10 8 2 43 7 3 1

Breastfeeding with water 84 16 2 0 81 14 3 1

Only breastfeeding for a period of six months

19 4 186 46 8 1 187 41

Other 9 2 2 0 21 4 1 0

No Answer 0 0 126 31 0 0 199 44

Source of Information about Newborns – As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. At base line, the primary source of information was family elders which shifted to CRPs at end line.

Decision Makers to Seek Treatment – With regards to decision maker to seek treatment, there was a considerable increase in proportion of women in Khudabad who were engaged in decision making at end line (10% at base line to 39% end line).

Table 33: Source of Information about New-borns (Reported by Wives)

Khudabad Kamal Khan

Base line (N=517) End line (N=513) Base line (N=581) End line (569)

# % # % # % # %

No one 97 19 3 1 100 17 9 2

Friend 15 3 7 1 15 3 19 3

Family elders 367 71 161 31 417 72 239 42

Trained health care provider

86 17 34 7 109 19 77 14

LHW 11 2 1 0 4 1 0 0

CRPs 8 2 205 40 32 6 16 3

Radio TV 1 0 2 0 2 0 1 0


Did Not Seek Treatment – Women who experienced complications sought treatment at a health facility. Key reasons for not seeking treatment, included failure to recognise the complication, and thinking that the complication would heal on its own. The number of women who failed to recognise the complications was higher at the end line.

Time Taken to Seek Healthcare – The time taken to seek health care showed improvement for women in Khudabad with almost three fifth seeking health care immediately (59%) at end line compared with 50% at base line.

Table 35: Did not Seek Treatment (Reported by Women)

Khudabad Kamal Khan

Base line (N=10)

End line (11)Base line

(N=15)End line

(N=3)

# % # % # % # %

Did not think the ailment was serious 1 10 8 73 2 13 2 67

Thought they will get better on own 2 20 2 18 4 27 1 33

Discussed with elder or community elder who suggested staying home

1 10 0 0 0 0 0 0

Other 1 10 1 9 4 27 0 0

No Answer 4 40 0 0 4 27 0 0

DNK 1 10 0 0 1 7 0 0

Table 34: Decision-makers to Seek Treatment (Reported by Women)

Khudabad Kamal Khan


# % # % # % # %

Myself 47 10 178 39 43 8 248 45

Husband 374 81 254 55 490 86 277 51

Father 2 0 1 0 0 0 7 1

Mother 1 0 6 1 2 0 6 1

Father-in-law 6 1 11 2 8 1 5 1

Mother-in-law 9 2 9 2 7 1 2 0

Brother 3 1 0 0 0 0 1 0

Sister 1 0 1 0 0 0 0 0

Brother in law 3 1 0 0 2 0 0 0

Sister in law 0 0 0 0 0 0 0 0

Other 1 0 0 0 2 0 0 0

Don't know 15 3 0 0 16 3 0 0


Table 36: Time Taken to Seek Healthcare (Reported by Wives)

Khudabad Kamal Khan

Base line (N=417)

End line (N=449)

Base line (N=528)

End line (N=543)

# % # % # % # %

Immediately 210 50 266 59 257 49 290 53

After 1-6 hours 137 33 90 20 177 34 130 24

After 7-12 hours 2 0 7 2 8 2 19 3

13-24 hours 4 1 1 0 3 1 5 1

Between 1-2 days 26 6 38 8 35 7 62 11

>2 days 36 9 47 10 46 9 37 7

Don't know 2 0 0 0 2 0 0 0

Table 37: Reasons for Delay (Reported by Women)

Khudabad Kamal Khan

Khudabad (n=85)

Kamal Khan (n=178)

Khudabad (n=83)

Kamal Khan (n=94)

# % # % # % # %

Had to discuss with family 15 18 11 6 10 12 4 4

Husband wasn’t home 10 12 39 22 7 8 7 7

Had to generate funds 53 62 122 69 61 74 74 79

No transport 4 5 5 3 4 5 8 9

Didn’t know where to go 2 2 0 0 1 1 0 0

Elders/others prohibited 0 0 0 0 0 0 0 0

Other 1 1 1 1 0 0 1 1

Total 85 100 178 100 83 100 94 100

Reasons for Delay – When the reasons for delay in seeking health care were explored, it was found that generating funds was the main reason for women in Khudabad both at base line and end line. However, there was a slight improvement in terms of a lower proportion of women who didn’t know where to go, had no transport or had to discuss with the family.

Where was Treatment Sought – The utilisation of the public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/clinic stayed as the most sought health providers both at base line and end line.


Table 38: Where was Treatment Sought (Reported by Women)

Khudabad Kamal Khan

Base line (N=462)

End line (N=460)

Base line (N=570)

End line (N=546)

# % # % # % # %

Lady Health Worker 6 1 2 0 1 0 3 1

TBA 48 10 42 9 17 3 25 5

Dispensary 0 0 1 0 0 0 0 0

Local Govt. hospital 6 1 27 6 6 1 34 6

District Govt. hospital 21 5 43 9 23 4 41 8

Tehsil Hospital 50 11 30 7 55 10 37 7

Private Clinic 54 12 64 14 40 7 89 16

Private Doctor 270 58 249 54 416 73 306 56

Pharmacist 0 0 0 0 0 0 1 0

Table 39: What Prompted to Seek Healthcare? (Reported by Wives)

Khudabad Kamal Khan

Base line (N=462)

End line (N=460)

Base line (N=570)

End line (N=546)

# % # % # % # %

Vomiting 260 56 227 49 348 61 290 53

Shortness of breath 189 41 217 47 292 51 217 40

Severe headache 247 53 206 45 351 62 238 44

Swelling of face 78 17 82 18 127 22 80 15

Severe lower pain 159 34 171 37 286 50 231 42

Heavy menstrual bleeding 14 3 24 5 12 2 28 5

High blood pressure 96 21 137 30 136 24 176 32

Fits or convulsions 52 11 21 5 43 8 29 5

Anaemia 36 8 56 12 76 13 85 16

Jaundice 5 1 5 1 43 8 12 2

What Prompted Them to Seek Healthcare – Vomiting, shortness of breath and severe headaches were common reasons for seeking health care in Khudabad both at base line and end line. High blood pressure, heavy menstrual bleeding and severe lower pain prompted a higher proportion of women at end line to seek health care.



Wives in Khudabad demonstrated an increase in their ability to recognise danger signs such as bleeding, blurred vision, convulsions, difficulty in breathing, severe weakness, severe abdominal pain and difficulty in breathing during the post-partum period. The perceived impact of post-partum danger signs on a woman’s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad. The most common sources of information regarding danger signs during the post-partum period in Khudabad was family elders at base line, however, CRPs emerged as an important source of information at the end line. The perceived risk to the life of newborn increased from 76% at base line to 94% at end line among women in Khudabad. The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination; avoid feeding food, initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth. The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessive crying were correctly identified as signs of danger. The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% suggesting at end line that child should only be breastfed for first six months of life.

As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. With regards to decision maker to seek treatment, there was considerable increase in proportion of women in Khudabad who were engaged in decision making at end line (10% at base line to 39% end line).

OBJECTIVE 3: Community Resource Persons and Timely Referral (Increased Timely Referral for Complicated Deliveries and Facility Births)

Place of Delivery for Last Pregnancy – The last place of delivery for women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at public sector health facility. Comparing with program women data, a higher proportion of women (24%) gave birth at public sector health facility while 28% delivered at home. The program women data revealed that for around 66% women delivery was conducted by skilled health provider.

Figure 4: Comparison of place of delivery at baseline with program women (Khudabad)

Place of Delivery at Base LineWives in % (N=517)

Place of Delivery-Programme

Women in % (N=864)


A higher proportion of women in base line study had live birth (91%) compared to programme women (85%). Almost 9% of the programme women had miscarriage/abortion while 5% had still birth.

Figure 5: Who Conducted Delivery (Reported by Programme women) (N=864)

Figure 6: Comparison of Outcome of Delivery for Women in Base Line Study with Programme Women

Live BirthCongenital AbnormalityDont KnowStill BirthOther

Live BirthAbortion Miscarriage

Still BirthMissing

Outcome of Delivery at Base LineReported by Wives in % (N=517)

Outcome of Delivery in %(reported by Programme Women)

(N=864)

Reason for Delivery at Selected Place – For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed distantly by advice from family, confidence in provider, costs and advice from provider. The pattern was similar for Khudabad and Kamal Khan.


Information Gained from IEC Material – More than two-thirds of women reported receiving information on ANC, birth preparedness and PNC. Thus the project was well executed in terms of providing materials to community women.

Visits by CRPs – The CRPs had set targets that involved visiting all households with in the catchment population once a month and visiting pregnant women twice a month.

Women indicated a good presence of CRPs in the area. Almost 91% of the women claimed that a CRP had visited them and 87% said they had received IEC material. Thus the CRPs had actively visited households to carry out their duties.

Table 40: Reason for Delivery at Selected Place (Reported by Women)

Khudabad Kamal Khan Khudabad Kamal Khan

# % # % # % # %

Convenience 236 46 193 33 362 71 356 63

Cost 27 5 31 5 49 10 48 8

Confidence 19 4 37 6 17 3 30 5

Advice from provider 8 2 9 2 7 1 15 3

Advice from family 37 7 46 8 72 14 107 19

Other 10 2 20 3 6 1 13 2

No Answer 180 35 245 42 0 0 0 0

0 0

KhudabadN=150

KhudabadN=150

Kamal KhanN=157

Kamal KhanN=157

100 100

91 87

01 0

Figure 7: CRP Visited(Reported by Women - Birth Audit)

Figure 8: Received IEC Material (Reported by Women - Birth Audit)

0

20

Antenatal Care

Birth preparedness and safe delivery

Postnatal care of mother & neonatal

40

60

80

70% 75%61%

Figure 9: Information Gained from IEC Material (Reported by Women - Birth Audit)


4.3.6 Qualitative Findings

Preferred Place for Childbirth

In the intervention community (Khudabad), there have been significant changes in mind sets. Health facilities were considered the safest place for delivery as they are equipped with the necessary equipment and trained staff to deal with all kinds of complications. Despite realising that facility based births were safer, women continued to deliver at home. Quantitative analysis suggests that costs and convenience are the basic factors affecting the decision regarding place of birth. Regarding birth in health facilities, women in Kamal Khan said they had heard bad experiences as well, and that they could not afford it. Men in Kamal Khan (non-intervention community) considered home-based births to be safer.

In Khudabad, TBAs are no longer preferred due to their attitude. They were said to be rude and misbehaved with household members. Hospitals were considered safer for giving birth since they were better equipped to deal with emergencies. Private hospitals were preferred over public hospitals due to better service quality, paramedical staff and flexible timings in most instances. In contrast, public hospitals were said to be quite ill-equipped as compared to private health facilities. The community complained about poor service quality and high absenteeism in public hospitals. On the other hand, private hospitals were unaffordable and therefore not an option for the poor.

Home-based deliveries were still considered convenient in Kamal Khan. Facility births are safer as they have facilities and skilled staff; however travelling was a problem in most villages as transport was not easily available. Although hospitals were considered safer; other financial and transport constraints caused most households to make choices based on convenience rather than quality.

The health facilities in Dadu were not functional round the clock, thus impeding the delivery of institutional EmONC services. The BHU in both the intervention and control UC were only open till 2pm. The MCH centre of Khudabad was initially open till 2pm, and was later converted into a 24/7 facility towards the end of the project. Apart from the MCH centre the civil hospital of Dadu is also open 24 hours a day but is distant and hard to reach for the people of Khudabad and Kamal Khan. People reported that at the UC level, the BHUs and MCH centre were poorly equipped and did not have medicines. In addition, the quality of service is poor and absenteeism is high. Public facilities are visited mostly for ANC and in case of complications, as they are more affordable to the community than private facilities. Many women felt that the public hospital staff members run private clinics in the evening, where they sell off the medicine provided by the government to medical stores. In emergencies, healthcare providers tell the family to take the patient to a private hospital – often ones that they themselves operate.

Health providers in the non-intervention UC (Kamal Khan) were said to be well trained but seldom available. Furthermore, in days when available, their timings were restricted to 2pm. People had to travel to Johi for even a simple injection. In some health centres the doctors were well-mannered and skilled; however cultural restrictions did not allow pregnant women to seek health care from male doctors. Some TBAs suggested the doctors were barely available during the entire working day. Also the doctors were unable to deal with complicated cases. Absenteeism was common and limited hours further restricted the use of facilities in Kamal Khan.

It is clear from the above discussion that the three delays can be reduced if public centres are staffed with trained personnel, have medicines available, can handle complicated pregnancies and births, effectively take care of neonates, operate on a 24/7 basis to provide EmONC, have electricity, water, beds, and other basic equipment. While many of these facilities were provided at the MCH and BHU levels in Khudabad through the project, the outcome of health care services was beyond the control of the project. The project intervention had no power over staff absenteeism, behaviour and practices.

There is no guarantee anywhere, even in hospitals women die.

A COMMUNITY

MEMBER

The doctor at the health centre in another village appears for a day and then disappears for the next 10 days.

A TBA


Knowledge and Practices of TBAs

A vast difference was noted in the knowledge, sophistication and skill levels of TBAs in Khudabad and Kamal Khan. At the base line, we had found that the TBAs were generally fixed in their own ways and reluctant to change. They were also suspicious of referrals which they had felt would reduce their “business”. They were educated in timely referrals and some basic good practices during this intervention. At the end line, TBAs in Khudabad were well aware of EmONC. They had adequate knowledge on regular check-ups and nutrition, were able to recognise signs of complications during pregnancy as well as complicated pregnancy cases early on, and seem to have referred women to the hospital in time. TBAs in Kamal Khan were unable to provide any details on handling pregnancies, care necessary during pregnancy and the importance of ANC and PNC visits; and could only provide some basic details on how to handle newborn babies. A few suggested they were experienced in recognising whether the delivery will be easy or difficult.

TBAs in the intervention area, who had received training from the project team, were better able to take care of pregnant women; guiding them for regularly spaced ultrasound tests. Previously they had attempted to take care of all situations, even when they were clearly unable to. However they were able to identify which situations they could manage and when they should refer and also appreciated the links that the intervention had created for them to refer to. The project team trained TBAs appeared technically competent; they have a delivery kit, wear gloves and wash their hands with soap. They were well aware of precautions during pregnancy, ANC visits and neonatal health. They however were unable to demonstrate knowledge about postnatal care.

Normal Practice Regarding Births

There was mixed evidence for normal practices regarding childbirth. High absenteeism in public health facilities severely affected the availability of services for pregnant women, particularly for cases of childbirth. As a result, in some villages of Khudabad births were conducted at home under the supervision of a TBA. In other villages, families were in favour of facility based births and among those who could afford, most births were conducted in private hospitals. Many people suggested getting an initial check-up and information from a TBA, and then going to see a doctor and deliver at civil hospital Dadu. Families in Kamal Khan mostly preferred childbirth at home by Traditional Birth Attendants. As seen in the quantitative section, a number of men and women understood that facility births were safer but could not afford to have their deliveries at facilities.

There were a few instances where the research team reported that families had gone to facilities at the onset of labour. However the men became upset 6-7 hours into the process because they were used to calling the TBA for home deliveries when birth was imminent. It was discovered that for many of the families, the understanding of labour was the time of crowning to birth – a mere few minutes – rather than the 6-8 hours that start from the first onset of labour pains and end at birth. When they went to the facility at the onset of labour pains as instructed by intervention personnel, they were irate when the labour stretched for longer than they had to been accustomed to. Some even expressed suspicions that they had been prematurely summoned in order to extract money from them and in one instance a husband even called the local parliamentarian to intervene and have the doctor deliver the child more quickly.

In general women favoured going to private health facilities for ANC; however they preferred to deliver at home. In Kamal Khan, women preferred to deliver at home assisted by a TBA and only went to health facilities in case of complications.

Men worried about inadequately trained TBAs who had no formal training or knowledge on how to use medical instruments. However, they felt that there was little privacy in health facilities for the women to

With the help of Project Team a village health committee was formed which helped us solve all kinds of problems related to health.

A FATHER-IN-LAW.

Project Team formed a mechanism for financial and EmONC support, they gave us PKR 300-500 for transport in case of emergency, which is quite a benefit for us, being poor community. Such a mechanism should be formed in other areas as well.

A MOTHER-IN-LAW


deliver and therefore preferred having their wives deliver at home. Those in favour of facility based births said they took women to the MCH Centre in case of a normal delivery and only went to the DHQ if there was a complication or they were referred there. The “Thardeep Project” was frequently referred to and praised for raising the standard of health facilities nearby. These views were echoed by the TBAs in Khudabad who said that they were the first ones to be called for delivery at home. If they were unable to handle the case, they would ask the family to take the woman to the hospital. The pervasive poverty in Khudabad also drives many towards home deliveries with facilities sought only for complications. Among these, public facilities were preferred because they were cheaper. Most such women went to Khudabad District Hospital, which had been equipped by the project.


The time taken to seek health care showed improvement for women in Khudabad with almost three-fifths seeking health care immediately (59%) at end line compared with 50% at base line. The utilisation of the public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/clinic remained as the most sought health providers both at base line and end line. The place of delivery for last pregnancy among women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at a public sector health facility. Comparing with programme data, a higher proportion of women (24%) gave birth at public sector health facility while 28% delivered at home. The programme women data revealed that for around 66% women delivery was conducted by a skilled health provider. For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed by advice from family, confidence in provider, costs and advice from provider. Around one-fifths of the women (22%) and husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line.

4.4 OBJECTIVE4&5:VillageHealthCommittees–VHC,CommunitybasedfinancingandAccessto EmONC Services and Facilities

Mechanisms to Provide Financial Support – Around one-fifths of the women (22%) and one-fifths of the husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. In the control UC Kamal Khan, only 1% of the women and 3% of the husbands were aware of such measures.

There is a trained nurse who takes good care of pregnant women who have come for childbirth. Her behaviour is very polite

COMMUNITY

INFLUENCER

You need to have money or a reference to get good treatment in public hospitals

A COMMUNITY

MEMBER

We took a pregnant woman from our family to a hospital. The doctor asked the family to wait as the delivery will take time. Our woman was in severe pain and we didn’t have money to go to another doctor. We brought the woman back home and called the midwife, but the child died in the womb.

A COMMUNITY

MEMBER

0

5

BaselineN=500

Khudabad Kamal Khan

BaselineN=521

EndlineN=513

EndlineN=569

10

15

20

25

30

25

03 01

22

Figure 10: Mechanism to Provide Financial Support (End line)


Source of Information for Financial Support Mechanisms – CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line. CRPs were actively involved in creating awareness about the mechanism and became the primary source of information in Khudabad.

Presence of a Community Mechanism to Provide Support for Transport – A considerably higher proportion women and their husbands (43% & 47% respectively) had knowledge of community mechanism to provide transport support in Khudabad at end line compared to base line.

Table 41: Source of Information for Financial Support Mechanisms (End line)

Khudabad Kamal Khan

Husband (N=124)

Wife (N=114)

Husband (N=15)

Wife (N=7)

# % # % # % # %

Friend or relative 27 22 12 11 9 60 4 57

CRPs 84 68 86 75 6 40 2 29

TBA/Dai 4 3 4 4 0 0 0 0

Doctor/Nurse/LHV 0 0 1 1 0 0 0 0

LHW 0 0 0 0 0 0 0 0

Husband 2 2 3 3 0 0 0 0

Village Health Committee member 6 5 1 1 0 0 1 14

Other 1 1 7 6 0 0 0 0

0

05

HusbandN=501

HusbandN=551

HusbandN=500

HusbandN=521

Khudabad Kamal Khan

WifeN=517

WifeN=581

WifeN=513

WifeN=569

10

15

20

25

30

40

45

50

35

04

47

43

09 0907

05

11

Figure 11: Knowledge of Community Mechanism to Provide Transport Support


Receive Community Support for EmONC Services – A higher proportion of women and their husbands (23% & 33% respectively) in Khudabad received community support for EmONC services when compared with base line. A 10% increase for husbands and 4% increase for women is a considerable accomplishment within a span of 12 months of intervention.

Types of Support from Community for EmONC services – Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%).

Source of Funds – Few households had their own savings. Around one-fifths of the women (21%) in Khudabad at end line had own funds available for delivery while more than three-fifths had to take a loan (64%).

Table 42: Type of Support from Community for EmONC Services (Reported by women, End line)

Khudabad (N=117) Kamal Khan (N=15)

# % # %

Fund for transport 42 36 6 40

Transport 29 25 2 13

Fund for treatment 39 33 7 47

Referral advise 4 3 0 0

Don't know 3 3 0 0

0

5

Baseline N=501

Husband • Khudabad

Endline N=500

10

15

20

25

30

35

23

33

Figure 12: Receive Community Support for EmONC Services


Table 43: Source of Funds – Wives

Khudabad Kamal Khan

Baseline (N=462)

End line (N=460)

Baseline (N=570)

End line (N=546)

# % # % # % # %

Own funds 101 22 98 21 61 11 88 16

Savings from the family 48 10 28 6 21 4 25 5

Village committee 9 2 25 5 13 2 1 0

Loan 279 60 294 64 449 79 408 75

Selling household items 11 2 14 3 11 2 23 4

Other 6 1 1 0 2 0 1 0

No Answer 8 2 0 0 13 2 0 0

Use of VHC Fund – Around a quarter (24%) of the women who delivered at a place other than home, availed the VHC fund. This is a considerably low utilisation of available funds which needs to be addressed by improving access and reducing the hassle in availing funds.

Mode of Transport – The mode of transport was mostly rented transport; although around 11% also said they used the VHC transport.

0

Khudabad N=75 Kamal Khan N=21

20 %

40

24

05

Figure 13: Avail VHC fund – Birth Audit (Reported by Women)


4.4.1 Postnatal and Postpartum Care

4.4.1.1 Postpartum Care

Women who went to a Health Facility for Postpartum Check-up – Around 28% of the women at base line in Khudabad went to a health facility for postnatal check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high end line.

%

%

Khudabad Baseline N=56

Kamal Khan Baseline N=66

Khudabad Endline N=74

Kamal Khan Endline N=60

0

20

40

60

80

4% 5%2%

100

Own Transport VHC Transport Rented Friends or Relatives transport

Figure 14: Mode of Transport – Birth Audit (Reported by Women)

95% 95%

2%

2%

2%0% 0%

7%2% 3%

88%

0

05

BaselineN=517

Khudabad Kamal Khan

BaselineN=581

EndlineN=513

EndlineN=569

10

15

20

25

30

35

40

28

3738

30

Figure 15: Did you go to a Health Facility for a Post-partum Check-up (Reported by Wives)


0

10

BaselineN=500

Khudabad Kamal Khan

BaselineN=521

EndlineN=513

EndlineN=569

20

30

40

50

60

70

80

90

44

51

85

70

Figure 16: Physical Examination within 24 Hours of Delivery (Reported by Women)

Who Examined the Woman Immediately after Birth – The overall trend remained same for Khudabad at base line and end line with most of the women being examined by lady doctors and TBAs. However, there was an improvement in proportion of women examined by trained TBAs from 0% at base line to 6% at end line.

Postnatal Care

Physical Examination within 24 Hours of Delivery – There was considerable improvement in the proportion of women who had a physical examination within 24 hours of delivery. Around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line. Training health staff and improving the couple’s knowledge had a joint effect on accessing post-partum care.

Table 44: Who Examined the Woman Immediately after Birth (Reported by Wives)

Base line End line

Khudabad (N=229)

Kamal Khan (N=298)

Khudabad (N=361)

Kamal Khan (N=486)

# % # % # % # %


Trained TBA 1 0 1 0 20 6 9 2

TBA 71 31 84 28 144 40 219 45

Nurse 22 10 29 10 27 7 25 5

Lady Doctor 116 51 157 53 156 43 225 46

Gynaecologist 0 0 3 1 1 0 0 0

Other (Specify) 0 0 0 0 0 0 2 0

Don't know 12 5 13 4 0 0 0 0

%


0

10

BaselineN=517

Khudabad Kamal Khan

BaselineN=581

EndlineN=513

EndlineN=569

20

30

40

50

17 19 45

36

Figure 17: Women Who Were Examined Within the First Week (Reported by Women)

Physical Examination within the First Week of Delivery – Women in Khudabad reported as much as a 19% increase in post-partum care within first week of delivery at end line. The overall trend remained same for Khudabad at base line and end line with most of the women being examined by lady doctors and TBAs. However, there was an improvement in proportion of women examined by trained TBAs from 2% at base line to 15% at end line.

Mechanisms for Providing Referrals and Financial Support for EmONC Services

Women were aware of the mechanism run by the project team for helping poor women who need EmONC. They were also aware of the sessions that the project team had conducted on maternal and child health and claimed to participate in the monthly meetings. The VHC arranges vehicle and also provides money for fuel. There were no support mechanisms in Khudabad. Only one group mentioned a community committee where everyone contributed PKR 20 to help pregnant women in case of emergency. The committee was developed by another NGO working in the area.

In Khudabad, men showed awareness about a mechanism to provide financial support but they did not have complete information. Most suggested selling livestock or borrowing money at the time of an emergency.

Table 45: Who Were They Examined By (Reported by Women)

Baseline End line

Khudabad (N=89)

Kamal Khan (N=112)

Khudabad (N=186)

Kamal Khan (N=258)

# % # % # % # %


Trained TBA 2 2 0 0 28 15 13 5

TBA 37 42 68 61 130 70 221 86

Nurse 6 7 3 3 2 1 0 0

Lady Doctor 37 42 30 27 21 11 20 8

Gynaecologist 1 1 0 0 1 1 0 0

Other (Specify) 1 1 1 1 1 1 1 0

Don't know 2 2 3 3 0 0 0 0

The Thardeep programme provided rickshaws and motorcycles for rent; we would only pay for petrol at the time of childbirth. It was good but an ambulance would be much better

COMMUNITY

INFLUENCER

%


Most men said that families usually start saving money from the beginning of the pregnancy. In Kamal Khan however, there was no mechanism for support during emergencies. Men claimed to borrow money from neighbours, relatives or feudal lords or sell livestock to arrange funds for EmONC.

The community suggests developing a committee for providing finance in birthing emergencies. However, low level of trust within the community inhibits this development. The participants requested third party assistance to develop and manage a committee that can help families during childbirth. No one in the community had been able to run such a committee alone, because there is no trust in the community.

The Thardeep VHC fund was considered very helpful by the villagers; although they suggested the need for an ambulance.

There was no mechanism in Kamal Khan to provide financial support in emergency situations. People borrow or mortgage crops for money. Sometimes villagers contribute to transport costs and at other times people beg for money and/or borrow. The land lord also sometimes helps with money or transport. One village had a committee but the manager appropriated the funds for his personal use instead of giving them to families in cases of emergency. The committee was a local fund that is generated by village members contributing to a common goal. Transport is a problem especially in childbirth related emergencies. A committee was setup in one of the villages of Kamal Khan; however it was never implemented or heard of. In the absence of any committee, the villagers (who are all mostly relatives) help each other out.

Financial help solves part of the problem and helps reduce delays in childbirth. However, the lack of transport within the village still needs to be addressed. Having money but no transport also causes unnecessary delays in seeking EmONC, putting both mother and child at risk. Efforts to provide transport services or an ambulance need to be considered as next steps in helping these communities.

4.4.2 Summary of Findings – OBJECTIVE 4 AND 5

A considerably higher proportion of women and their husbands (43% & 47% respectively) had knowledge of community mechanism to provide transport support in Khudabad at end line compared to base line (4% & 9%, respectively). A higher proportion of husbands (33%) in Khudabad received community support for EmONC services when compared with base line (23%). Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%). Around 28% of the women at base line in Khudabad went to a health facility for post-partum check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high during end line assessment. The overall trend remained the same for Khudabad at base line and end line with most of the women being examined immediately after birth by lady doctors and TBAs. However, there was an improvement in the proportion of women examined by trained TBAs from 0% at base line to 6% at end line. Regarding post natal care, around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line.

4.5 OBJECTIVE 6: Readiness of Staff and Supplies and Uptake of Services

Time Taken to be Seen at a Health Facility– The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times.


Table 46: Time Taken to be Seen at a Health Facility (Reported by Women)

Base line End line


# % # % # % # %

<30 min 217 47 239 42 346 75 410 75

30min - 1 Hour 169 37 261 46 104 23 120 22

2-4 Hours 47 10 44 8 8 2 14 3

>4 Hours 6 1 5 1 2 0 2 0

No Answer 23 5 21 4 0 0 0 0

4.6 Health Facility Audit

The health facility audit was carried out both at the time of conduct of base line and end line surveys. The audit included observation and staff response for key information related to management, staffing, availability of medicines and equipment at the BHUs and MCH centres in Khudabad and Kamal Khan. The interventions were directed towards reducing third delay in receiving Emergency Obstetric and Neonatal care at a health facility.

4.6.1 Summary of Findings

Overall, basic health services were being provided in all health facilities. Health promotion activities included health sessions which are conducted mostly in the community through community resource persons. Outreach activities were mostly limited to routine immunisation services and supervision of LHWs.

During the programmatic interventions, a functional referral system was established and patients were being referred for antenatal, postnatal care, delivery and neonatal care as well as FP services from primary care level (i.e. MCH Centre Khudabad and BHU Aminani) to the secondary level. There was no referral system in place in the non-intervention area of BHU Kamal Khan. Use of referral system was found to be effective as understood by the vehicle through VHC used at the time of delivery for transport to health facility though the programmatic data. The availability of transport at the time of emergency obstetric situations is a testament that the project through its interventions (and contributions of VHCs and CRPs) was successful in reducing the second delay in seeking EmONC services (result reflected in section 4.7 for predictors of facility based deliveries).


Table 47: Summary Table for Health Facility Audit

UC Khudabad UC Kamal Khan

Management Protocols No written protocolsWeak monitoring and evaluation mechanism

No written protocolsWeak monitoring and evaluation mechanism

Staff Position Frequent employee turnoverMCH centre was well-staffedSome positions in DHQ remained vacant

Frequent employee turnoverKey positions in UC Kamal Khan remained vacant

Medicines and Supplies Some medicines to treat routine health problems were available; however key drugs and supplies such as gauze for dressing were not available in any facility.

Some medicines were available while many medicines and supplies remained unavailable at the facilities.

Equipment and Instru-ments

Project implementers provided equip-ment to public health facilities

Most basic medical equipment was unavailable No laboratory equipment

Child Delivery Facilities Only available at MCH centreMCH centre converted into 24 hours service providerLabour room in DHQ could not be built

MCH centre had limited timings. No labour room in BHU Aminani

Medicines and supplies were generally available but some important medicines were not in stock such as emergency drugs, anti-hypertensive medicines, water for injection and plasma expanders. A delay of fifteen days was reported in the supply of medicine (from 21st May to 11th June 2013) in the BHU Aminani. Medical equipment was not fully available and some basic medical equipment was not available in BHU Aminani and Kamal Khan. As supported through the project interventions, the MCH Centre Khudabad was well equipped and backed up with an ambulance, oxygen cylinder, ultrasound machine and suction machine. There was no labour room in BHU Aminani or a separate bathroom for the female patients. The presence of such provisions in the MCH centre, reflect that through support in provision of materials and equipment, the said facilities could be enhanced at primary care level (Table 47). The results from MCH also highlight the importance of having adequate availability of materials, medicines and equipment to enhance service utilisation at the primary care level.

There was little monitoring and supervision support from the district level managers. Supervision and monitoring mechanism was based on a short and single monthly visit of the District Support Manager (DSM) of the PPHI to all facilities. Since these DSMs are commonly non-medical personnel, the effectiveness of such single monthly visits is also further understood to be compromised, in adding value to the quality and range of services. The majority of support staff positions were filled in all facilities. Some positions such as medical technician/assistant and Dais were vacant. WMO of MCH Centre Khudabad highlighted the need of the training and refresher courses of the staff e.g. LHVs, Vaccinator and TBAs.

4.6.2 AvailabilityofSpecificHealthServices

Most basic health facilities were being provided by all the facilities including general curative, antenatal, natal, postnatal, EPI and family planning services. However, child delivery services were only provided at the MCH centre. Nutritional rehabilitation services were not available in BHU Kamal Khan and MCH


Centre Khudabad; BHU Kamal Khan also did not provide growth monitoring services for newborns and infants.

Outreach activities are an integral part of a first level healthcare facility (FLCF). These services usually include outreach for routine immunisation, family planning, midwifery, health education, antenatal and postnatal services and surveillance for certain diseases. In the visited facilities primary outreach activities included EPI and supervision of LHWs in BHU Kamal Khan; health education, family planning, antenatal, natal and postnatal care and EPI activities in BHU Aminani; and a whole range of above mentioned services including health education were being offered in MCH centre Khudabad.

As the FLCFs are primary level care facilities, many of the higher level services required by the patients were not be available at the centre. As ascertained through such cases these patients were being referred to secondary and/or tertiary care hospitals. The referrals observed during the end line activity. In the visited facilities patients were being referred for antenatal services, natal and postnatal services as well as child care from BHU Aminani and MCH centre Khudabad while BHU Kamal Khan was not referring any patients. The findings suggest that in the project intervention areas, where interventions focused to enhance the referral of patients and effectively linked the FLCFs with higher tiers of service provision in the health system, the project was successful in increasing the referrals. This thus improved the service delivery as per the patient needs through ensuring the mandated range of services at the FLCF, while also augmenting the referral system.

4.6.3 Health Facility Management

Management Protocols

The clinical protocols for acute conditions such as diarrhoeal diseases, EPI, ARI, Malaria, Tuberculosis and FP were available in some forms. Application and action on these protocols was unclear due to a lack of standardised written protocols and a well-organised monitoring and evaluation system to ensure the quality of services.

Figure 18: Display of Management and Clinical Protocols at BHU Aminani


Staff Position

The FLCFs are mandated to have certain a number of support staff members for efficient functioning and facilitation in the provision of the services from the facility. The majority of technical positions were filled in all three facilities including medical officer, women medical officer, dispenser and medical technician. However some support staff was not posted in in BHU Kamal Khan especially the midwife.

The woman medical officers were attending the facilities on alternate days in BHU Aminani and Kamal Khan. No medical assistant, Dai/midwife or laboratory technician was available in BHU Aminani. Only the MCH centre Khudabad was providing services with well trained, committed and sufficient staff members. As noted earlier, the programmatic efforts to support the MCH centre, as ascertained through the end-line assessment of the MCH centre reflect positive results for the intervention areas. The interventions need to be expanded to include the BHUs in a more robust manner to hence improve service delivery at the FLCF level.

Medicines and Supplies

The FLCFs are required to provide basic/primary health care and preventive facilities for which there is proscribed essential list of medicines/supplies and vaccines. The list includes dressing materials, disinfectants, analgesics, antibiotics, emergency drugs, anticonvulsants, IV fluids, Oxytocin, antihypertensive, anaesthetics, contraceptive and some miscellaneous such as water for injection, ORS, anti-helminthic drugs, anti-malarial drugs, iron tablets and vaccines.

During the end line survey, some key drugs and supplies were not available in any facility. These materials included gauze for dressing, any emergency drugs (except cortisone), anti-convulsants, anaesthetics, plasma expanders, anti-hypertensive drugs. In addition, water for injection (distal water) was available in BHU Kamal Khan only. Family Planning materials, including Condoms and IUCDs were not available in BHU Aminani. Iron-folate tablets were only available in BHU Kamal Khan. Contraceptive pills and injections were not available even in MCH Centre Khudabad. Only 100 packets of ORS were being supplied per month to the BHU Aminani.

As elicited through the findings of the end line survey, the project was partially successful in ensuring the requisite medicines and their disbursement during the implementation period. It is hence concluded that through higher emphasis on ensuing the availability of supplies and medicines, the quantity and quality of service can be enhanced at the FLCF level.

Figure 19: Medicine supply and their storage in BHU Kamal Khan and Aminani respectively


Equipment and Instruments

In addition to medicines and supplies some important equipment should also be available at primary care facilities for provision of the mandated range of services. These include some basic medical equipment such as stethoscope, blood pressure apparatus, thermometer, weighing scales (adult and infant), foetoscope, tape measure and examination couch. Preventive services such as routine immunisation require a functional refrigerator, thermometer and vaccine carriers for adequate storage of vaccines and maintenance of cold chain. As per the government criteria for service provision, some basic laboratory equipment to conduct basic laboratory investigations (e.g. haemoglobin status, Urine and Stool Routine examinations etc.) should also be available such as microscope, centrifuge, test tubes and glass slides. It was found during the end line survey that generally this equipment was available in both the surveyed FLCFs i.e. BHU Aminani and MCH Centre Khudabad in the intervention areas.

Health education material was available in BHU Aminani only. Wheel chairs, stretchers, adult weighing scales and rubber sheeting/mackintosh were available in MCH Centre Khudabad but there was no otoscope, torch or tongue depressor at this centre. An ambulance, oxygen cylinder, ultrasound machine and suction machine were also there and in good conditions. All basic medical equipment except for a wheel chair, stretcher, rubber sheeting, suture set and nebuliser were available in BHU Aminani.

Most of the basic medical equipment was not available in BHU Kamal Khan, and no laboratory equipment was found at this BHU. There was a significant difference in availability of equipment and instruments following the intervention period. However, there was lack of laboratory testing at the intervention area facilities.

From these findings of the end line survey, it may hence be deduced that the project was successful in ensuring the availability of most of the services at the FLCF level; however, ensuring basic laboratory investigations were identified to be the weaker areas of project implementation.

4.6.4 District Health Information Systems

Health Management Information System (HMIS) is considered to be the pillar of the district health system. This pillar is essential to facilitate the monitoring and review of functioning of a health facility and its services. The primary care facility prepares a DHIS report and sends to its supervising authority on a monthly basis. It was found during the end line survey, that in each health facility at least one staff member was trained on DHIS reporting, which was usually the

Figure 20: Infant Weighing Scale at BHU Kamal Khan

Figure 21: Medical equipment at MCH Centre Khudabad

Figure 22: Record of supervisory visit by District Manager PPHI

at BHU Aminani


dispenser. All facilities were sending their monthly reports on a regular basis. Feedback on the DHIS report from the supervisory level was however reported by BHU Aminani only. There were no supervisory visits from the district level to hold a meeting with staff to review the DHIS record at the facility.

4.6.5 Supervision

The general supervision of all facilities was found to be carried out regularly by the PPHI staff. The District Support Manager, PPHI visited these facilities on a monthly or bi-monthly basis. Mostly the supervision was documented by signatures of DSM on some registers/documents. However, there was no documentation for feedback, suggestions and appreciation given. No staff meeting was held during these supervisory meetings.

4.6.6 Inspection

Inspection of Facility through Observation

Overall there was sufficient space available in each facility for provision of services; at least 7 to 10 rooms were present in each facility including stores for medicines and supplies. Waiting areas were available for male and female patients; however the latrines were not separate and were quite unclean, and not in useable condition.

Cleanliness and Overall Condition of the Building

Generally the cleanliness was found to be sub-optimal. The health facilities were littered and unclean. The furniture was unkempt and poor maintenance of the health facility made it look shabby. The best maintained facility in terms of cleanliness and maintenance was the MCH centre of Khudabad. Such improved cleanliness, reflected the success of interventions at this level, however, the BHU level is suggested to adopt similar efforts to maintain cleanliness, and hence ensure better environment for service provision.

Overall status of health facilities in the area

The BHU in Aminani was found to be well equipped with beds, water, electricity, and necessary equipment; however, the BHU was not capacitated to deal with delivery related complications and the service hours were limited to 8:30 am to 2 pm. The MCH centre in Khudabad was also fully equipped to deal with complications and was open till late at night, on the other hand DHQ Dadu had no birthing facilities and that is why most people continued to prefer private health facilities. The staff at private health facilities was reported to be cooperative and highly competent.

There was no other health centre in the area except for the Khudabad MCH centre which was open 24 hours a day. TBAs were reported to take complicated cases to this centre because of its service hours and enhanced capacity to provide Basic EmONC services. This was reported to save families a distant trip to Dadu city at night. The TBAs indicated that equipment provided by the project team to the health centre in Khudabad was useful, and as a result it was well equipped to deal with childbirth and pregnancy related complications. The TBAs gave mixed reviews on the effectiveness of health facilities. It is believed that these mixed responses were based on different experiences – some had positive and some had negative experiences. The general belief was that hospitals were now better equipped to deal with complicated maternal cases.

Paramedical staff only comes when the doctor is there. The health centre is not equipped for emergencies.

A FATHER-IN-LAW.

The medicines prescribed are not available in local stores. There is water and electricity but beds and equipment are in poor condition

AN INFLUENTIAL

PERSON

Staff in public hospitals colluded with private ultrasound, x-ray and blood tests labs. They earn commission on diverting patients to the private clinics.

AN INFLUENTIAL

PERSON


The facility in Khudabad had beds, water, and electricity and was in decent condition. In case of electricity failure, there was a back-up generator available. VHCs suggested the presence of an ambulance but the patients had to pay for the fuel costs themselves. It was shared by the VHC members that Project Team also gave PKR 300-400 for transport in case of emergency. Doctors and staff were available at the Khudabad health facility from 9 am to 2 pm. Medicine supplies, however, were reported to be not available at the facility and had to be purchased elsewhere. After new providers were appointed, the environment was considered to have improved.

In Kamal Khan, there was no hospital nearby. The staff in public hospitals also operates private clinics, where they apparently sell the medicine that is given to them by the government to medical stores. In an emergency, the healthcare providers at the public hospital tell the family to take the patient to a private hospital. Medical staff at public hospitals is frequently absent, or positions are vacant altogether. The only exception is the BHU in Aminani where personnel were reported to adhere to facility timings.

There were no skilled doctors in the Johi hospital, which was the nearest hospital for the villages of Kamal Khan. In Kamal Khan, men claimed the health facilities were poorly equipped and patients weren’t treated properly unless they had a reference from an influential community member. Beds were made available to the poor only on the basis of a strong reference (i.e. by local influential people) or by the patient giving financial incentives to the staff. Doctors in Kamal Khan were not punctual and absenteeism was high. The TBAs claimed that the hospitals were distant and poorly equipped. Even basic facilities such as water and electricity were missing. Pregnant women were mostly taken to private hospitals since public hospitals faced shortage of beds, medical equipment and poor staff presence. The private hospitals were well equipped to deal with complications but were expensive. Other issues such as community rivalries sometimes restrict access to health care in which cases villagers go to health centres in Johi. The hospital in Johi was found to be equipped with beds, electricity and water; however hospital staff often asks for non-monetary gifts such as bundle of cotton stems. Furthermore, the health centre in Johi was reported to frequently suffer from power outages which impeded the provision of EmONC services.

Availability of Skilled Paramedical Staff

Reviews for availability of skilled paramedical staff were mixed. Some members of the community were satisfied. Staff in selected health facilities was trained as part of the intervention and respondents seemed satisfied with the service quality. Community claimed the staff was well behaved in Khudabad; no complaints of scolding or mistreating patients were recorded. However, they were not trained or equipped to deal with all the complications and referred the difficult cases to bigger hospitals. In Kamal Khan, the paramedical staff at the nearest health facilities was poorly trained, rude and unwilling to help. Most qualitative component respondents suggested they were only treated well if they knew someone in the staff. Women in Kamal Khan claimed the paramedical staff was poorly trained and rude. Some also complained that doctors in public health facilities in Kamal Khan mistreated patients and frequently scolded them.

Others were not very satisfied and said they were mistreated at public facilities. Paramedical staff in the Khudabad MCH centre was said to be well-trained, and cooperative; however they did not deal with emergency cases. According to these community respondents trained paramedical staff from public hospitals had their own private practices and was usually available in private hospitals. Other healthcare providers in the hospital had been appointed based on personal contacts and did not provide healthcare. Nurses were said to have very little training or experience. Most people believed that nurses were hired based on personal references. The medical staff was believed to give preference to patients who appeared to be affluent and gave them a much better quality of service. Many women who gave birth in the Khudabad

There was an organisation where we would collect money for a needy hour. But the villagers have stopped giving money. Population wise the village is quite big and there are many such cases every month. The money collected was not enough for all the cases.

A COMMUNITY

MEMBER

There was an organisation where we would collect money for a needy hour. But the villagers have stopped giving money. Population wise the village is quite big and there are many such cases every month. The money collected was not enough for all the cases

A COMMUNITY

MEMBER


The doctors give up treatment at the slightest sign of complication

AN INFLUENTIAL

PERSON

We took a pregnant woman from our family to a hospital. The doctor asked the family to wait as the delivery will take time. Our woman was in severe pain and we didn’t have money to go to another doctor. We brought the woman back home and called the midwife, but the child died in the womb

A COMMUNITY

MEMBER

Government doctors say, come to their private clinic for delivery, in spite of poverty, in emergency we go to their private clinic.

A MOTHER IN-LAW.

In public hospital doctors take care of rich people and give them all kinds of facilities.

A FATHER IN-LAW

MCH centre, reported that there were no special services. The hospital was ill equipped to deal with emergencies. There were no beds, paramedical staff, medicines, water or electricity. According to some, private hospitals were far better equipped.

Suggestions to Improve/Change Overall Health Service Delivery and Particularly EmONC

The community wanted to arrange transport for emergency cases, train the health centre personnel, and keep the centre open for 24 hours. Villagers also wanted to enrol in short courses on maternal and child health so they know about the complications and the need for health care and become self-reliant. Villagers reported to not have transport and it was difficult to take a woman to the hospital especially at night and therefore wanted to be trained in childbirth. They also suggested the need for funds for medical help. Respondents suggested that a focal person from the Thardeep project be provided to help the community upgrade and maintain services and ensure availability of medicines at health centres. Monitoring of health facilities would help improve service quality in health centres. Poor people demanded free medicine and most households suggested the need for an ultrasound machine within the village to avoid travel to city and also to save money. It was opined that more villages required committees similar to those developed by the project. In some villages, the committee was developed; however the people were extremely poor and could not even afford to contribute PKR 10. In such cases, it was perceived that alternative mechanisms such as charity need to be developed and sustained. Funds from the committee or charity were suggested to be used to buy an emergency transport vehicle to facilitate the villagers.

Community members in Kamal Khan said they wanted a health facility that offered round the clock EmONC service with ensuring electricity and water supply, availability of beds, and oxygen cylinders so that families would be able to avoid transport costs to distant hospitals. The Focus group respondents were interested in organising a committee where they put in a fixed amount of money every month to help those in need. Such an organisation was initiated before but did not survive long because people were not educated and were unable to realise the benefits of the system.

4.6.7 Summary of Findings

A third component of the intervention attempted to reduce the delays at health facilities and provided some basic medical equipment to public sector health facilities as well as training paramedical staff and TBAs. The operational hours of the MCH centre were extended from 2 pm to 8 pm. The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times. However, the qualitative findings repeatedly revealed high absenteeism, vacancies of key paramedical staff and unpleasant staff attitudes, especially towards the poor, as a major deterrent to institutional births. Community members frequently complained of poor treatment, being yelled at or scolded or being asked for a reference before they were treated adequately. The project however had little control over these problems.

Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. It was found that use of vehicle arranged through VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery.


4.7 Predictors of Facility Based Deliveries

Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. The multivariate logistic regression modelling was simultaneously tested for goodness of fit (i.e. robustness of the developed multivariate model) to ascertain the best statistical model for identifying predictors of having a facility based delivery during the current pregnancy (Table 48).

It was found that use of vehicle arranged through VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery. These predictors were statistically significant when adjusted for

1. Use of folic acid during the current pregnancy (indicator for better health practices during pregnancy and as a result of antenatal care use),

2. Received TT vaccine (indicator for use of ANC from health facility),

3. Number of living children (indicator for reproductive health burden of a respondent)

4. Last delivery through Caesarean Section (indicator for high risk during current pregnancy)

The follow-up data hence reflects that those who had used a vehicle arranged by VHC for transport to a health facility at the time of delivery were 41 times more likely to have delivered on a facility as compared to those who did not utilise such a transport service. Furthermore, those who had history of abortion/stillbirth during the past pregnancy were almost five times (Adjusted OR=0.22) less likely to deliver at a health facility for the current pregnancy. In this regard, those who were identified to have a higher risk of adverse pregnancy related complications were 3.54 times more likely to deliver at a health facility. The developed multivariate regression model was tested for goodness of fit. This fitness test reflected a very good fit (χ2 goodness of fit p-value <0.97), thus endorsing the robustness of prediction model.

These predictors help us understand that the use of vehicle arranged by VHC at the time of delivery reflects the effectiveness of this intervention in enhancing institutional deliveries. The finding can thus support the conclusion that the transport availability through VHCs is proven to be an effective intervention and successfully enhances the facility based birthing (and concomitantly through skilled birth attendants) becoming more prevalent in the intervention areas. The high value of Odds Ratio of 41 and a wide 95% Confidence Interval (9.3 – 184.4), needs to be understood in the context of relatively smaller number of

Table 48: Predictors of Having Facility Based Deliveries – Program Data

Sig. Adj OR* 95% C.I. for EXP(B)

Lower Upper

Vehicle Used for Delivery at facility - Yes 0.00 41.34 9.27 184.35

Used Folic Acid during current Pregnancy – Yes 0.22 1.85 0.69 4.96

Received TT vaccine current pregnancy – Yes 0.85 0.90 0.32 2.54

Abortion/Stillbirth in last pregnancy - Yes 0.01 0.22 0.65 .729

Number of living children 0.46 .92 .74 1.14

Last delivery through C Section - Yes 0.48 .36 .02 5.9

Current Pregnancy High Risk – Yes 0.03 3.54 1.10 11.34

* Adj OR = Adjusted Odds Ratio


cases using vehicular transport from VHC during the follow-up period. Hence given the broad confidence interval with simultaneous statistically significant result for adjusted odds ratio, also portray that despite small numbers of VHC vehicle service users, the intervention has a profound effect on improving institutional births in served populations.

Those who were screened through antenatal care and identified to be at high risk of pregnancy and/or delivery related complications were found to be 3.54 times more likely to have an institutional delivery. The result supports the notion, that through the programmatic interventions antenatal screening was effective in identifying high risk pregnancies, and those once identified to be at high risk of complication, were more likely to have institutional deliveries and through skilled care providers. It is important to highlight here, that non-LHW covered areas where community based screening is not conducted through community based arm of the health system, the project needs to be commended for enhancing antenatal care at the facility level. This hence resulted in skilled care use at the time of delivery.

Concomitantly the covariate of adverse pregnancy outcome during the last pregnancy (i.e. abortion or stillbirth) leading to less predisposition to have a facility based pregnancy (Adj OR = 0.22) seems to be a biologically non-plausible finding. However, it should be understood that despite having adverse perinatal outcomes in the past there is still possibility that women do not seek institutional deliveries in the served communities. This finding needs to be viewed from a health systems perspective, where history of adverse pregnancy outcome needs to be used for classifying women at high risk of pregnancy/delivery complication. Such cases need to be focused more through programs to enhance skilled birth attendance and institutional deliveries.


The reducing delays in seeking EmONC services was a multi-dimensional intervention project that adopted a diverse set of methods to understand, improve and demonstrate the effect of various interventions at the community and FLCF levels to reduce the three delays in seeking Emergency Obstetric and neonatal care in rural settings of Sindh province.

The project introduced interventions of

1. Community Resource Persons (CRPs) in both men and women segments of the population.

2. Community organization at the village level to formulate Village Health Committees, that played a role to improve the maternal and neonatal health outcomes

3. Establishment and regulation of a community based emergency transport mechanism to reduce the second delay in accessing EmONC care

4. Use of financial support mechanisms to reduce both second and third delay in seeking EmONC care

5. Employing diverse approaches to enhance awareness and knowledge among men and women on various aspects of MNCH through the use but not limited to IEC materials, counselling and group meeting sessions

6. Supporting the staff and facilities through provision of materials and capacity building at the facility level

7. Supplementing referral mechanisms for reducing second and third delays for seeking EmONC services

5.1 KEY FINDINGS

The project was able to demonstrate the effect of various interventions to successfully reduce the 3 delays of seeking and utilising EmONC care at the community and facility level through involvement of CRPs and establishing effective referral systems supported through financial and transport means and executed with the support of Village Health committees.

5.1.1 Birth Outcomes

Birth outcomes improved during the course of the project as assessed through birth audit, end-line survey and programmatic per-post intervention data. It was found that the incidence of adverse pregnancy outcomes reduced in the intervention areas. This was correlated with an enhancement in institutional deliveries and conducted by higher proportion of skilled birth attendants (Trained TBAs, Doctors and LHVs) as compared to the baseline. As narrated by the qualitative participants, support through VHCs (financial and transport) facilitated them to seek timely care through timely referrals and availability of services at the nearest health facility.

Similar improvements have been documented in Pakistan through intervention projects that focused to improve referral systems through better community based linkages and by increasing awareness and knowledge among married women of reproductive ages, and supplementing the skills of TBAs through capacity building44

5.1.2 Facility Based Births

Promoting institutional deliveries is empirically known to reduce maternal and neonatal mortality in developing country settings across the globe and in South Asia including Pakistan45, 46. To produce an impact on the maternal and neonatal mortality in this manner, the demonstrated behaviour change model of knowledge attitudes and practices was adopted in this intervention project. Through improving knowledge

5. Summary, Discussion and Conclusions


among women and their husbands, by employing community resource persons (trusted local residents who could easily access potential beneficiaries easily) to change attitudes through positive deviance methods (promoting birth preparedness and ability to identify complications) and using simple but effective approaches of timely referral and provision of financial and transport support; the project was successfully able to enhance institutional births attended by skilled birth attendants. The findings as demonstrated through multivariate regression revealed that transportation at the time of delivery (once complication is identified) significantly enhances facility based deliveries. This is thus anticipated to reduce maternal and perinatal disease burden and mortality in the project areas.

5.1.3 Antenatal Care

Antenatal care is empirically known to improve the maternal health indicators among women in Pakistan. It is also known to reduce adverse pregnancy outcomes and result in higher proportion of normal weight births with lesser impact on the health of women47 through counselling, iron-folate supplementation and on-going/regular screening for danger signs of complications.48 ,49

Through the project interventions of male and female CRPs and their roles in enhancing knowledge and awareness at the community level, reflected to be the major contributors for enhancing antenatal care among pregnant women in the intervention areas. The project was able to demonstrate enhancement in knowledge levels among both men and men, enhanced capacity to identify pregnancy related complications at the household level, improved referrals for antenatal care, increase uptake of ANC through skilled providers and financial support were the key variables in improving the antenatal care adoption in intervention areas of Dadu. These results as achieved through the innovative techniques of having separate CRPs (male and females) were able to demonstrate that if men (who are decision makers for healthcare seeking and utilisation at the household level and often neglected in intervention projects) have better knowledge about maternal health aspects can result in improved uptake of antenatal care in rural and resource constrained settings of the Sindh province.

5.1.4 Postnatal and Neonatal Care

Similar to the pattern observed for natal and prenatal care, the project was able to demonstrate improvements in awareness about postnatal care, capacity to identify postpartum complications (e.g. PPH) and having immediate support at the community level through community based VHCs can effectively enhance the uptake of postnatal care in rural settings. Given the low prevalence of formal schooling in the targeted communities (especially among females), the project was able to demonstrate the importance of context specific and culturally acceptable interventions of CRPs, with males educating and facilitating male counterparts and females supported through women CRPs. It is understood, that if such pilots are replicated at scale, they may greatly contribute towards increasing the uptake of postnatal and neonatal care (especially during emergency situations) and hence contribute in reducing the maternal and perinatal disease burden. Such successful interventions if taken to scale through implementation research initiatives and development of scale-up plans to help the country to achieve its Millennium Development Goals 4 & 5.

5.1.5 Role of Community Resource Persons and VHCs in Reducing the Three Delays

Use of CRPs and Village Health Committees, especially the gender-sensitive approach adopted in this project, clearly demonstrates the positive effect on knowledge, attitudes, behaviours and practices related to MNCH in the intervention areas of the project. Employing such local resources has been demonstrated


to be highly effective in improving maternal and child health outcomes in the country and specially Sindh (e.g. MARVI workers project by HANDS). This is all the more important in areas where there is a dearth of community based service providers such as LHWs and Community Midwives. Community Resource Persons and Village Health Committees have been employed in the past for various post-disaster relief activities and WASH programmes in the country in recent times. Their involvement at the community level for improving MNCH services utilisation, especially for the poor and marginalised segments of the populations reflects an excellent and implementable model for improving key maternal and child health indicators through reducing the three delays in seeking EmONC care in rural settings of the country.

5.2 LIMITATIONS

It is understood that despite several strengths the project also had some limitations. These pertained to the following aspects

1. Lack of programmatic data (enrolment and follow-up of pregnant women) in non-intervention areas may have limited the capacity to ascertain the natural reduction in the 3 delays and how much was actually possibly attributable to the programmatic interventions. This is however, understood to have less impact, given that base line and end line surveys in both intervention and non-intervention areas somewhat reduced the inability of the project to relate the effect of interventions in Khudabad as compared to Kamal khan areas.

2. The unavailability of the duration of gestation at the time of enrolment during pregnancy (i.e. duration of exposure to interventions) may possibly have resulted in lack of adequate adjustment in regression analysis and inability to use Cox regression methods to acquire adjusted measures of association to gauge the true effect of project interventions. This however, is understood to have led to non-differential misclassification of information given that a pre-post intervention design (in the absence of time duration of exposure) may still be used to accurately assess the predictors of favourable health practices (i.e. outcome of interest of institutional births/skilled attendant) through odds ratios.

3. Loss to follow-up was small for the programmatic data, with birth outcomes elicited for 91.3% of the enrolled and followed women and their respective neonates. This loss to follow-up is however assumed to result in lesser impact on the assessment of outcomes, given that there was no systematic loss to follow-up. Such lack of systematic loss to follow up is hence understood to have less impact on the project results through information bias, given that follow-up studies of relatively small durations (e.g. 12 months) may at times have more than one third (33%) loss to follow-up; while the present study only had 8.7% loss to follow-up.

4. Finding educated female CRPs. In order to include the most marginalised groups, all populations in the UC were targeted. In areas where literacy levels are low, finding literate CRP selection was a challenge and sometimes the eligibility criteria of education was intentionally lowered to facilitate the most marginalised clusters.

5. Creating the VHC fund was one of the most difficult tasks. The project team worked hard to open an account in local bank branches; however the banks were strongly hesitant to open an account for the community. The process was tedious and frustrating at best. The programme was finally able to find a solution – accounts were opened in the local post office rather than a bank - and the VHC fund was operational in the sixth month of the programme; effectively reducing its functional period from 12 months to 6.

6. Availing VHC funds was sometimes difficult due to unavailability of cash on hand. If cash was not available at the time of need, the money had to be retrieved from the account after an emergency for


childbirth was proclaimed. The process was time-consuming and often inconvenient. Although this was partially overcome by reimbursing expenses after the fact, it still meant that families had to seek funds in the face of an emergency and often had to rely on loans as they had done so prior to this intervention.

7. The last intervention involved ensuring that hospitals where women were referred are equipped with staff and medical equipment. While the project successfully trained TBAs and provided some basic equipment to public health facilities the outcome variables such as provision of health care by public facilities were still beyond the project’s control.

8. In retrospect, UC Kamal Khan was a poor control for comparison. Although demographic characteristics for the two UCs (Khudabad and Kamal Khan) were similar; however, floods in Kamal Khan in 2010 had brought considerable relief work and interventions to the UC and these interventions were continuing while our intervention was underway, thus changing indicators in Kamal Khan on a regular basis and making it a poor control.

9. The MCH centre had the highest clientele. These were converted into 24/7 facilities. Frequent turnover of staff at the MCH centre affected referrals negatively. This meant the new staff had to be recruited and trained – an exercise repeated several times during the intervention. FMOs were also not available for several months.

10. The main sample at base line to draw attitudes and practices included women who have given birth in the past 3 years. Women who had given birth in the past 1 year were only a small secondary part of the sample. To maintain consistency at end line, a similar approach was adopted. However, for the purpose of end line evaluation changes in practices can only be measured for women who had given birth in the past one year (when the interventions were implemented). Therefore the primary sample for the purpose of evaluation should have been women who had given birth in the past year.

5.3 LESSONS LEARNED

Several lessons have been learned during the course of this research regarding the project’s implementation, working with the community and challenges in making such interventions more effective. The interventions to create and raise awareness were commendable. Surveys show the active role of CRPs in the community and high rates of coverage. IEC materials were helpful in emphasising critical health seeking situations. The intervention was tailored to the target communities and focused on both men and women to improve information sets. In addition, some further lessons are listed below:

1. The utilisation of VHC funds needs to be addressed through improved access and reducing difficulty in availing the funds. Currently the process of retrieving funds was difficult. It required prior consent of the project staff (done to build accountability of VHC members). This was done in reaction to an incident that happened in one community; where the VHC member retrieved and kept all funds from the account. To discourage this practice and potential misuse of funds; the project team decided to restrict open access to funds by VHC members. Effectively this limited the availability of funds during off hours and emergencies. Households bore the costs first and then claimed reimbursements; which meant that they still had to seek funds and incurred delays.

2. The project worked closely with government partners, however little progress seems to have been made in terms of accountability mechanisms in public hospitals and reduced waiting times. High rates of turnover in public health sector (including 5 new EDOs health, and 3 changes in woman medical officers in 12 months) impeded the effectiveness of the intervention to reduce third delay. Providing training and medical equipment alone will not ensure quality of services in public health facilities.


3. The project was successful in increasing knowledge and in bringing behavioural changes that did not involve significant cost implications, such as ANC visits, maternal and child immunisation, and exclusive breastfeeding. However other behaviours such as preferring facility based births, and going for PNC visits may need more time and positive reinforcement as they have both cost and social implications.

4. At least among some households, social norms favour many children while a lower premium is placed on the health and lives of the mothers and these children. This not only promotes large families but less attention is also paid to each individual family member’s health and wellbeing. It may be useful to understand who among the communities would be less amenable to messages; reach the more amenable ones with conventional interventions but also seek to understand what may be done to reach others.

5. The project duration was too short to bring significant changes in behaviour, particularly since a significant amount of project time was spent in organising and establishing the interventions which left little time for project operations. While creating awareness requires less time; changing behaviours is a tedious and long term process. In order to change behaviours, the community must be able to realise the tangible and intangible gains of new practices and behaviours. Furthermore, positive reinforcements are required for sustained change of behaviours. Economic improvements also play a significant role in this process. Behavioural changes that have financial and economic implications are even harder to achieve in low income communities such as in UC Khudabad.

6. Economic conditions of the selected UC were poor, and hence facility births were not affordable for most. Given these economics realities, most people prefer home based births; even when they realise facility based births are safer. This poor purchasing power in the community also has profound effects on the availability and quality of services and effectiveness of interventions, resulting in little change in birth places across UC Khudabad. Currently, as a result of the interventions, the shift in birthing place from home to public facilities was due to interventions that trained staff, provided equipment and operationalised these facilities to work in 2 rather than one shift (from 8 am to 8 pm, rather than only until 2 pm).

5.4 RECOMMENDATIONS

On the basis of research project findings, the following set of policy recommendations are put forward:

1. As more than 42% of Pakistan’s rural population is not covered by the LHW programme; the CRP model can be considered a potential solution for providing healthcare in non-covered areas, if it is scaled up. Currently the federal and provincial governments are facing technical, human and financial resource constraints for investing in the LHW program and expanding it further into non-covered areas. In this context, the federal and provincial governments; as well as donors can adopt the CRP model as a low cost alternate to the LHWs in the un-covered areas till the government is able to deploy LHWs in these areas. CRPs can be trained to be an effective, community based solution for providing information and referrals to rural, non-covered areas.

2. The CRP programme to work in non-covered areas should have community mobilisation as an integral component. This may take the form of the VHCs, support groups or Community Organisations. The evidence from this research project has demonstrated that active community institutions are essential to ensure community ownership and support mechanism for CRPs to address social and cultural barriers at the local level. Moreover, these community institutions should engage with district health management to initiate the process of local accountability for improving health results.

3. Identification of high risk pregnancy was a predictor for facility based deliveries. This finding endorses the importance of antenatal care in promoting facility based deliveries. This result also helps us to


recommend that whatever the mechanism may be (i.e. risk identification during pregnancy and through LHWs/CRPs/TBAs or other approaches), the public sector possibly in partnership with the private sector should work to provide universal coverage for screening of women during pregnancy.

4. The role of VHC as a predictor of facility based delivery provides evidence for the value of the community based support systems and health financing mechanism for emergency transport services. To gain better results, the community should have an effective role in designing and implementing financing schemes with a focus on poorest of the poor, as well as on local resource mobilisation.

5. TBAs play an important role in referring complicated cases to health facilities and promoting institutional deliveries. Being key local stakeholders, TBAs should be formally included in the health programmes, trained and provided regular supportive supervision to ensure positive results.

6. Properly equipped and functional health facilities play instrumental role in meeting the demand for quality services. Keeping in view the nature of MNCH issues, difficulties in access and rural poverty, the health facilities located in rural areas should be made functional round the clock.

7. The evidence from the research project indicates that frequent transfers of the healthcare providers leads to sub-optimal results. A policy framework should be devised to minimise transfers.


1 National Institute of Population Studies P, Measure DHS. Pakistan Demographic and Health Survey 2006-7. 2008.

Ref Type: Report

2. National Institute of Population Studies P, Measure DHS. Pakistan Demographic and Health Survey 2006-7. 2008.

Ref Type: Report

3. Alam AY, Nishtar S, Amjad S, Bile KM. Impact of wealth status on health outcomes in Pakistan. East Mediterr Health J 2010;16 Suppl:S152-S158.

4. Lawn JE, Zupan J, Begkoyian G, Knippenberg R. Newborn Survival. 2006.

5. Banerjee AV, Duflo E. The Economic Lives of the Poor. J Econ Perspect 2007;21:141-167.

6. Banerjee A, Deaton A, Duflo E. HEALTH, HEALTH CARE, AND ECONOMIC DEVELOPMENT: Wealth, Health, and Health Services in Rural Rajasthan. Am Econ Rev 2004;94:326-330.

7. De B, V, Tonglet R, Van LW. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West? Trop Med Int Health 1998;3:771-782.

8. Nour NM. An introduction to maternal mortality. Rev Obstet Gynecol 2008;1:77-81.

9. Nour NM. An Introduction to Global Women’s Health. Rev Obstet Gynecol 2008;1:33-37.

10. Khan S. Briefing Paper: Gender Inequality, Social Exclusion and Maternal and Newborn Health. 2010. The Research and Advocacy Fund.

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11. Bhutta ZA, Chopra M, Axelson H et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 2010;375:2032-2044.

12. Noor NM. An Introduction to Maternal Mortality. Rev Obstet Gynecol 2008;1:77-81.

13. Turab A, Ariff S, Habib MA et al. Improved accessibility of emergency obstetrics and newborn care (EmONC) services for maternal and newborn health: a community based project. BMC Pregnancy Childbirth 2013;13:136.

14 Morelli R, Missoni E. Training TBAs in Nicaragua. World Health Forum 1986;7:144-149.

(15) Alisjahbana A, Peeters R, Meheus A. TBAs can identify mothers and infants at risk. World Health Forum 1986;7:240-242.

(16) Namboze JM. Maternal Health Services. In: Sofoluwe GO, Bennett FJ, eds. Principles and practice of community health in Africa. Ibadan: University Press; 1985;323-333.

17 Wilson A, Hillman S, Rosato M et al. A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries. Int J Gynaecol Obstet 2013;122:192-201.

18 Hussein J, Kanguru L, Astin M, Munjanja S. What kinds of policy and programmeme interventions contribute to reductions in maternal mortality? The effectiveness of primary level referral systems for emergency maternity care in developing countries. A systematic review. 2011. EPPI Centre.

Ref Type: Report

19 Greenwood BM, Bradley AK, Byass P et al. Evaluation of a primary health care programmeme in The

6. References


Gambia. II. Its impact on mortality and morbidity in young children. J Trop Med Hyg 1990;93:87-97.

20. Greenwood AM, Bradley AK, Byass P et al. Evaluation of a primary health care programmeme in The Gambia. I. The impact of trained traditional birth attendants on the outcome of pregnancy. J Trop Med Hyg 1990;93:58-66.

21. Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368:1133-1135.

22. Maine D, Rosenfield A. The Safe Motherhood Initiative: why has it stalled? Am J Public Health 1999;89:480-482.

23. Maine D, Rosenfield A, McCarthy J, Kamara A, Kucas AO. Safe Motherhood Programmes: Options and Issues. New York, NY, USA.: Columbia University Press, 1991.

24. Fauveau V, Chakraborty J. Women’s health and maternity care in Matlab. In Matlab, women, children and health. In: Fauveau V, ed. Dhaka: ICDDR’B; 1994;109-138.

25. Filippi V, Ronsmans C, Campbell OM et al. Maternal health in poor countries: the broader context and a call for action. Lancet 2006;368:1535-1541.

26. Koblinsky MA, Tinker A, Daly P. Programmeming for safe motherhood: a guide to action. Health Policy Plan 1994;9:252-266.

27. Turmen T, AbouZahr C. Safe motherhood. Int J Gynaecol Obstet 1994;46:145-153.

28. Rutstein SO. The DHS Wealth Index: Approaches for Rural and Urban Areas. 2008. USAID.

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29. Rutstein SO, Johnson K. The DHS Wealth Index. 2004. Measure DHS.

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30. Graneheim UH, Lundman B. Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Educ Today 2004;24:105-112.

31. Darmstadt G. Can Changing Behaviour Save Newborn Lives? http://www.healthynewbornnetwork.org/blog/can-changing-behavior-save-newborn-lives. 2013.

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32. Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc Sci Med 1998;46:981-993.

33. Goldie SJ, Sweet S, Carvalho N, Natchu UC, Hu D. Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. PLoS Med 2010;7:e1000264.

34. Goldenberg RL, McClure EM. Maternal mortality. Am J Obstet Gynecol 2011;205:293-295.

35. Barros AJ, Ronsmans C, Axelson H et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012;379:1225-1233.

36. Goldenberg RL, McClure EM. Disparities in interventions for child and maternal mortality. Lancet 2012;379:1178-1180.

37. Knight HE, Self A, Kennedy SH. Why are women dying when they reach hospital on time? A systematic review of the ‘third delay’. PLoS ONE 2013;8:e63846.


38. Pandey P, Sehgal AR, Riboud M, Levine D, Goyal M. Informing resource-poor populations and the delivery of entitled health and social services in rural India: a cluster randomised controlled trial. JAMA 2007;298:1867-1875.

39. Chowdhury N. Safety lessons from Matlab, Bangladesh. Plan Parent Chall 1998;28-29.

40. Koenig MA, Roy NC, McElrath T, Shahidullah M, Wojtyniak B. Duration of protective immunity conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh. Am J Public Health 1998;88:903-907.

41. DeGraff DS, Phillips JF, Simmons R, Chakraborty J. Integrating health services into an MCH-FP programme in Matlab, Bangladesh: an analytical update. Stud Fam Plann 1986;17:228-234.

42. Yunus M, Sohel N, Hore SK, Rahman M. Arsenic exposure and adverse health effects: a review of recent findings from arsenic and health studies in Matlab, Bangladesh. Kaohsiung J Med Sci 2011;27:371-376.

43. Ronsman C, Vanneste AM, Chakraborty J, Ginnelen JV. A Comparison of Three Verbal Autopsy Methods To Ascertain Levels and Causes of Maternal Deaths in Matlab, Bangladesh. International Journal of Epidemiology 1998;27:660-666.

44. Jokhio, A. H., H. R. Winter, et al. (2005). “An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.” New England Journal of Medicine 352(20): 2091-2099.

45. Janjua, N. Z., E. Delzell, et al. (2008). “Determinants of low birth weight in urban Pakistan.” Public Health Nutrition 12 (6): 789 - 798

46. Jehan, I., H. Harris, et al. (2009). “Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan.” Bulletin of World Health Organization 87: 130

47. Agha, S. and T. W. Carton (2011). “Determinants of Institutional delivery in rural Jhang, Pakistan.” International Journal of Equity Health 10: 31-42.

48. Khan, A. (1999). “Mobility of Women and Access to Health and Family Planning Services in Pakistan.” Reproductive Health Matters 7(14): 40-48.

49. Ashraf, T. (1996). “Maternal mortality: A four-year review.” Journal of the College of Physician and Surgeon Pakistan 6: 159-162.


7.1 Map of district Dadu

7. Appendices


7.2 WOMEN’S QUESTIONNAIRE (QUANTITATIVE SURVEY)

1

CONSENT FORM

Project Information

Research Title: Research on Removing Three Delays for improving Access to Emergency Obstetric and Neonatal Care in Non-LHW areas of Pakistan.

Project Number:-N/A

ERC Ref No: Grant: RAF

Principal Investigation: Mr. Bashir Anjum Organization: Rural Support Programmes Network

Location: Islamabad Phone:051-2822476

Invitation to Participate: :

.

.

.�

.

Purpose of the Study .1 :

(Three Delays)

.

.

Procedures and Process of the Research Study .2 :2030

.

.

.

.

Possible Risks and Discomforts .3 : .


2

Confidentiality .a رازداري : ��و ا�� ب� آ�� ئن �� ڏ ��ئت �� ڏ�� ئ �� ، �� ا�ئن وٽ ان ��ي �� ڻ �� ا�� ن �ئ �

�¥ ��ال ۽ ��اب �� ڳ�� ڳ�� ئ و��ا ۽ ��ب�� ئ�� ا��و�� و��ڙ �ئن ��وه �� ب� ��د � ��و، . ��ئ�� ا�ئ� ��د آ��و�� ڏ�ڳ �ئ°�� ڊ ڏ ��ئت �� ڳ�� ڳ�� ®��ظ ��ي، ��»ئ �ªف ۽ . �� ي ��ئن �� ڏ ��ئت �¨ئڻ� � ��ب� ا

. �ªف �®´�´� ²�³ ڏ�� Interview .b ئ ڳئ¶ئ / ا��و��·� :

ا��و�� ئدي �ئ«º �� ر�ئرڊ �� و��و ۽ ب�� ۾ �� . �� ۾ �»� ��و30 �ئن 20ا��و�� ئن ��ئن �� ئ��ي ´¸ئن � ��و ا�� . ��ئت ��°��³ �� ´ �ئ� و��ي

Possible Benefits .4 ئئ�ا� �«�� :�� ®´�Ã ۾ ��Â ��ڳ �� Áو��ئ�ن ��ب� �ئئ�و � ��و، �� وي �ئ ��ئ �ئئ�ن ۽ �ن Àئول �ئرن �� ب�� ئر��¿ئل �� ¾�ور�� ئن ��

. �� É Ê�®ªح ��ڳ �� »��Ç �� ئ��Å�Æن ۽ ��و��ام ��ڙڻ ۾ ��د ڏ��اFinancial Consideration .5 �¾ئو�� Æئ� :

�� Æ�� ئ�� ب�� جÌ �� و، �� وي �� ئن ۽ ��ئن�� ۾ �¸� و�ڳ �� ئن �� ب� �ئ�Æ ��ئو¾� ´�´®� ��. �ئ��Å�Æن ��ڙڻ ۾ ا�² ��دار ادا ��و

Treatment Alternatives .6 ب�لÆج �� ² ا��: . �� ®´�Ã �ئن �� وا�� ئ��

Available Treatment Options for Adverse Events .7 ن��Æ�� ۾ ��د ��ج ��ن ��Æئ�� ئ��: . �� ®´�Ã �ئن �� وا�� ئ��

Termination of this Research Study & Voluntary Participation .8

Ç�Æ��Â �: �®´�Ã �� ا ��ئم ۽ ر¾ئ�ئرا� �ئڻ�� ئص �ئرڻ� �� بب� �� ي �� ®´�´� ۾ �¸� � و��ا آ��، ان ��ي ��ئن ب� �� ®´�Ã ۾ �¸� و�ڳ �ئ � / ا�� ن �ئ �

��»��Ï ��ئن �®´�Ã ۾ �¸� Ðئ و�� ئ ا��و�� . ��»��Ï ��ئن �¸� و�� ئ �� ب� وÇÎ ا��و�� ² ��ي �� ئ. و�ڳ �� آزاد آ�� و��و �Ñا �� ² �� ئ �� ان ��¸�� ئن �ئن Ç®ª �ئ��، ا�ئن ۽ �� ادارن �ئن ��د ��Ã �� ب ÇÎو �. ب

Available Sources of Information & Questions .9 ئت ۽ �·ئ ڳئ¶ئ �� د ذر��ئ��: . �� ®´�Ã ۽ را¾� ئ�� ب�� Éر ��ڳ �� ئن ��Ïي �� ب� ��Ô ڏ �ئڻ��نھ �ئن �ئب� ��ئت �ئª ��ي �� ئ

�Æئ�ا : ئª ²ا� ��Öب 051-2822476: راب��

Emergency .10 ر�®ئل�ª ئ�� : � ��ئن �� Ç®ª ��ن ¾�ور��ن � �� Øا Ù��«� ² �ئ وڌ��، . �ئ ان �ئ ��زم ��ر��ن ��اÃ�´®� ��SDAR دوران ��»��Ï ��ئن �� ب� ز

��»��Ï ا�ئن �� ا�� م �� ®´�Ã �� دوران ��ئن ۽ ��ئ �� ب�� Â»ئر آ�� ا�ئن ا��ن و�� ئرش ��ا�� . ��»� ��ئن �� Ü ۾ ��ا �� ئ� ��ئن ��Ç ��د �ئª ��ي ��

Authorization (VERBAL) .11 زبئ�(ا�ئزت(: �ß�� Çن ۽ �ئئ�ن بئب�� ن �� ئرم �� آ�� ۽ ��¸�� آ�� آئ�ن �� ®´�Ã ۾ ر¾ئ�ئرا� �Éر �¸� و��س، ان �ئ �´¸�، ��É´ئ ۽ ��»�

آئ�ن ��ئن �� را¾� ئ�� . ��ن �� ئرم �� ´ ب� �ئª �ئ� آ�� ۽ �� ئرم ۾ ��د ��اد �� À �ßئڻ �ڳ آ��. آ�ئ�� ڏ� وئ� آ��. ��ده و�ئ�ª ، �Îبئئ� ۽ �´ئ�� Îئ�� ب�� و

_____________________ Ê�®ª �� ئر��ڙßرا¾°� ڏ�

_________________: ��ن

. ��»��Ï �ڳئ�� ئڻ��ن را¾� ئ�� Ð Ê�®ª ��ي ��، �� ا��و�� و��ڙ زبئ� را¾� ئ�� و�ڳ �� ¸��Ã ��و


3

Women’s Questionnaire (Quantitative Survey)

(Quantitative Survey) عورتن الء سوالنامو To be filled for women who have had a pregnancy during the last 3 years

ڀريو ويندو جنھن کي گذريل ن سالن ۾ حمل ٿيو ھجي.جو ان عورت

Section 1: Household and Basic Information:

: Household and Basic Information سي�شن:01 گھر جي بنيادي معلومات

1. Union council .2 يونين �ائونسل

Taluka تعلقو

3. District ضلعو

4. Household No. گھر جو نمبر

5. Village ڳوٺ

6. Household address گھر جو پتو

7. Caste ذات

8. Religion: مذھب

9. Name of Head of Household گھر جي سربراھه جو نالو

10.

Languages spoken in this household

گھر ۾ ڳالھائيندڙ ٻوليون

1. Sindhi سنڌي

2. Balochi بلوچي 3. Urdu ردو ا

4. Other (specify) (لکو) ا ٻئي

Interviewer visits

.14 .13 .12 .11 انرويو ندڙ جا دورا

Visit دورو

Name of Interviewer انرويو ندڙ جو نالو

Date تاريخ

Start time شروع جو وقت

End time اختتام جو وقت

Response جواب

1st پھريون

2nd ٻيو

3rd �يون

Codes for Question 14 جو وڊ 14سوال نمبر

1. Complete interview مل ان�رويو نام مل ان�رويو Incomplete interview .2 م

3. No one was home وبه نه ھيو ان�رويو ڏيڻ کان ان ارDeclined interview .4 گھر ۾


4

15. Name of supervisor: سپروائيزر جو نالو

16. Name of coder: �وڊر جو نالو

17. Name of data enterer:

�رڻ جو نالوڊي�ا ان�ري

Section 2: Socio Demographics Section

No. Question سوال Response جواب 201. How old are you?

توھان جي عمر �يتري آھي_________ years سال___________

202. Educational Level: (number of years of completed education) تعليمي قابليت (تعليم حاصل �رڻ جا سال)

_________ years سال___________

203. Distance to facility with maternity services: ماء ۽ ٻار جي صحت مر�ز تائين مفاصلو

(Maternity services include care of mother during pregnancy, birthing and immediately post birth) (ماء ۽ ٻار جون صحت سھولتون ، ماء جي حمل دوران سارسنڀال پيدائش ۽

پيدائش کانپوء)

1. <5 km 5 لومي�ر تائين يا گھٽ�

2. >5 km 5 لومي�ر کان مٿي�

204. If <5 km, describe approximate distance to facility w/ maternity services: �لومي�ر کان گھٽ آھي ته ماء ۽ ٻار جي صحت مر�ز 5جي�ڏھن مفاصلو

تائين تقريبن مفاصلو لکو.

1. 1 km 2. 2 km 3. 3 km 4. 4 km 5. 5 km

205. Distance of TBA who provides maternity services: دائي جي�ا حمل جون سھولتون ڏي ٿي ان جي گھر تائين مفاصلو

1. <5 km 5 لومي�ر تائين يا گھٽ�

2. >5 km 5 لومي�ر کان مٿي�

206. If <5 km, describe approximate distance to TBA w/ maternity services: �لومي�ر کان گھٽ آھي ته دائي جي گھر تائين تقريبن 5جي�ڏھن مفاصلو

مفاصلو لکو

1. 1 km 2. 2 km 3. 3 km 4. 4 km 5. 5 km

207. Monthly household Income گھر جي ماھوار آمدني

_____________________

208.

Use observation to see what the primary construction material is used to build the house? Mark all that apply

مشاھدو ري ڏسو ته گھر جي تعمير ۾ ھ�و بنيادي سامان (اھي سڀ جھه لکو جيو استعمال ٿيل آھي) استعمال ٿيل آھي

Walls ڀتيون

1. Bricks – un-plastered چيون سرون

2. Bricks and cement سيمينٽ ۽ سرون

3. Wood اٺ

4. Thatch کن واري ڇت

5. Mud گاري واري ڇت

6. Other (specify) )ا ٻي لکو)

Roof ڇتيون

1. Tin sheets �ين جي شيٽ

2. Roofing tiles ڇت واري �ائيل

3. Concrete پختا (سيمينٽ واري )

4. Wood

اٺ 5. Thatch


5

�ک ۽ پن

6. Other (specify ) �ا ٻي( لکو )

Floor پٽ

1. Cement سيمينيٽ

2. Sand/ mud ي ۽ گاروم

3. Concrete پ�و 4. Tiles ائيلز 5. Wood اٺ�

6. Other (specify) ) �ا ٻي (لکو

209.

How many rooms are there in the household? گھر ۾ �يترا �مرا آھن ؟

(excluding toilet, kitchen, and garage) کانسواء)(غسل خانو ، بورچي خانو ۽ گيراج

______________________

210. What is the ownership status of the house?

گھر جي مال�اٹي حيثيت �ھ�ي آھي؟

1. Owned پنھنجو

2. Rented رائي تي�

3. Other (specify) و ٻيو� (لکو)

211. What is the main source of drinking water?

پيئڻ جي پاٹي جي اھم ذريعو �ھ�و آھي؟

1. Piped پائيپ الئين 2. Open/ closed well/ hand pump

کليل/ بند کوھه /نل�و3. Tube well/ bore

�يوب ويل / بورينگ4. Mineral water

منرل وا�ر5. River/ stream/ canal/ spring

ندي / وا�ر / �ئنال / مينھن جو پاٹي 6. Other (specify) �و ٻيو (لکو)

212. What do you do to make the water safer to drink?

الء بنائڻ الء ڇا �ندا آھيو؟توھان پاٹي کي استعمال

1. Use mineral water منرل وا�ر جو استعمال

2. Boil it اوٻاري �ري

3. Use water filter فل�ر وا�ر جو استعمال

4. Use chlorination/ tablets پاٹي صاف �رڻ واريون گوريون

5. Nothing �جھه به نه

6. Other (specify) �و ٻيو (لکو)

213. Does the household have electricity?

ڇا گھر ۾ بجلي موجود آھي؟

1. Yes ھا

2. No نه

214. What fuel type is used for cooking?

گھر ۾ رڌپچاء الء استعمال ٿيندڙ اينڌڻ؟

1. Gas گيس

2. Wood اٺيون�

3. Oil تيل

4. Other (specify) (لکو) و ٻيو�

215. What kind of toilet facility is available in the household?

گھر ۾ استعمال ٿيندڙ غسل خانو / سنداس جو قسم �ھ�و آھي؟

1. Flush latrine �اموڊ

2. Pit latrine پٽ لي�رين


6

3. Open field کليل زمين


216. How is the household waste disposed?

گھر جو گند �چرو �ٿي اڇاليو وڃي؟

1. Municipal committee collects ميونسپل �امي�ي کٹي وڃي ٿي

2. Garbage man collects ڀنگي کٹي وڃي ٿو

3. Thrown outside in open ٻاھر اڇاليو وڃي ٿو

4. Buried پوريو وڃي ٿو


217.

Does the household have any of the following? ڇا گھر ۾ سامھون ڏنل مان �جھه موجود آھي؟

(tick all that apply) (موجود شين جي نشان لڳايو)

1. Radio ريڊيو

2. Television �يليويزن

3. Iron استري 4. Mobile phone موبائيل

5. Land line/ phone فون

6. Refrigerator فريج

7. Air conditioner نڊيشنرايئر

8. Gas stove گئس وارو چلھو

9. Microwave oven رو و يومائي اون

10. Sewing machine سالئي مشين

11. Washing machine واشنگ مشين

12. Computer مپيو�ر

13. Bicycle لسائي

14. Motorbike ل مو�رسائي

15. Motor car مو�رار

16. Tractor ر��ري

17. Donkey cart گڏ ھه گاڏو

18. Livestock چوپايو

a. Cow/ buffalo ڳئون/ مينھن

b. Sheep/ goat ريرڍ/ ٻ

c. Poultry يون

19. Other (specify) ٻيو جھه (لکو)


7

Section 3: Birth Preparedness and Antenatal care

جي تياري ۽ دوراني حمل جي سارسنڀال ويم - 3سي�شن :

No. Question سوال Response جواب

Skip ي ڏيوڇڏ

301. Do you know about any problems or complications a woman can have during pregnancy?

ڇا توھان حمل جي دوران ٿيندڙ مسئلن ۽ دگين بابت ڄاڻ رکو ٿا؟يپيچ

1. Yes ھا

2. No نه

99. Do Not Know ڄاڻ ناھي

If 2 or 99 then go to 303

يا 2جي�ڏھن پوء سال نمبر 99

تي وڃو 303

302. What complications or problems do you know about?

توھان �ھ�ين پيچيدگين يا مسئلن بابت ڄاٹو ٿا؟ (Mark all that apply)

شين تي نشان لڳايو)(انھن

1. None �جھه به نه

2. Bleeding رت اچڻ

3. Severe headache شديد مٿي ۾ سور

4. Blurred vision اکين اڳيان انڌيرو

5. Convulsions جھ��ا

6. Swollen hands/face/feet ھٿن، پيرن ۽ منھن تي سوڄ

7. High fever تيز بخار

8. Loss of consciousness بيھوشي

9. Difficulty breathing ساھه ۾ ت�ليف

10. Severe weakness گھٹي �مزوري

11. Severe abdominal pain گھٹو پيٽ ۾ سور

12. Accelerated/ reduced fetal movement پيٽ ۾ ٻار جي حر�ت ۾ تيزي / گھ�تائي

13. Water breaks without labor ليبر کانسواء پاٹي اچڻ

14. Other (specify_____________________ (لکو)______________�و ٻيو

99. Don’t know خبر ناھي

303. In your opinion, can a woman die from any problems or complications during pregnancy? توھان جي خيال ۾ عورت حمل دوران پيچدگين ۽

اھم مسئلن جي �ري فوت ٿئي سگھي ٿي؟

1. Yes ھا 2. No ه ن

99. Do Not Know ڄاڻ ناھي

If 99 then go to 305

99يا 2جي�ڏھن پوء سال نمبر

تي وڃو 305

304. From whom did you receive most information about complications that a woman can face during pregnancy?

گھٹو �ري توھان �نھن کان حمل جي دوران

1. No one �نھن کان به نه

2. Friend


8

دوست ايندڙ پيچدگين بابت معلومات حاصل �ندا آھيو؟3. Family/ elders

گھر جا ڀاتي / بزرگ4. Trained health care provider ( Doctor/ LHV/

Nurse/ CMW) تربيتي يافته صحت �ار�ن (ڊا��ر/ ايل ايڇ

وي/ نرسري / مڊوائيف)

5. LHW ايل ايڇ ڊبليو

6. Community Volunteer ڳوٺاٹو رضا�ار

7. Radio / TV ريڊيو ۽ �يليويزن

8. Newspaper اخبار

9. Other (Specify)__________________ �و ٻيو (لکو)________________

305. In your opinion how many antenatal care visits should a pregnant women make to a health facility?

عورت کي حامال توھان جي خيال ۾ �نھن به دوراني حمل سارسنڀال الء صحت مر�ز جا

�يترا دورا �رڻ گھرجن؟

1. At least One گھٽ ۾ گھٽ ھڪ

2. At least two گھٽ ٻهگھٽ ۾

3. At least three گھٽ ۾گھٽ �ي

4. At least four گھٽ ۾ گھٽ چار

5. More than four چار کان وڌيڪ

6. Other (Specify)_____________________ �و ٻيو (لکو)__________________

99. Do not know خبر ناھي

306. From whom did you receive information about antenatal care?

توھان �نھن کان دوراني حمل جي سارسنڀال بابت ڄاڻ حاصل �ئي آھي؟


2. Friend دوست

3. Family/ elders گھر جا ڀاتي / بزرگ

4. Trained health care provider ( Doctor/ LHV/ Nurse/ CMW) تربيتي يافته صحت �ار�ن (ڊا��ر/ ايل ايڇ

وي/ نرسري / مڊوائيف)



7. Radio / TV ريڊيو ۽ �يليويزن

8. Newspaper اخبار

9. Other (Specify)__________________ �و ٻيو (لکو)________________

307. In your opinion what are important components of Antenatal care?

وراني حمل جي سارسنڀال جا توھان جي خيال ۾ دآھن؟زا �ھ�ا اھم ج

1. Checking for Anemia رت جي کوٽ چيڪ �رائڻ

2. Measure Blood Pressure بلڊپريشر ماپڻ


9

(Mark all that apply) (انھن شين تي نشان لڳايو)

3. Weighing وزن رائڻ

4. Immunization (Tetanus injection) ا لڳرائڻ (جھ� ن الء)�

5. Counseling about food and rest requirement کاڌي ۽ آرام بابت صالح مشورو

6. Urine test پيشاب جي چ اس

7. Check the position and movement of the fetus پيٽ ۾ ٻار جي جڳھه ۽ حر ت بابت ڄاڻ

8. Others ٻيو جھه

99. Don’t Know خبر ناھي

308. During your last pregnancy, how many antenatal visits did you have with a healthcare provider?

گذريل حمل دوران توھان دوراني حمل جي سارسنڀال الء صحت ار ن وٽ يترا دفعا

ويا آھيو؟

1. None 2. One

3. Two

4. Three

5. Four or more 6. Not Applicable

ھڪ به نه ھڪ

ٻه�ه

چار ۽ ان کان وڌيڪNot Applicable

If 1 then go to 310

پوء 1جي�ڏھن 310ال نمبر وس

تي وڃو

309. Whom did you see mostly for antenatal visits during previous pregnancy?

حمل دوران توھان دوراني حمل جي گذريل سارسنڀال الء �نھن وٽ ويا؟

1. None �نھن وٽ به نه

2. TBA/ Dai دائي


4. CMW مڊوائيف

5. Private sector LHV پرائيويٽ ايل ايڇ وي

6. Private lady doctor پرائيويٽ ڊا��ر

7. Public sector LHV گورنمينٽ ايل ايڇ وي

8. Public sector doctor گورنمينٽ ڊا��ر

9. Other (Specify_______) ٻيو �و (لکو)

310. Which of these did you receive in your last pregnancy

خدمتون يون�ھ� گذريل حمل دوران توھانيون؟� حاصل

1. Checking for Anemia رت جي کوٽ چيڪ �رائڻ

2. Measure Blood Pressure بلڊپريشر ماپڻ

3. Weighing وزن �رائڻ

4. Immunization (Tetanus injection) ��ا لڳرائڻ (جھ��ن الء)

5. Counseling about food and rest requirement کاڌي ۽ آرام بابت صالح مشورو

6. Urine test پيشاب جي چ�اس

7. Check the position and movement of the fetus پيٽ ۾ ٻار جي جڳھه ۽ حر�ت بابت ڄاڻ

8. Others ٻيو �جھه



10

311. Have you heard about birth preparedness? ڇا توھان ويم جي تياري بابت ٻڌو آھي؟

1. Yes ھا

2. No ه ن

If 2 then go to 313 جي�ڏھن ٻه پوء

313سوال نمبر تي وڃو

312. From whom did you receive information about the birth preparedness?

ويم جي تياري بابت توھان �نھن کان ڄاڻ حاصل �ئي؟


2. Friend دوست


4. Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

تربيتي يافته صحت �ار�ن (ڊا��ر/ ايل ايڇ وي/ نرسري / مڊوائيف)

5. LHW ايل ايڇ ڊبليو 6. Community Volunteer

رضا�ارڳوٺاٹو 7. Radio / TV ريڊيو ۽

�يليويزن8. Newspaper

اخبار 9. Other (Specify)__________________

�و ٻيو (لکو)________________

313. In your opinion, what are some things a woman can do to prepare for birth?

توھان جي خيال ۾ �جھه اھ�يون �ھ�يون شيون آھن جي�ي عورت ويم جي تياري الء

�ري سگھي ٿي؟(Mark all that apply)

(انھن شين تي نشان لڳايو)

1. Arrange transport گاڏي جو انتظام

2. Save money پئسن جو انتظام

3. Identify blood donor نشاندھيرت ڏيڻ واري جي

4. Identify skilled provider تربيتي يافته صحت �ار�ن جي نشاندھي

5. Identify the place for delivery پيدائش جي جڳھه جي نشاندھي

6. Procure clean delivery kits صاف ڊيلوري �ٽ خريد �رڻ

9. Other (Specify) ______________________ _�و ٻيو (لکو)_________________

314. During your last pregnancy, did your family discuss where you would go to deliver?

ڇا گذريل حمل دوران توھان جي گھروارن ويم جي جڳھه بابت ڳالھه ٻولھه �ئي ؟

1. Yes ھا

2. No نه

If 2 then go to 316

ته جي�ڏھن ٻه پوء سوال نمبر

تي وڃو 316 315. If yes, then where?

جي�ڏھن ھا ته �ٿي؟1. Home (Including home of relative/TBA etc)

گھر (مائٽ جو گھر/ دائي وغيره)2. Private facility

خانگي صحت مر�ز3. Public facility

گورنمينٽ صحت مر�ز4. CMW house

مڊ وائيف جو گھر5. Other (specify)___________________

�و ٻيو (لکو)_________________

316. What preparations did you make for your most recent delivery?

توھان پنھنجي آخري حمل دوران �ھ�يون تياريون �يون؟

(Mark all that apply)

1. None �ابه نه

2. Save funds بچتپئسن جي

3. Had antenatal visits with CMW, TBA or other provider


11

(سامھون ڏنل تي نشان لڳايو) سي ايم ڊبليو، دائي يا ٻئي صحت ار ن سان گڏ دوراني حمل جي سارسنڀال جا دورا

4. Visited intended delivery facility رٿيل ويم مر ز جو دورو

5. Arrange transport گاڏي جو انتظام

6. Identify blood donor واري جي نشاندھيرت ڏيڻ

7. Identify skilled provider صحت ار ن جي نشاندھي

8. Identify the place for delivery ويم جي جڳھه جي نشاندھي

9. Procure clean delivery kits ويم جي ٽ جو انتظام

10. Others (Specify)______________ و ٻيو (لکو)________________

Section 4: Skilled Care at Child Birth:

: ٻار جي پيدائش دوران ماھراني سارسنڀال:4ي شن س

No. Question سوال

Response جواب

Skip ڇڏي ڏيو

401. In your opinion, what are some serious health problems that can occur during labor and childbirth that can put the life of a woman in danger?

توھان جي خيال ۾ اھ�ا �ھ�ا اھم صحت جا دوران اچي سگھن ٿا ويم ۽ ويم مسئال جي�ي

جي�ي عورت جي زندگي کي خطري ۾ وجھي سگھن ٿا؟

1. None �و به نه

2. Severe bleeding شديد رت اچڻ

3. Severe headache گھٹو مٿي ۾ سور




7. Labor lasting >12 hours ٻارنھن �ال�ن کان وڌيڪ ليبر

8. Placenta not delivered 30 minutes after baby پليسين�ا من�ن کانپوء به 30ٻار جي پيدائش جي

جو ٻاھر نه اچڻ9. Other (specify)________________

و ٻيو (لکو)__________


If 1 or 99 then go to 404 جيڏھن ھڪ يا

ته پوء سوال 99تي 404نمبر وڃو

402. In your opinion, could a woman die from any problems or complications during labor?

جي دوران ويم توھان جي خيال ۾ ابه عورت پيچيدگين ۽ مسئلن جي ري فوت ٿئي سگھي

ٿي؟

1. Yes ھا 2. No ه ن 99. Do not Know خبر ناھي


ته 99جيڏھن 404سوال نمبر

تي وڃو

403. From whom did you receive most information about danger signs that a women can face during delivery?

جي دوران ايندڙ خطرناڪ ويم توھان نھن کان نشانين بابت معلومات حاصل ئي آھي؟

1. No one نھن کان به نه

2. Friend دوست

3. Family/ elders


12

گھر جا ڀاتي / بزرگ4. Trained health care provider ( Doctor/ LHV/

Nurse/ CMW) (ڊا��ر/ايل ايڇ تربيتي يافته صحت �ار�ن

وي/ نرسري/ مڊوائيف)5. LHW

ايل ايڇ ڊبليو6. Community Volunteer

ڳوٺاٹو رضا�ار7. Radio / TV

ريڊيو / �يليويزن8. Newspaper

اخبار9. Other (Specify)__________________

�و ٻيو (لکو)______________

404. Where did you deliver your last baby? ٻار کي �ٿي جنم ڏنو؟توھان پنھنجي آخري

1. Home گھر

2. CMW/ TBA’s home مڊوائيف يا دائي جو گھر

3. Private Health facility پرائيويٽ اسپتال

4. BHU/ RHC بي ايڇ يو / آر ايڇ يو

5. THQ/ DHQ تعلقو / ضلعا اسپتال

6. Other (Specify) ____________ �و ٻيو (لکو)__________________

405. Why did you deliver there? توھان ڇو اتي ٻار کي پيدا �يو؟

1. Convenience سھولت

2. Cost خرچ

3. Confidence in the provider’s ability صحت �ار�ن جي قابليت تي اعتماد

4. Advice from provider صحت �ار�ن جي صالح

5. Advice from family گھر ڀاتين جي صالح

6. Other (Specify)___________________ (لکو)_________________�و به ٻيو

406. In case of facility delivery, who referred you to go to the facility?

جي نتيجي ۾ �نھن توھان ويم صحت مر�ز تي کي مو�ليو؟

Instruction for enumerator: If answer of Q 404 is any type of facility ask this question.

404ھدايت : جي�ڏھن سوال نمبر انيومري�ر الء جو جواب �و به صحت مر�ز آھي ته ھي

سوال پڇو




4. Friend/ relative دوست / عزيز


6. Doctor/ LHV/ Paramedic ڊا��ر/ ايل ايڇ وي / پئراميڊڪ

7. Other (Specify)__________________ �و ٻيو به (لکو)____________

:ھدايت جي�ڏھن سوال نمبر

جو 404جواب �و به صحت مر�ز آھي ته ھي سوال پڇو

407. Who helped you deliver your baby there?

دوران اتي �نھن مدد �ئي؟ ويم توھان جي



3. LHV ايل ايڇ وي

4. Doctor ڊا��ر

5. Other (Specify)_____________________


13

�و ٻيو به (لکو)________________408. What was outcome of last delivery?

جو �ھو نتيجو ن�تو؟ ويم آخري 1. Normal Health Child

مناسب صحت وارو ٻار2. Still birth

مرده ٻار جي پيدائش 3. Child with congenital abnormality

نقص پيدائشي 4. Other (specify)_______

�و به ٻيو(لکو)____________99. Don’t know

خبر ناھي

409. What was the cost of your most recent delivery? دوران توھان جو �يترو خرچ آيو؟ ويم آخري

1. Rs._____________ �يترا پئسا____________

2. Not Applicable


410. In your opinion, what is the best place for child delivery?

جي جڳھه ويم توھان جي خيال ۾ سڀ کان بھتر �ھ�ي ھئي؟

1. Home گھر

2. Friend/ neighbor/ relative home دوست/ پاڙيسري / عزيز جو گھر

3. Dai/ TBA home دائي جو گھر

4. CMW home مڊوائيف جو گھر

5. LHV facility ايل ايڇ وي جو مر�ز

6. BHU/ RHC بنياد صحت مر�ز/ ڳوٺاٹو صحت مر�ز

7. THQ/ DHQ تعلقو / ضلعو اسپتال

8. Private facility خانگي اسپتال

9. Other (specify)_____________ ٻيو �جھه به (لکو)____________

411. Who is the best person to provide medical care during labor and delivery?

دوران سڀ کان بھتر عالج جون ويم ۽ ويم سھولتون �ير فراھم �ري ٿو؟


11. CMW مڊ وائيف

12. LHV ايل ايڇ وي

13. Doctor ڊا��ر

14. Other (Specify)_______________ ٻيو �جھه به (لکو)______________


14

Section 5: Skilled Care for Obstetric Emergencies خطرناڪ حالت ۾ ماھرانه سارسنڀال زچگي دوران :5س�يشن No. Question سوال Response جواب

Skip

ڇڏي ڏيو501. Do you know of any medical problems you had

before you became pregnant? ڇا حامال ٿيڻ کان پھرين توھان کي �و طبي

مسئلو ھيو؟

1. Yes ھا

2. No نه 99. Don’t know خبر ناھي

502. Have you ever had any complications during your pregnancy?

ڇا توھان کي حمل جي دوران �ي پيچيدگيون ھيون؟

1. Yes ھا

2. No نه



يا 2جي�ڏھن ته پوء سوال 99

تي 601نمبر وڃو

503. If yes when were they? جي�ڏھن ھا ، اھي �ڏھن ٿيا؟

(read responses to the interviewee) (ان�رويو ڏيڻ واراي جا جواب پ�ھو)

(Allow multiple responses) (گھٹا جوابن جي اجازت آھي)

1. Complications during pregnancy حامل جي دوران پيچيدگيون

2. During childbirth پيدائش جي دوران

3. During the first 40 days after delivery ڏينھن کانپوء 40پيدائش جي

504. Was treatment sought for complications? ڇا پيچدگين جو عالج يو ويو؟

1. Yes ھا

2. No نه

If 1 then go to 506

ته 1جيڏھن پوء سوال نمبر

تي وڃو 506 505. If no, why not?

جيڏھن نه ، ته پوء ڇا الء؟1. Did not think the ailment was serious

بيماري کي سنجيدگي سان نه ورتو 2. Thought that will get better on own

سوچيو ته خود بخود ٺيڪ ٿي ويندو3. Discussed with elder or community elder who

suggested staying home وڏن سان صالح مشورو �رڻ کانپوء گھر ۾

رھو4. Other (Specify)______________

(لکو)_____________�و ٻيو


506. If yes, how much time was taken to take decision for the treatment? جي�ڏھن ھا ته پوء عالج �رڻ جي فيصلي وٺڻ

۾ �يترو �ائيم لڳو؟

1. Immediately جلد

2. After 1-6 hours �ال�ن کانپوء 6ھڪ کان

3. After 7-12 hours �ال�ن کانپوء 12کان 7

4. 13-24 hours �ال�ن کانپوء 24کان 13

5. Between 1 and 2 days ھڪ کان ٻنھي ڏينھن جي وچ ۾

6. More than 2 days ٻن ڏينھن کانپوء

99. Don't know خبر ناھي

507. Who was involved in making the initial decision that you (woman) should go for treatment? توھان کي عالج الء وڃڻ گھرجي جو شروعاتي

فيصلو �نھن ورتو ؟(mark all that apply)

(ڏنل جوابن تي نشانو لڳو)

1. Myself خود

2. Husband م�س

3. Father پيء


15

4. Mother ماء

5. Father in law سھرو

6. Mother in law سس

7. Brother ڀاء

8. Sister ڀيڻ

9. Brother in law ڏير

10. Sister in law ڏيراٹي

11. Other (Specify)________________ �و ٻيو (لکو)______________

99. Don't know خبر ناھي 508. Who made the final decision that you should be

taken for treatment? عالج الء وٺي وڃڻ جو آخري فيصلو �نھن

�يو؟

Myself خود

Husband م�س

Father پيء

Mother ماء

Father in law سھرو

Mother in law سس

Brother ڀاء

Sister ڀيڻ

Brother in law ڏير

Sister in law ڏيراٹي

Other (Specify)________________ و ٻيو (لکو)______________

Don't know خبر ناھي

509. Where were you taken for treatment? Prompt: Did you go to see anyone else? (Mark all that apply)

عالج الء توھان نھن وٽ ويا؟جلدي پڇو : توھان ٻئي نھن وٽ به وڃڻ چاھيو

پيا؟ (ڏنل جوابن تي نشان لڳايو)

1. Lady Health Worker ليڊي ھيلٿ ورر

2. TBA دائي

3. Dispensary ڊسپينسري

4. Local government hospital or clinic لول گورنمينٽ اسپتال يا دوا خانو

5. District government hospital ضلعا حومت اسپتال

6. Tehsil Hospital

تعلقا اسپتال7. Private Clinic or Hospital

خانگي دوا خانو يا اسپتال 8. Private Doctor

پرائيويٽ ڊا�ر9. Pharmacist

ميڊيل اس�ور


16

10. Pir/ Faqir پير / فقير

11. Traditional healer (including Hakim & homeopath)

روايتي عالج (ح�يم ۽ ھومپيٿڪ )12. Other (Specify)_____________

�و ٻيو (لکو)______________99. Don't know

خبر ناھي510. If necessary would you go to the same person

again? جي�ڏھن ضروري آھي ته توھان ساڳي ماٹھو

وٽ ٻيھر ويندا؟

1. Yes ھا

2. No نه

If 2 then go to 512

ته 2جي�ڏھن پوء سوال نمبر

تي وڃو 512 511. If yes, then why?

جي�ڏھن ھا، ته ڇو؟

512. If no, then why not? جي�ڏھن نه، ته ڇا الء؟

513. If necessary would you go to the same facility again? جي�ڏھن ضروري آھي ته توھان ساڳي صحت

مر�ز ويندا؟

1. Yes ا ھ

2. No ه ن

If 2 then go to 515

ته 2جي�ڏھن سوال نمبر پوء تي وڃو 515

514. If yes, then why? جي�ڏھن ھا، ته ڇو؟

515. If no, then why not? جي�ڏھن نه، ته ڇا الء؟

516. What prompted you (woman) to seek treatment? توھان کي �ھ�ي شيء عالج �رڻ الء مجبور

�يو؟(e.g. what symptoms)

(مثال طور �ھ�يون نشايون)(mark all that apply)

ڏنل جوابن تي نشان لڳايو

1. Vomiting ال�يون

2. Shortness of breath ساھه ۾ ت�ليف


4. Swelling of face چھري تي سوج

5. Severe lower abdominal pain پيٽ جي ھيٺ حصي ۾ ت�ليف

6. Heavy menstrual bleeding گھٹي ماھواري اچڻ

7. High blood pressure گھٹو بلڊپريشر

8. Fits or convulsions جھا

9. Anemia/ pale color of body

رت جي گھتائي ، جسم جو پيلو ٿيڻ10. Jaundice/ yellow color of body or eyes

سائي/ جسم يا اکين جو پيلو ٿيڻ 11. Other (Specify)____________________

جھه ٻيو (لکو)____________ 99. Don’t Know

خبر ناھي

517. Once the decision was made to take you for treatment, when did you go?

ھڪ دفعو عالج الء فيصلو ٿي ويو ته اوھان ڏھن ويا؟

(i.e.; immediately, e.g. within 1 hour or was there

1. Immediately ان وقت

2. After 1-6 hours الن جي اندر 6کان 1

3. After 6-12 hours


2يا 1جيڏھن نمبر ته پوء سوال

تي وڃو 519


17

a delay) (مثال طور ان وقت ، ھڪ �الڪ جي اندر يا

ان ۾ دير لڳي)

�ال�ن جي اندر 12کان 6 4. Between 1 and 2 days

ھڪ کان ٻن ڏينھن جي وچ ۾ 5. More than 2 days

ٻن ڏينھن کان وڌيڪ99. Don't know

خبر ناھي518. If there was a delay (more than 6 hours in

question above) what was the reason for the delay? جي�ڏھن دير ٿي ته ان جو �ھ�و سبب ھو(مٿي

�ال�ن کان وڌيڪ) 6ڏنل سوال مطابق

1. Had to discuss with family گھر ڀاتين سان صالح مشورو �رٹو ھيو

2. Husband wasn’t home م�س گھر ۾ موجود نه ھيو

3. Had to generate funds پئسن جو انتظام �رٹو ھيو

4. Did not have means of transport گاڏي جو انتظام نه ھيو

5. Didn’t know where to go خبر نه ھئي ته �اڏي وڃٹو آھي

6. Elders/ others prohibited بزرگن / ٻين اعتراض �يو

7. Other (Specify)______________ �جھه ٻيو (لکو)_____________

519. Was it difficult to find the funds to send you for treatment?

ڇا توھان کي عالج الء مو�لڻ دوران پئسا ھٿ �رڻ ۾ مش�الت پيش آئي؟

1. Yes ا ھ

2. No ه ن


520. Where did the funds come from for you to go for treatment? (i.e. who paid?) توھان کي عالج �رڻ الء پئسا �ٿان آيا (�نھن

ڏنا)؟

1. Own funds from my own savings جمع �يل رقم خرچ �ئي

2. From savings from the family گھر ڀاتين جي جمع �يل رقم

3. From village committee ڳوٺاٹي �مي�ي کان

4. From loan قرض مان

5. Selling household items/ livestock etc گھر جون شيون و�ٹي �ري / چوپايو وغيره

6. Other(Specify)_____________________ �جھه ٻيو (لکو)_____________

521. Was it difficult to find transport to send you for treatment?

ڳولڻ ۾ ڇا عالج الء وڃڻ دوران سواري مش�الت پيش آئي؟

1. Yes ھا

2. No نه


522. What was mode of transport to take you for treatment?

ڇا عالج وڃڻ الء �ھ�ي سواري ھئي؟

1. Own transport پنھنجي سواري

2. Public transport پبلڪ �رانسپورٽ

3. Taxi �ي�سي

4. Ambulance ايمبولنس

5. Other (Specify)_________________ �جھه ٻيو (لکو)_______________

523. How much did the transport cost? سواري الء �يترو خرچ آيو؟

1. Rs.____________ پئسا لکو____________

99. Don’t know


18

خبر ناھي524. How long did it take to get there?

اتي پھچڻ الء �يترو وقت لڳو؟1. <1 Hour

2. 1-2 hours

3. 2-4 Hours

4. >4 Hours

�الڪ يا گھٽ 1 �الڪ 2کان 1 �الڪ 4کان 2 �ال�ن کان وڌيڪ 4

525. When you got to the facility how long did you have to wait before being evaluated? جڏھن توھان صحت مر�ز پھتا ته عالج شروع

ٿيڻ کان پھرين �يترو انتظار �يو؟

1. < 30 min

2. 30 min - 1 Hour

3. 2-4 Hours

4. >4 Hours

اڌ �الڪ کانپوء �الڪ 1منٽ يا 30

جي دوران�الڪ 3کان 2 �الڪ کان وڌيڪ 4

526. Who evaluated you? �يو؟ توھان جو معائنو �نھن

1. Lady Health Worker ليڊي ھيلٿ ور�ر

2. Trained Birth Attendant دائي

3. CMW �ميون�ي مڊوائيف

4. Nurse نرس

5. Lady Doctor ليڊي ڊا��ر

6. Gynecologist ڊائناالجس�ڪ

7. Other (Specify)________________ �جھه ٻيو (لکو)____________

99. Don't know خبر ناھي

527. How much did you have to pay? توھان کي �يتري رقم خرچ �رٹي پئي؟

1. Rs.____________ پئسا لکو____________


528. Did they refer you to some other facility or provider? ڇا انھن توھان کي �نھن ٻي سھولت مر�ز يا

صحت �ار�ن ڏانھن مو�ليو؟

1. Yes ھا

2. No ه ن

If 2 then go to 601

2يا 1جي�ڏھن ته پوء سوال نمبر

تي وڃو 601 529. If YES: Where to?

جي�ڏھن ھا : ته �يڏانھن؟

1. THQ تعلقا اسپتال

2. DHQ ضلعا اسپتال

3. Private Facility پرائيويٽ سھولت

4. To the city (to a larger hospital) شھر ڏانھن (�نھن وڏي اسپتال ۾)

5. Other (Specify)________________ �جھه ٻيو (لکو)________________

530. Did you go there? ڇا توھان اتي ويا؟

1. Yes ھا

2. No ه ن

531. Would you go there (to the original Facility) again if necessary?

1. Yes ھا If 2 then go to 533 and if 99 then go to 601


19

No .2 ڇا توھان اتي (پھرين سھولت گھر ) وري ويا؟ ه ن



تي وڃو ۽ 533ته 99جي�ڏھن

تي 601پوء وڃو

532. If yes, then why? جي�ڏھن ھا ته ڇو ؟

533. If no, then why not? جي�ڏھن نه ، ته ڇو نه؟

Section 6: Early Postpartum Care

کانپوء جي شروعاتي سارسنڀال: ويم 6سي�شن

No. Question سوال Response جواب Skip ڇڏي ڏيو

601. In your opinion what danger signs a woman can experience during postpartum period?

کانپوء توھان جي خيال ۾ �ا به عورت ويم �ھ�ين خطرناڪ نشانين کي منھن ڏئي

سگھجي؟

1. None �ا به نه



4. Blurred vision ڌنڌلو ڏسڻ




8. Difficulty in breathing ساھه ۾ ت�ليف

9. Severe weakness گھٹي �مزوري

10. Severe abdominal pain پيٽ ۾ گھٹي ت�ليف

11. Other (specify)_______________ �جھه ٻيو (لکو)___________



99يا 1جي�ڏھن ته پوء سوال نمبر

تي وڃو 604

602. In your opinion, can these danger sign risk the life of women?

توھان جي مطابق، اھي خطرناڪ نشانيون عورت جي زندگي الء خطرو آھن؟

1. Yes ھا

2. No ه ن




تي وڃو 604

603. From whom did you receive the information about danger signs during postpartum period?

توھان ويم کانپوء ايندڙ خطرناڪ نشانين جي باري ۾ ڄاڻ �نھن کان حاصل �ئي؟

1. No one �نھن کان نه

3. Friend دوست

2. Family/ elders


20

گھر ڀاتي/ بزرگ3. Trained health care provider ( Doctor/ LHV/

Nurse/ CMW) تربيتي يافته صحت �ار�ن (ڊا��ر / ايل

ايڇ وي/ نرس / �ميون�ي مڊوائيف)4. LHW

ڊبليو ايل ايڇ 5. Community Volunteer



اخبار8. Other (Specify)_______________

�جھه ٻيو (لکو)____________604. Did anyone examine you in the first 24 hours

after you gave birth?

�ال�ن اندر توھان جي 24 پيدائش کانپوء �نھن معائنو �يو؟

1. Yes ھا

2. No نه

If 2 then go to 607


تي وڃو 607

605. If yes then who examined you?

جي�ڏھن ھا ، ته پوء �نھن معائنو �يو؟

1. Lady Health Worker ليڊي ھيلٿ ور�ر

2. Trained Traditional Birth Attendant تربيتي يافته دائي

3. Traditional Birth Attendant دائي

4. Nurse نرس

5. Lady Doctor

ليڊي ڊا��ر6. Gynecologist

گائنا�الوجسٽ7. Other (Specify)_____________

�جھه ٻيو (لکو)___________ 99. Don't know

خبر ناھي

606. Where were you examined?

توھان معائنو �ٿي �رايو؟1. Home

گھر ۾2. At the TBA’s home

دائي جي گھر3. At CMW’s home/ facility

�ميون�ي مڊوائيف جي گھر/ صحت مر�ز 4. At other private facility

پرائيويٽ سھولت مر�ز تي5. At BHU/ RHC

بنيادي صحت مر�ز/ ڳوٺاٹو صحت مر�ز6. At DHQ/ THQ

ضلعو / تعلقو اسپتال

607. Did anyone come to your home to examine/ evaluate you in the first week after you gave birth?

جي ھڪ ھفتي اندر توھان جي گھر �و ويم معائنو �رڻ الء آيو؟

1. Yes ھا

2. No نه

If 2 then go to 609


تي وڃو 609

608. If yes then who? 1. Lady Health Worker


21

ليڊي ھيلٿ ور�ر جي�ڏھن ھا ته �نھن؟2. Trained Traditional Birth Attendant

تربيت يافته دائي3. Traditional Birth Attendant

دائي4. Nurse

نرس5. Lady Doctor

ليڊي ڊا��ر6. Gynecologist

گائنا �االجسٽ7. Other (Specify)________________

�و ٻيو (لکو)____________99. Don't know

خبر ناھي609. Did you go to a health facility for your checkup

after the delivery?

کانپوء توھان معائني الء �نھن صحت ويم مر�ز ويا؟

1. Yes ھا

2. No نه

Section 7: Neonatal Care شن�ڄاول ٻار جي سارسنڀال نئين : 7سي

No. Question سوال Response جواب Skip ڏيوڇڏي

701. In your opinion what are most common danger sign that a newborn can experience during neonatal period?

ڄاول ٻار نئونتوھان جي مطابق �وبه شروعاتي عرصي دوران �ھ�يون خطرناڪ

نشانين کي ڏسي سگھي ٿو؟

1. None �ابه نه

2. Turning Red ڳاڙھو ٿي وڃڻ

3. Turning Blue نيرو ٿيڻ

4. Not Breathing ساھه نه کٹڻ

5. Not feeding ٿڃ نه پيئڻ

6. Excessive Crying گھٹو روئڻ

7. Not Moving حر�ت نه �رڻ

8. Other (specify)________________ �جھه ٻيو (لکو)_________

99. Don’t know. خبر ناھي


کان 1جي�ڏھن ته پوء سوال 99


702. In your opinion can these danger signs risk the life of child? توھان جي مطابق اھي خطرناڪ نشانيون ٻار جي

زندگي الء خطرو آھن؟

1. Yes ھا

2. No ه ن


703. In your opinion what are most important things to be done for health of newborn?

نئين ڄاول نفورجي مطابق ويم کانپوء توھانٻار جي صحت جي حوالي سان �ھ�يون اھم

1. Bathing ڄمڻ کانپوء وھنجارڻ

2. Covering with blanket or chadar چادر يا �وال ۾ ڍ�ڻ


22

شيون �ري سگھجن ٿيون؟ (Mark all that apply)

(ڏنل جواب تي نشان لڳايو)

3. Cleaning صاف �رڻ

4. Showing to family گھر ڀاتين کي ٻار ڏيکارڻ

5. Feeding with food or medicine غذا يا دوا پيارائڻ

6. Vaccination ��ا

7. Exclusive Breastfeeding صرف ۽ صرف ماء جي ٿڃ ڏيڻ

8. Other (Specify)_________________ �جھه ٻيو (لکو)____________


704. How long after birth was the newborn given bath?

ڄاول ٻار کي �يتري عرصي کانپوء نئين گھرجي؟ جارڻنوھ

Instruction for enumerator: Immediately means bath is given between as soon as the child is born and within 1 hour of birth انيومري�ر الء ھدايتون: فوري طور جو مطلب ٻار

ھڪ �الڪ جي اندر جلد جي پيدائش کانپوء جارڻ گھرجينکان جلد وھ

1. Immediately after birth پيدائش کان فورن بعد

2. 1 to 2 hours after birth �ال�ن کانپوء 2کان 1پيدائش جي

3. 2 to 3 hours after birth �ن کانپوء �ال 3کان 2پيدائش جي

4. 3 to 6 hours after birth �ال�ن کانپوء 6کان 3پيدائش جي

5. 6 hours after birth �ال�ن کانپوء 6پيدائش جي

6. Don’t remember ياد ناھي

705. In your opinion what is Exclusive Breastfeeding? توھان جي خيال ۾ صرف ۽ صرف ماء جي ٿڃ

ڇا مراد آھي؟ مان

1. Breastfeeding with other milk when mother’s milk is short جي�ڏھن ماء جي ٿڃ گھٽ آھي ته ماء جي ٿڃ

سان گڏوگڏ ٻاھريون کير ڏيڻ2. Breastfeeding with other foods when mother’s

milk is short جي�ڏھن ماء جي ٿڃ گھٽ آھي ته ٿڃ سان

گڏوگڏ ٻئي غذا ڏيڻ3. Breastfeeding with water

ڏيڻ پاٹي ٿڃ سان گڏ 4. Only breastfeeding for a period of six moths

مھينن تائين صرف ۽ صرف ماء جو کير ڏيڻ 6 5. Other(Specify)________________

�جھه ٻيو (لکو)___________

706. Did you feed your child with the colostrum (please explain as below)?

پيدائش کانپوء پھرين ٿڃ ٻار کيڇا توھان ؟پياري

(Colostrum is the thick milk that comes first after delivery)

(�ولس�رم جو مطلب اھا گھا�ي ٿڃ آھي جي�ا آھي پياري ويندي پيدائش کان فورن بعد

1. Yes ھا

2. No نه


707. How long after birth did you first put your child to the breast?

1. Immediately within minutes جلد �جھه منٽ کانپوء


23

پيدائش کانپوء �يڏي مھل توھان ٻار کي پنھنجي ڇاتي سان لڳايو؟

2. Hours ______ �الڪ ________

3. Days _______ ڏينھن__________

4. Did not breast feed ٿڃ نه ڏيڻ

708. Why Exclusive Breastfeeding is necessary for newborn? (Mark all that apply)

صرف ۽ صرف ماء جي ٿڃ نئين ڄاول ٻار الء ڇو ضروري آھي؟

( ڏنل جوابن تي نشان لڳايو)

1. Builds strong body مضبوط جسم

2. Good for growth سٺي واڌ ويجھه

3. Keeps the child from getting infections بيمارين کان بچائڻٻار کي

4. Other (Specify)_________________ �جھه ٻيو (لکو)__________

709. How many months did you exclusively breastfeed your child?

�يترا مھينا توھان ٻار کي صرف ۽ صرف ٿڃ ڏنو؟

1. None بل�ل نه

2. Less than six months مھينا کان گھٽ 6

3. Six months مھينا 6پورا

4. Other (specify)______________ �جھه ٻيو (لکو)___________

5. Don’t remember ياد ناھي

710. From whom do/ did you receive the information about newborn care and danger signs?

توھان �نھن کان نئين ڄاول ٻار جي سارسنڀال متعلق ۽ خطرناڪ نشانين جي باري ۾ ڄاڻ

حاصل �ريو؟

1. None �نھن کان به نه

2. Friend دوست


4. Trained health care provider (Doctor/ LHV/ Nurse/ CMW) تربيت يافته صحت �ار�ن ( ڊا��ر ايل ايڇ

وي/ نرس/ �ميون�ي مڊوائيف)5. LHW

ليڊي ھيلٿ ور�ر6. Community Volunteer



اخبار9. Other (Specify)________________

�جھه ٻيو (لکو)___________

Section 8: Community support for emergency services: شن�: ايمرجنسي ۾ ڳوٺاٹي مدد :8سي

No. Question سوال Response جواب Skip ڇڏي ڏيو

801. In your opinion is there any mechanism in the community to provide financial support for eligible families for EmONC services?

توھان جي مطابق توھان جي ڳوٺ ۾ ماء ۽ نئين ڄاول ٻار جي مالي مدد جي حوالي سان �و

طريقي�ار آھي؟

3. Yes ھا

4. No نه



99يا 2جي�ڏھن ته پوء سوال



24

802. If yes, who provided you information about

community based mechanism? جي�ڏھن ھا، ته ڳوٺ ۾ موجود طريقي �ار بابت

ڄاڻ ڏني؟توھان کي �نھن

1. Friend or relative دوست يا عزيز

2. Community Volunteers ڳوٺاٹو رضا�ار


4. Doctor/ Nurse/LHV ڊا��ر/ نرس/ ايل ايڇ وي

5. LHW ليڊي ھيلٿ ور�ر

6. Husband م�س

7. Village Health Committee member ڳوٺاٹي صحت �مي�ي

8. Other (Specify)_______________ �جھه ٻيو (لکو)___________

803. In your opinion is there any community mechanism to provide the support for timely referral?

توھان جي مطابق توھان جي ڳوٺ ۾ ريفرل جي حوالي سان �و طريقي �ار آھي؟

1. Yes ھا

2. No نه


804. Did you receive any support from community for EmONC services?

ڇا توھان ايمرجنسي ۾ ماء ۽ ٻار جي سھولتن بابت ڳوٺ وارن کان �ا مدد حاصل �ئي؟

1. Yes ھا

2. No نه


If 2 or 99 then end the interview and thank the respondent

99يا 2جي�ڏھن ته پوء ان رويو

ختم �ريو ۽ رويو ڏيڻ واري ان

جو ش�ريو ادا �ريو

805. If yes, what support you received from community for services in case of emergency?

جي�ڏھن ھا توھان ڳوٺ وارن کان ايمرجنسي ۾ �ھ�ي مدد حاصل �ئي؟

1. Fund for transport گاڏي جو �رايو

2. Transport سواريء

3. Fund for treatment خرچ عالج جو

4. Referral advise ريفرل جو مشورو

5. Other (Specify)________________ �جھه ٻيو (لکو)__________



��

RSPN Page 1 Birth Audit Questionnaire

��پيدائش بابت معائنو

�� راضپو �

��

��

��

��

Invitation to Participate:

1. Purpose of the Study

2. Procedures and Process of the Research Study

Possible Risks and Discomforts .3

Possible Benefits .4

Financial Consideration .5

Termination of this Research Study & Voluntary Participation .6

Available Sources of Information & Questions .7

Authorization (VERBAL) .8

�� گھر جي شناخت �1. � �� :گھر جي آئي ڊ ي��

2. � ��تعلقو�� 3. �� ڳوٺ��

4. � ��گھر جو پتو��

5. � ��ذات�� مذھب��

�� گھر جون خصوصيتون�� سوال � �� جواب �201. � Distance to facility with maternity services:

فاصلو ائين م ٻار جي صحت مرڪز ت ۽ ماء (Maternity services include care of mother during pregnancy, birthing

and immediately post birth)

1. <5 km ڪلوميٽر تائين يا گھٽ 5 �� >5 km ڪلوميٽر کان مٿي 5 �

7.3 BIRTH AUDIT QUESTIONNAIRE


��


ئش ، ماء جي حمل دوران سارسنڀال پيدا تون ٻار جون صحت سھول ۽ (ماءپوء) ان پيدائش ک ۽

202. � If <5 km, describe approximate distance to facility w/ maternity services:

جي صحت ڪلوميٽر کان گھٽ 5جيڪڏھن مفاصلو ٻار ۽ اء آھي ته م مرڪز تائين تقريبن مفاصلو لکو.

��

203. � Distance of TBA who provides maternity services: دائي جيڪا حمل جون سھولتون ڏي ٿي ان جي گھر تائين مفاصلو

1. <5 km ڪلوميٽر تائين يا گھٽ 5 2. >5 km ڪلوميٽر کان مٿي 5

204. � If <5 km, describe approximate distance to TBA w/ maternity services: ڪلوميٽر کان گھٽ آھي ته دائي جي گھر تائين 5جيڪڏھن مفاصلو تقريبن مفاصلو لکو

1. ��2. ��3. ��4. ��5. ��

205. � �� گھر جي ماھانه آمدني

��رپيا______________پاڪستاني �

206. �

Use observation to see what the primary construction material is used to build the house? Mark all that apply

مشاھدو ڪري ڏسو ته گھر جي تعمير ۾ ڪھڙو بنيادي سامان استعمال ٿيل آھي (اھي سڀ ڪجھه لکو جيڪو استعمال ٿيل

آھي)

Walls ڀتيون

1. Bricks – un-plastered / ڪچيون سرون 2. Bricks and cement / سيمينٽ ۽ سرون 3. Wood / ڪاٺ 4. Thatch / ڪکن واري ڇت 5. Mud / گاري واري ڇت 6. Other (specify) / (لکو )ڪا ٻي

Roof �ڇتيون

1. Tin sheets / ٽين جي شيٽ 2. Roofing tiles / ڇت واري ٽائيل 3. Concrete / (سيمينٽ واري) پختا 4. Wood / ڪاٺ 5. Thatch / ڪک ۽ پن �� Other (specify) / ( لکو )ڪا ٻي�

Floor پٽ �

1. Cement /سيمينيٽ 2. Sand/ mud /مٽي ۽ گارو 3. Concrete / وپڪ 4. Tiles /ٽائيلز 5. Wood /ڪاٺ �� Other (specify) /(لکو) ڪا ٻي�

207. �

How many rooms are there in the household? گھر ۾ ڪيترا ڪمرا آھن ؟

(excluding toilet, kitchen, and garage) نو ۽ گيراج کانسواء) بورچي خا انو ، (غسل خ

________________

208. �What is the ownership status of the house?

گھر جي مالڪاٹي حيثيت ڪھڙي آھي؟1. Owned / پنھنجو 2. Rented / ڪرائي تي 3. Other (specify) / (لکو) ڪو ٻيو

209. �What is the main source of drinking water?

پيئڻ جي پاٹي جي اھم ذريعو ڪھڙو آھي؟

1. Piped ئين� پائيپ 2. Open/ closed well/ hand pump

کليل/ بند کوھه /نلڪو

3. Tube well/ bore / ٽيوب ويل / بورينگ 4. Mineral water / منرل واٽر 5. River/ stream/ canal/ spring

جو پاٹيندي / واٽر / ڪئنال / مينھن

6. Other (specify) / (لکو) ڪو ٻيو

210. �What do you do to make the water safer to drink?

يو؟ ا آھ ڇا ڪند �ء کي استعمال �ء بنائڻ توھان پاٹي

1. Use mineral water / منرل واٽر جو استعمال 2. Boil it / اوٻاري ڪري 3. Use water filter / فلٽر واٽر جو استعمال 4. Use chlorination/ tablets


��


پاٹي صاف ڪرڻ واريون گوريون

5. Nothing / ڪجھه به نه 6. Other (specify) / (لکو) ڪو ٻيو

211. �Does the household have electricity?

ڇا گھر ۾ بجلي موجود آھي؟ 1. Yes /ھا 2. No / نه

212. �What fuel type is used for cooking?

دڙ ين ڌپچاء �ء استعمال ٿ اينڌڻ؟گھر ۾ ر

1. Gas / گيس 2. Wood / ڪاٺيون 3. Oil /تيل 4. Animal Dung / اٺيڇ 5. Other (specify) / (لکو) ڪو ٻيو

213. �What kind of toilet facility is available in the household?

گھر ۾ استعمال ٿيندڙ غسل خانو / سنداس جو قسم ڪھڙو آھي؟

1. Flush latrine / ڪاموڊ 2. Pit latrine / پٽ ليٽرين 3. Open field / کليل زمين 4. Other (specify) / (لکو) ڪو ٻيو

214. �How is the household waste disposed?

؟ٿو گھر جو گند ڪچرو ڪٿي اڇ�يو وڃي

1. Municipal committee collects ميونسپل ڪاميٽي کٹي وڃي ٿي

2. Garbage man collects / ڀنگي کٹي وڃي ٿو 3. Thrown outside in open / ٻاھر اڇ�يو وڃي ٿو 4. Buried / پوريو وڃي ٿو 5. Other (specify) / (لکو) ڪو ٻيو

215. �

Does the household have any of the following? ڇا گھر ۾ سامھون ڏنل مان ڪجھه موجود آھي؟

(tick all that apply) (موجود شين جي نشان لڳايو)

1. Radio / يو�ري 2. Television / ٽيليويزن 3. Iron / استري 4. Mobile phone / موبائيل 5. Land line/ phone / فون 6. Refrigerator / فريج 7. Air conditioner / ايئر ڪن�يشنر 8. Gas stove / گئس وارو چلھو 9. Microwave oven / مائيڪرو و يو اون 10. Sewing machine / س�ئي مشين 11. Washing machine واشنگ مشين 12. Computer / ڪمپيوٽر 13. Bicycle / سائيڪل 14. Motorbike / موٽرسائيڪل 15. Motor car / موٽرڪار 16. Tractor / ٽريڪٽر 17. Donkey cart / گڏ ھه گاڏو 18. Livestock / چوپايو

a. Cow/ buffalo / ڳئون/مينھن b. Sheep/ goat / رڍ/ ٻڪري c. Poultry / ڪڪڙيون

19. Other (specify) / (لکو) ٻيو ڪجھه �

��

� �� سوال � �� جواب � �� ڇڏي ڏيو �

301. � How old are you? �توھان جي عمر ڪيتري آھي

��سالن ۾��

�

�


��


302. � ��تعليم جو قسم؟

�� عام تعليمي�� مذھبي تعليم�� ڪو به نه /اٹپڙھيل4. �� ٻيو ڪو لکو�

��ته سوال نمبر 3جيڪڏھن

تي وڃو 304 �

303. � ��

�تعليمي سطح ( تعليم مڪمل ڪرڻ جا سال)

�� سالن ۾��

�

304. � ��

ڇا توھان وٽ پيدائش جو سرٽيفيڪيٽ يل چئو ۽ تفص ڏسڻ �ء ته ؟(جيڪڏھن ھا آھي

ڪريو) جو نقل �

��ھا��نه��

�

305. � ��

لکو)توھان ڪڏھن شادي ڪئي آھي؟ (سالن ۾ �

�� سال��

�

306. � ��گذريل ويم ڪٿي ٿيو؟

��

ه جي ايت: ان ڳالھ رٽير �ء ھد نوٽ: انيومخاطري ڪريو ته گذريل ويم گذريل ھڪ

�سال اندر ٿيو ھجي.

1. �� خود گھر ۾ /مائٽن ۾

2. �� گھر ۾ دائي ھٿان ��3. ��

گھر ۾ سي ايم ڊبليو ھٿان 4. ��سي ايم ڊبليو جي گھر ��5. ��

مرڪز خانگي صحت 6. ��

�سرڪاري صحت مرڪز7. �� ڪو ٻيو_______��

�

307. � ��توھان ڪھڙو ڪم ڪريو ٿا؟

�� بيروزگار / گھريلو ڪم ڪار

�� ھارپو��

�سوئيٽر سبھڻ��

رسي ٺاھڻ/ ڪپھه ڇن�ڻ��

��قالين ٺاھڻ يا ھٿ جو پکو ٺاھڻ

� �� استاد / ٽيوشن پڙھائڻ�� ڍور ڍڳو پالڻ�� صحت ڪارڪن��دائي�� گھريلو م�زم�� ٻيو ڪو�� .11�� ڪا خبر ناھي��

�

308. � � �� توھان جي مڙس جي عمر ڪيتري آھي؟

��سالن ۾ لکو ______________

�� خبر ناھي��

�

309. � �� مڙس جي تعليم حاصل ڪرڻ جو قسم

�� عام تعليم�� مذھبي تعليم��

�� ته سال نمبر 3جيڪڏھن


��


�� ڪابه نه/ اٹپڙھيل�� ڪو ٻيو لکو��

�

تي وڃو 311 �

310. � ��تعليم حاصل ڪرڻ جا سال (مڙس)

��سالن ۾��

�

311. � ��ان جو روزگار ڪھڙو آھي؟

�� بيروزگار�� مزدور�� ھاري�� آفيس ۾ ڪم ڪندڙ��

�سرڪاري م�زم��

�ڊاڪٽر/ ڊسپينسر � ��وڏو ڪاروبار�� ڪاروبارننڍو �� مزدور��رٽائرڊ�� گھريلو م�زم��مولوي / قاري�� ڪو ٻيو لکو��خبر ناھي��

�

312. � � ��

پيدائش کان پھرين توھان ارجيٻھن آخري ياھئا؟ٿسان ٽدفعو پي يتراڪ

�

_____________ �� گذريل حملن جو تعداد/��

�

313. � �� ڇا توھان جو ڪو به حمل اوچتو ضايع ٿي

�ويو؟��

ايت: اوچتو پيٽ ضايع ٿيڻ جو ھد انيومرينٽر �ء�مطلب قدرتي طور حمل جو ختم ٿيڻ آھي

��ھا��نه��خبر ناھي

� ��ته سوال نمبر 2جيڪڏھن

تي وڃو 315 �

314. � ��جيڪڏھن ھا ته ڪيترا؟� �� تعداد � �

315. � �� يو؟اڇا توھان ھٿراڌو طور ڪو حمل ضايع ڪر �

�� يع حمل ضا اڌو طور يت: ھٿر ٽر �ء ھدا انيومرينڪرائڻ مان مطلب ع�ج ذريعي حمل کي ختم

�ڪرائڻ آھي

��ھا��نه��خبر ناھي��

� ��ته سوال 99يا 2جيڪڏھن

تي وڃو 317نمبر �

316. � �جيڪڏھن ھا ته ڪيترا؟�� تعداد �

317. � �� ھا��


��


�� جيتوھان اڇ۾ ڻيٿسان ٽگذريل دفعي پي

�مرضي شامل ھئي ؟

�نه��خبر ناھي��

318. � ��

رھيو؟گذريل پيٽ ڪيترن مھينن تائين �

��مھينا لکو____________

��خبر ناھي��

�

319. � �� ھن پيدائش کان پھرين گذريل ويم جو ڇا نتيجو

�نڪتو؟

�زندھه ٻار�� مرده ٻار�� اسقاط حمل ��

ر مري ويو ويم جي سورن/ليبر ٻا پوء کان �� ڪو ٻيو��خبر ناھي��

�

320. � ��ويم مان جيڪو ٻار پيدا ٿيو اھو زنده آھي گذريل

؟�� اطري ه جي خ ڳالھ ھدايت: ان انيومرينٽر �ءڪريو ته گذريل ٻار ھڪ سال اندر پيدا ٿيو

�ھجي

��ھا�� نه��


تي وڃو 322 �

321. � ��ان ٻار جي ڪيتري عمر آھي؟

��

ھينن ۾ نھن يا م ٽر ء ھدايت: عمر ڏي ين مر انيو�لکو

�� ڏينھن يا مھينا ______________�� خبر ناھي��

�

322. � ��ٻار پيدا ٿيو؟ هڇا توھان کي ڪو مرد �

�� ھا��نه��خبر ناھي

��ته سوال 99يا 2جيڪڏھن


323. � ��ٿيا؟ توھان کي ڪيترا مرده ٻار پيدا �

��ڪل��پٽ��ڌيئرون�� ئي سگھان اٻڌنٿي �

��

�� سوال � �� جواب � ��ڇڏي ڏيو

401. � ��

ريسورس پرسن يٽميونڪ اڪ ٺو ڇا توھان ڙندڪ مڪ۾ صحت تي ٺوڳ(سي.آر.پي) يا

؟ يوڪدورو نڪارڪ



تي وڃو 404 �

402. � ��

اغذڪتصويرن وارو معلوماتي ڇا توھان � يو؟ڪحاصل


�


��


403. � ��

ري تصوي يء يڙھڪمان اغذڪتوھان انھ؟ئڪمعلومات حاصل �

��

الڀحمل جي دوران جي سار سن ��

��ڻاھٺويم �ء تياري ۽ ويم کي محفوظ �

��

ين ۽ ني جي سار ارٻ اولڄويم کانپو۽ ماءالڀسن �

�

404. � ��

توھان ويم کان پھرين دوران حمل اڇ ويا اسڪچ /معائني ؟�ء �

1. ��ھا��نه�� .2


تي وڃو 501 �

405. � �� /توھان ويم کان پھرين دوران حمل معائني

نھن وٽ ويا؟ اسڪچ ڪ �ء �

1. ��ريسورس پرسن (سي.آر.پي) يا يٽميونڪنڪارڙڪندڪ مڪ۾ صحت تي ٺوڳ

2. �� رشتيدار يا ڳوٺ جي بزرگ

3. �� لي�ي ھيلٿ ورڪر

4. ��دائي��ڊسپينسري�� .56. ��

بنيادي صحت مرڪز/ ڳوٺاٹو صحت �مرڪز

7. ��ني مرڪز/ خاندا ار جو صحت ماء ۽ ٻ

�بھبودآبادي جو مرڪز8. ��

�تعلقا/ ضلعا اسپتال9. � ��

�خانگي صحت مرڪز يا اسپتال10. � �� خانگي ڊاڪٽر��11. �� فارماسسٽ��12. �� پير / فقير��13. ��

�� روايتي ع�ج (حڪيم يا ھيموپٿڪ)

14. �� و ٻيو ڪ ��خبر ناھي��

�

406. � ��

/نرس رڪٽاڊ( ڇا اھو ساڳيو صحت ڪارڪن وغيره) ويم �ء ھيو جنھن سان توھان

�رابطو ڪيو؟

ھا��نه��

�

407. � ��

باري ۾ اڇ مائرن جي صحت جي يء انھ

�ھا��نه��

�� 409ته سوال نمبر 2يڪڏھن

�تي وڃو


��


؟نيڏمعلومات �

408. � �� معلومات ملي؟ يڙھڪ جيڪڏھن ھا ته �

� �

409. � ��

ين اڇ نئ جي صحت جي باري ارٻ اولڄانھيء؟نيڏ۾ معلومات �


�� 411ته سوال نمبر 2يڪڏھن

�تي وڃو

410. � ��معلومات ملي؟ يڙھڪ جيڪڏھن ھا ته �

� �

411. � ��

خطره اڙھڪتوھان جي خيال ۾حمل دوران ا؟ٿسگھن يٿ


2. Severe headache شديد مٿي ۾ سور

3. Blurred vision اکين اڳيان انڌيرو

4. Convulsions جھٽڪا

5. Swollen hands/face/feet ھٿن، پيرن ۽ منھن تي سوڄ



8. Difficulty breathing ساھه ۾ تڪليف

9. Severe weakness گھٹي ڪمزوري

10. Severe abdominal pain گھٹو پيٽ ۾ سور

11. Accelerated/ reduced fetal movement پيٽ ۾ ٻار جي حرڪت ۾ تيزي / گھٽتائي

12. Water breaks without labor اچڻ يبر کانسواء پاٹي ل

13. Other (specify_____________________

ڪو ٻيو (لکو)______________

99. Don’t know � اھي خبر ن

�

412. � �� ڪيترا دفعا عائني �ء ني حمل م توھان دورا

�ويا؟


�

413. � �� ڇا توھان ڪنھن مسئلي يا سڀ ٺيڪ آھي ني حمل سارسنڀال جي دورا اٹڻ �ء ابت ڄ ب

ويا؟ معائني �ء �

1. �� ويس ئني �ء عا قط م ڪو مسئلو نه ھيو ف �

2. ��ھا، ڪو مسئلو ھو

��خبر ناھي

��ته سوال 99يا 1 ھنڪڏجيوڃتي و 416نمبر �

414. � ��


��


�جيڪڏھن ھا ته ڪھڙو مسئلو ھو؟

415. � ��

يونڙھڪ معائني دوران توھان

يون؟ڪ حاصل خدمتون

1. Check the woman’s weight وزن ڪرائڻ

2. Check for anemia (looked at the eyes) رت جي کوٽ چيڪ ڪرائڻ

3. Urine test پيشاب جي چڪاس

1. Check the position and movement of the fetus پيٽ ۾ ٻار جي جڳھه ۽ حرڪت بابت ڄاڻ

4. Ultrasound of the abdomen �راساونٽجو ال ٽپي

5. Counseling for nutrition کاڌي بابت ص�ح مشورو

6. Counseling about where to deliver

بابت ص�ح مشورو ھهڳويم جي ج 7. Other ---- (please specify) ٻيو ڪجھه

416. � ��

ڇا حمل يا دوراني حمل سارسنڀال جي معائني دوران ڪو مسئلو / پيچيدگي

�سامھون آئي؟

�� ھا ��

�نه��

� ��ته سوال نمبر 2جيڪڏھن

تي وڃو 501 �

417. � �� مسئ� پيش آيا؟توھان کي ڪھڙا �

��

يڪ دايت: ھڪ کان وڌ يومرينٽر �ء ھ انجواب اچي سگھن ٿا جيڪي �ڳو ٿين انھن

تي نشان لڳايو �

ٽون�� .1 الي �2. �� ساھه ۾ تڪليف��3. ��ور�� گھٹو مٿي ۾ س �4. ��منھن تي سوڄ��5. ��

پيٽ جي ھيٺ حصي ۾ سور �6. ��

�گھٹو رت اچڻ 7. ��بل�پريشر ۾ واڌ��8. ��جھٽڪا��9. �� رت ۾ گھٽتائي��10. ��سائي��11. �� ڪو ٻيو��خبر ناھي��

�

418. � �� مسئلي جي شدت ڇا ھئ ؟

��ھلڪو�� وچولو��Severe /شديد�

�

419. � Were you referred to a health facility? ڇا انھن توھان کي ڪنھن ٻي سھولت مرڪز

�ڏانھن موڪليو؟

��ھا�� نه��

�

420. � ��

ڇا توھان کي خبر آھي ته حمل دوران �ٻچيداني جو معائنو ڪيو ويو؟

��ھا��نه�� خبر ناھي��

�

�


��


��

�� سوال ��جواب� ��ڇڏي ڏيو�

501. � �� اصل ۾ توھان ڪٿي ويم ڪرائڻ چاھيو ٿي؟

�� ان باري ۾ ڪڏھن به نه سوچيو

�� پنھنجي يا مائٽ جي گھر ۾

� ��دائي جي گھر ۾ ��

�سي ايم ڊبليو جي گھر يا مرڪز تي��خانگي اسپتال��

�بنياد/ ڳوٺاٹو صحت مرڪز�� تعلقا / ضلعا اسپتال �� ڪو ٻيو��خبر ناھي��



502. � �� ڇا توھان اتي ئي ٻار کي جنم ڏنو؟



تي وڃو 506 �

503. � �� جيڪڏھن توھان اصل ۾ سوچيل جڳھه تي

يل ، توھان جڳھه تبد يو ته پوء ويم نه ڪرا�ڪرڻ جو فيصلو ڇو ورتو؟

1. ��ريسورس پرسن (سي.آر.پي) يا يٽميونڪ نڪارڪ ڙندڪ مڪ۾ صحت تي ٺوڳ

جي ص�ح تي2. ��

�مڙس جي ص�ح تي 3. ��

�عزيز يا مٽ مائيٽ جي ص�ح تي4. ��وڏن جي ص�ح تي �5. ��

�دائي جي ص�ح تي 6. ��

سي ايم ڊبليو جي ص�ح تي7. ��

صحت ڪارڪن جي ص�ح مشوري �مطابق ڇاڪاڻ جو

8. ��مسئ� پيدا ٿيا

9. �� پئسا نه ھجڻ ڪري

10. �� ڪو ٻيو��

�

504. � �� جڳھه جي تبديلي ڇا جي ڪري ٿي؟

�� مسئلوليبر ۾ ��

�� ٹھو ھر ۾ ويم ڪرائڻ �ء صحيح ما گ

�جي نه ھجڻ ڪري �� ڪجھه ٻيو��

�� ته سوال 3يا 2جيڪڏھن


505. � ��

۾ تڪليف ھئي ويم جي سورن/جيڪڏھن ليبريو؟ لو ھ ڪھڙو مسئ ته پوء �

� �


��


506. � �� جيڪڏھن گھر ۾ ويم نه ٿيو ته توھان کي

ڏانھن منتقل ھهڳج يٻ نھنڪجي �ء ويم�ڪرڻ جي فيصلي وٺڻ ۾ ڪيترو ٽائيم لڳو؟

1. ��انھي وقت/جلدئي��2. ��

پوء 16 ان ڪ�ڪن ک 3. ��

پوء 612 ان ڪ�ڪن ک �4. �� پوء 12 ان ڪ�ڪن ک �5. ��

�ھڪ يا ٻن ڏينھن جي وچ ۾6. ��

کان وڌيڪٻن ڏينھن ��خبر ناھي��

�

507. � ��

ورتو؟ نھنڪڪٿي ويم ڪرائڻ آھي بابت فيصلو ��

يڪ دايت: ھڪ کان وڌ يومرينٽر �ء ھ جواب اچي ان�سگھن ٿا جيڪي �ڳو ٿين انھن تي نشان لڳايو

1. ��خود عورت��مڙس�� .23. �� پيء �� 4. �� ماء �� 5. �� سھرو��6. �� سس��7. �� ڀاء �� 8. �� ڀيڻ��9. �� ڏير��10. �� ڏيراٹي��11. ��

�عزيز يا مٽ مائٽ12. �� ڳ��

�وٺاٹن يا بزرگن 13. ��

ريسورس پرسن (سي.آر.پي) يٽميونڪ ڙندڪ مڪ۾ صحت تي ٺوڳيا

نڪارڪ 14. �� ڪو ٻيو��خبر ناھي�

�

508. � �� ويم ڪٿي ٿيو؟

�� گھر��

�صحت مرڪز ڏانھن ويندي��

�صحت مرڪز (لکو)��

پرائيويٽ ڪلينڪ يا اسپتال��

�مقامي (سرڪاري) اسپتال يا ڪلينڪ�� اسپتالضلعا �� تعلقا اسپتال�� سٽي اسپتال�� منتقل دوران�� ڪو ٻيو��خبر ناھي��


تي وڃو 701 �

509. � ��

ڪنھن ٻئي جڳھه تي وڃڻ بابت سوچڻ ۾

1. �� انھي وقت/ جلدئي��2. ��

پوء 16 ان ڪ�ڪن ک 3. ��

پوء 612 ان ڪ�ڪن ک �

�


��


ڪيترو وقت لڳو ۽ اصل ۾ اتي پھچڻ ۾ �ڪيترو وقت لڳو (سواري جو وقت)؟

4. ��پوء 12 ان ڪ�ڪن ک �

5. �� ھڪ يا ٻن ڏينھن جي وچ ۾

6. �� ٻن ڏينھن کان وڌيڪ


510. � �� جيڪڏھن جتي ويم ٿيٹو ھيو اتي پھچڻ ۾

�دير ٿي ته ان جو سبب ڇا ھيو؟

�� خاندان جو فيصلو وٺڻ ۾ وقت لڳو

�� ئيپئسن جي گھٽتا �� سواري ۾ ڪمي��

�خبر نه ھئي ته ڪٿي وڃٹو آھي��ڪو ٻيو�� خبر ناھي��

�

511. � ��

پئسا کي ع�ج خاطر موڪلڻ �ء ڇا توھان مشڪ�ت پيش آئي؟ھٿ ڪرڻ ۾ �

��ھا�� نه��خبر ناھي��

�

512. � � ��

پئسا توھان کي ع�ج خاطر موڪلڻ �ء�ڪٿان آيا ؟ (ڪنھن ڏنا)؟

� �

513. � �� تيء ڪصحت يٹاٺوڳتوھان اڇ مي جي کاتي ا

؟ئيڪمدد حاصل ڪرو اڪمان �

��ھا�� نه��

�

514. � ��

ھڪ دفعو ع�ج ڪرائڻ جو فيصلو ٿي ويو ته توھان کي ڪٿي وٺي ويو؟( صحت

�مرڪز جو نالو لکو)

1. Dispensary

ڊسپينسري2. Local government hospital or clinic

لوڪل گورنمينٽ اسپتال يا دوا خانو3. District government hospital

ضلعا حڪومت اسپتال

4. Tehsil Hospital تعلقا اسپتال

5. Private Clinic or Hospital خانگي دوا خانو يا اسپتال

6. Private Doctor پرائيويٽ ڊاڪٽر

7. Pharmacist مي�يڪل اسٽور

8. Pir/ Faqir پير / فقير

9. Traditional healer (including Hakim & homeopath)

روايتي ع�ج (حڪيم ۽ ھومپيٿڪ )10. Other (Specify)_____________

ڪو ٻيو (لکو)______________99. Don't know �خبر ناھي

�


��


515�

�� تيء ڪصحت يٹاٺوڳتوھان اڇ مي جي ا

؟ئيڪطرفان سواري جي مدد حاصل �

�ھا�� نه��


تي وڃو 518 �

516�

�� تيء ڪصحت يٹاٺوڳ اڇ مي جي طرفان ا

؟ئيو نيڏسواري جي مدد فورن

��ھا�� نه��


تي وڃو 519 �

517 �� يو؟ڳل ائمٽ يتروڪنه، ته ھنڪڏجي

��

518�

��توھان اتي ڪيئن ويو؟

�پيادل�� .12. ��پنھنجي سواري��3. ��

ڪرائي واري سواري(ٽيڪسي يا �رڪشو)

4. �� تيء ڪصحت يٹاٺوڳ مي جي طرفان ا

سواري5. ��

�عزيز يا مٽ مائٽ جي سواري

�

519 ��اتي پھچڻ ۾ ڪيترو وقت لڳو؟

��منٽن يا ڪ�ڪ ۾ لکو

�

520

�� پئسا ڏيٹا پيا؟ توھان کي سواري �ء ڇا �

� ھا��نه��خبر ناھي��

� ��ته سوال 99يا 2جيڪڏھن


521

��ڪيترا؟جيڪڏھن ھا ته �

��

�

��

�� سوال � � �� جواب� ��ڇڏي ڏيو�

601. � �� جڏھن توھان ويم گھر ويا ته چڪاس کان

ٹو پيو؟ڪرپھرين توھان کي ڪيترو انتظار

��منٽ يا ڪ�ڪن ۾ ____________

�

602. � �� توھان جي چڪاس ڪنھن ڪئي؟

�� لي�ي ھيلٿ ورڪر

�� لي�ي ھيلٿ وزيٽر��

�تربيت يافته دائي��

�غير تربيت يافته دائي�� نرس�� ڊاڪٽرياٹي � ��گائناڪا�جسٽ�� ٻيو ڪو��ڳو نٿو ٿي��خبر ناھي

�


��


603. � �� اتي توھان کي ڪيترن ماٹھن رابطو ڪيو؟

� �

604. � �� انھن ڇا ڪيو؟

��

يڪ دايت: ھڪ کان وڌ يومرينٽر �ء ھ انجيڪي �ڳو ٿين انھن جواب اچي سگھن ٿا


�� توھان کي ھيٺ �ٿو��

، نبض، حرارت ۽ ساھه جي بل�پريشرجي چڪاس ڪئي رفتار �

�� ڊرپ لڳائي �� ڪو ٻيو لکو��

�

605. � ��

. مثال طور نارمل ويمانھن توھان کي ڇا ٻڌايو؟يا آپريشن يندوٿ �

� �

606. � ��توھان کي ڪيترا پئسا ڏيٹا پيا؟

Rs._____________ �ڪيترا پئسا____________

�

607. � ��توھان کي ع�ج شروع ڪرڻ کان پھرين ڇا

چيو ويو ئسا ڏيڻ �ء ؟پ �

�� ھا�� نه��خبر ناھي�



608. � ��جيڪڏھن ھا ته توھان وٽ پئسا ھئا

�� ھا�� نه��خبر ناھي�

�� ته سوال نمبر 1جيڪڏھن

تي وڃو 610 �

609. � ��جيڪڏھن توھان وٽ پئسا نه ھيا ته ڇا انھن �توھان جو ع�ج ڪرڻ کان انڪار ڪيو؟

�� ھا �� نه ��خبر ناھي�

�

610. � ��يد ڪرڻ ا شئي خر ٻي ڪ ئن کانسواء انھن دوا

يو؟ �ء چ �

��ھا�� نه�


تي وڃو 701 �

611. � �� آيو؟جيڪڏھن ھا ته ڪيترو خرچ �

� �

��

�� سوال � ��جواب� ��ڇڏي ڏيو�

701. � ��توھان جو ويم ڪنھن ڪيو؟

�� ڪنھن به نه/ مريض خود

�� رشتيدار (ڪو صحت ڪارڪن نه ھيو)

��

غيرتربيتي يافته م�وائف يا دائي (ڳوٺ

�


��


�۾ موجود)��

�لي�ي ھيلٿ ورڪر�� دائي��نرس / م�وائف�� ڊاڪٽرياٹي��گائناڪا�جسٽ�� ڪو ٻيو�� خبر ناھي��

702. � ��تا ويا؟ ور اپاء ا ويم دوران ڪھڙ �

��



�� ويمپنھنجي رستي سان �

� �� / بوتلڊرپ �� ٻيون دوائون�� اوزارن جي ذريعي کولڻ�� مشين جي ذريعي ڇڪڻ��ڪو ٻيو��خبر ناھي��

�

703. � �� ويم ھيو؟اھو ڪھڙي قسم جو �

�� نارمل��

�اوزارن جي ذريعي��

�آپريشن جي ذريعي�� خبر ناھي��

�

704. � � �� جڏھن ليبر شروع ٿيو تڏھن توھان ڪيترن

�مھينن جي حمل سان ھيا؟

�� مھينن ۾ لکو

�� خبر ناھي��

�

705. � ��ڇا ليبر شروع ٿيڻ وقت توھان صحت مند ھيا؟

�� ھا�� نه��خبر ناھي��

�

706. � ��ليبر ڪيتري وقت تائين ھيو؟

��ن ۾ ڪ�ڪ �


�

707. � �� ٻاھر آئي؟ اورھہڇا

ھا�� نه��خبر ناھي��

�� ته سوال 99يا 2جيڪڏھن


708. � ��

پوء ان دائش بعد ڪيتري دير ک پي ار جي ٻٻاھر آئي؟ اورھہ �

�� منٽن ۽ ڪ�ڪن ۾


�

709. � �� ويم دوران يا پھرين توھان کي جھٽڪا آيا؟

�� ھا�� نه�� خبر ناھي��



710. � ��

ھٽڪا ج وء ائش کانپ يد ٻار جي پ جيڪڏھن ھا ته

�� ھا��نه��

�


��


ٿي ويا؟ بند �

711. � ��تي ھهڄڳ يٻ يڪٿ ڇا انھن توھان کي

منتقل ڪيو؟ /ليوڪمو �

ھا�� نه��

�� 715سوال نمبر 2جيڪڏھن �تي وڃو

712. � ��جيڪڏھن ھا ته ڪيڏانھن؟

� �

713. � �� ڇا توھان اتي ويا؟

�� ھا�� نه��


تي وڃو 715 �

714. � ��ا�ء �� جيڪڏھن نه ته ڇ � � �

715. � �� اڳيان توھان ڇا ڪيو؟

� �

716. � �� جيڪڏھن ضرورت پئي ته توھان وري اتي

�ويندا؟

�� ھا�� نه��

�

��

�� سوال � ��جواب ��ڇڏي ڏيو

801. � �� ويا؟ ارسنڀال �ء س م کانپوء ڇا توھان وي �

� ھا�� نه��

��انٽرويو ختم ته 2جيڪڏھن �ڪريو

802. � ��يو؟توھان احت ڪر ا وض وي ڪنھن وٽ �

��



�� ريسورس پرسن (سي.آر.پي) يا يٽميونڪنڪارڪ ڙندڪ مڪ۾ صحت تي ٺوڳ

�� غير تربيتي يافته دائي

�� لي�ي ھيلٿ ورڪر

�� لي�ي ھيلٿ وزيٽر��دائي�� نرس/ م�وائف�� ڊاڪٽر�� گائناڪا�جسٽ��

�ٻيو ڪو (وضاحت ڪريو)��خبر ناھي��

�

803. � ��

ڇا توھان معمول مطابق چڪاس يا ڪنھن �مسئلي خاطر ويا؟

1. �� معمول مطابق��ڪو خاص�� خبر ناھي��


تي وڃو 805 �

804. � ��ڪھڙو مسئلو ھو؟

� �

805. � ��

�� ھا�� نه��

�


��


ڇا توھان ويم دوران مليل سارسنڀال کان ئامطمئن ھ �

806. � ��

ساڳي جيڪڏھن ضرورت پوي ته توھان�ماٹھو وٽ ٻيھر ويندا؟


��

ته سوال نمبر 2جيڪڏھن تي وڃو 808

ته سوال نمبر 99جيڪڏھن تي وڃو 809 �

807. � ��جيڪڏھن ھا ته ڇو��

808. � �� جيڪڏھن نه ته ڇو نه��

� �

809. � ��

جيڪڏھن ضرورت پئي ته توھان ساڳي �صحت مرڪز وري ٻيھر ويندا؟


��

ته سوال نمبر 2جيڪڏھن تي وڃو 811

انٽرويو ختم ته 99جيڪڏھن �ڪريو

810. � ��جيڪڏھن ھا ته ڇو��

811. � �� جيڪڏھن نه ته ڇو نه��

��


7.4 CHECK LIST OF FOCUS GROUP DISCUSSIONS AND INDEPTH INTERVIEWS

FGDs IDIs


Community 1 2

Influential persons 2 5 5

TBAs 2 2 5 5

VHCs 3 -

Female community 2

Father in law 1 2 3 5

Mother in law 2 2 3 5

Wives 2 2 6 6

Husbands 2 2 6 6

Total 13 16 28 32


IN DEPTH INTERVIEWS/ FOCUS GROUP DISCUSSION

Location --------------------------------------------- Date--------------------------------------------------- Time: start ------------------ finished------------- Interviewer -------------------------------------------- Number of respondents -----------------------

Group 1. Husbands 2. Wives 3. Father in Laws 4. Mother in Laws 5. Religious Leaders 6.TBAs 7. Community members

Thanks I want to thank you for taking time to discuss the topic today.

Intro My name is ____________________________ and I would like to talk to you about community awareness for emergency obstetrics and neonatal care in non-LHW covered areas and capacity building of public sector health care providers for delivery of EmONC services.

Purpose Capacity building of health care provider to manage complications during pregnancy, natal, postnatal period and neonates and improve institutional or facility based deliveries, particularly for complicated deliveries, thereby contributing to reduction in maternal and neonatal mortality.

Confidentiality All responses will be kept confidential. This means that your interview responses will be part of the findings but we will ensure that any information we include in our report does not identify you as the respondent.

Duration The discussion will last somewhere from 60-90 minutes.

Tape/Notes

I will be taking notes during this interview. We may also tape the sessions because we don’t want to miss any of your comments. Is it okay with you if we tape the discussions? If we are on tape, please be sure to speak up so that we don’t miss your comments. We would also like to inform you that you can refuse to answer any of the questions at any time during the discussion/interview. This will not affect your participation in the rest of the interview.

Clarifications Are there any questions about what I have just explained?

Consent Are you willing to participate in this interview? No. Question Probe

1. What you know about EmONC? 1) Knowledge about pregnancy 2) Knowledge about natal, post natal and neonatal

2. What is the normal practice regarding delivery of your children?

1) Place of delivery (Home by self/ relative, Home w/ TBA, Home w/ CMW ,TBA/ Dai’s home ,CMW/ TBA’s home, BHU/ RHC, THQ/ DHQ, Private Health facility etc

3 Which place is safer for delivery of your children?

1) Which place respondents preferred 2) Why is this place preferred by respondent (Ask

reason) 3) Any bad experience to not choose other places

4 Do you think that you and your family have sufficient knowledge/information about recognizing pregnancies and complicated pregnancies?

1) Information required during pregnancy 2) Knowledge about natal, post natal and Neonatal (prompt for what they know) 3) Knowledge about complications during Pregnancy (prompt for what complications)

5. Do you think that health facilities of your area are adequately equipped to deal complicated pregnancy cases?

1) Need of bed for patients 2) Tools for handling emergency 3) Personnel 4) Electricity, water, other infrastructure

6. Do you think that Para medical staff of 1) Staff Qualification

7.5 FOCUS GROUP DISCUSSIONS AND INDEPTH INTERVIEWS


your health facility is properly skilled? 2) Can manage complications 3) Cooperative/ polite

7. Are there social restraints on women’s movement for care seeking purpose?

1) Normally who takes decision regarding delivery of children

2) Can women go outside home alone for this purpose

8. What would you like to improve/change overall health service delivery and particularly EmONC?

1) More training of staff 2) More equipment need 3) Current equipments are not in good condition 4) Infra structure of your facility 5) Arrangement of transport that may be used to

transport women to facilities in emergency 6) Availability of medicines 7) Anything else (prompt)

9. Any other suggestion that you may have?

1) Generating funds on community level for arrangement of transport for emergency

Thank you for your time

Notes __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


7.6 CRP MODEL

Communities were linked directly to health facilities using a referral mechanism implemented through trained Community Resource Persons (CRPs). The CRPs were community activists identified from within the community through a process of dialogues with the VHCs and the local community. They were trained by RSPN to undertake community mobilisation activities for health related interventions. They disseminated information in the community through group meetings and household visits and referred women to health facilities.

Selection Criteria for CRPs

CRPs were selected on the following criteria:

• Resident of the assigned area.

• CRPs must be literate (can read and write) and qualify the literacy test given by project team. Higher qualification will be preferred

• Age between 18- 45 years and preferably married

• Family support for mobility in the assigned area

• Willing to go house to house in assigned population (for female CRPs only)

Capacity Building

CRPs were trained in a 7 day training course that has been developed by RSPN. The training focused on: a) sensitisation of the CRPs towards maternal and child health situation, discussing reasons of poor health and their roles and responsibilities for improvement in the situation, b) enhancement of CRPs’ knowledge about available modern contraceptive methods, c) building the capacity of CRPs to use the IEC material and undertake behaviour change activities through group meetings and household visits; and d) quality record keeping of their work.

Group Meeting

Trained male and female CRPs created awareness among the MWRAs, their spouses and extended family members including mother-in-laws and father-in-laws about the maternal and neonatal health through group meetings. Each pair of CRPs had approximately 75 married couples in their catchment population. Male and female CRPs covered all these target couples in about 5 group meetings. Separate meetings were organized with 15-20 men/women. Each round of group meeting was conducted on the following topics as detailed below:

Round-1: Importance of antenatal care, food and rest for pregnant women, danger signs during the pregnancy and referral

Round-2: Birth preparedness including the saving at family level for emergency needs, use of clean delivery kit, complicated deliveries and referral

Round-3: Danger signs during delivery, postpartum period, neonates and referral and neonatal care


Household Visits

After completion of the group meetings phase (2 months), female were involved for household visits for a period of 10 months. They conducted household visits of the each MWRA at least once in a month as mentioned below:

Referral and Follow-up

Female CRPs referred women for services to the health facilities and follow up with each MWRA by giving them a referral slip. Each referral slip had three parts; one for the client (i.e., the pregnant woman), the second to be given to the project’s community mobilisation officers (CMOs) and the third to be retained by CRPs. CMOs would collect these slips from each CRP on a weekly basis, after which the project’s research officers would visit the health facilities and meet with healthcare providers to track whether the referred clients had actually visited the facilities. Additionally, the research officers validated 5% of all clients (selected randomly) who availed services from health facilities through an interview and by tallying information with the CRP record.

Monitoring of the Community Mobilisation Activities

The group meetings and household visits conducted by the CRPs were monitored by the social organizers and VHCs. The social organizers monitored the first group meeting of each CRP and validated at least one meeting conducted by each CRP. The findings of the monitoring were shared with the CRPs and they were provided guidance to conduct the group meetings as per methodology. The female CMO also monitored and validated a certain percentage of the household visits conducted by the female CRPs on monthly basis. In addition, the VHCs also provided feedback about the monthly visits of the female CRPs.

MWRA Status Discussion/ Information to be provided to MWRA

Non-User (not using any FP methods)

CRPs visited such women once in a month and motivated them to use contraceptive methods by providing them information on benefits of birth spacing. Such women were also provided information regarding nutrition, child health and survival and immunization including polio vaccination.

User (currently using any FP method)

Visited at least once in a month. Discussed the proper use of contraceptive methods. Were motivated the user for continuation of method if side effects are normal or expected, and were referred to MBLCs if the side effects are unusual. Such women were also provided information on nutrition and child survival, health and routine immunization including polio vaccination.

Pregnant Women Pregnant women (1-8 month of pregnancy): Such women were visited twice in a month and CRPs provided information to them on importance of ANC, danger signs during pregnancy, risky pregnancies, birth preparedness, and importance of CDKs.

Pregnant women in last month of pregnancy (9th month): CRPs visited such women thrice in a month and provided them information on natal care, danger signs during delivery, postnatal care, Postpartum Hemorrhage (PPH) and neonatal care

Women with neonates (0-28 days after delivery)

Such women were visited thrice in a month by CRPs. First visit was conducted immediately after or on first day of delivery in case of home delivery. CRP provided information about neonatal care (bathing, initiation of Breast Feeding (BF) immediately after delivery, etc.), information about PPH, will identify the cases of PPH and made arrangements for referral of mother to health facility if she displays signs of PPH. Second and third visit was conducted in the first week and third week after delivery respectively to reinforce the message and practices related to neonatal care.


Honorarium

Female CRPs were taken on board for 12 months (2 month group meeting phase and 10 months household visit phase) and were paid an amount of PKR 1500 per month as honorarium. Male CRPs were only taken on board for a 2 month period of group meetings, and were paid PKR 1500 per month as honorarium.


Rural Support Programmes Network (RSPN)House No. 7, Street 49, F-6/4, Islamabad, PakistanTel: 00-92-51-2829141,2829556, 2822476,2826792,2821736Fax: +92 51 2829115Email: [email protected]: www.rspn.org

RAF-RSPN Endline Report

Documents

Transcript of RAF-RSPN Endline Report