Group 2 Rh

INTERVENTIONS TO REDUCE MATERNAL MORTALITY IN DISTRICT BUNER, NWFP PAKISTAN BY DR TARIQ DR MARIAM DR TEHSEEN DR IFTIKHAR

The tragic fact is that every year more than half a million women lose their lives as a result of complications due to pregnancy or childbirth, the causes of maternal mortality are clear – as are the means to combat them. Yet women continue to die unnecessarily

Peter Salama, UNICEF’s Chief of Health

MATERNAL MORTALITY     



Largest health inequity in the world Total of 536000 maternal deaths worldwide in 2005, Developing countries accounted for 99% (533000) of these deaths., Sub-Saharan Africa and South Asia accounted for 86% of global maternal deaths. In the developing world, woman’s lifetime risk is one in 76, compared with one in 8,000 in the industrialized world. The riskiest place to give birth is Niger, where that risk is estimated to be one in seven.

IN PAKISTAN  





We are losing three women per hour More than 30,000 young women die every year in Pakistan. More than 80 % women are delivered at home in the presence of unskilled birth attendants. In majority of secondary and tertiary healthcare centers, emergency obstetrical care is not available on twenty-four hour basis.

CAUSES OF MATERNAL MORTALITY 13%

2% D ire c t In d i r e c t o th e r s 85%

DIRECT CAUSES PPH 10%

P e rp s e p

5% 33%

7% 7% 3% 7%

e c la m p s ia AP H O b s tr la b a b o rtio n

12%

16%

e m b o lis m

ia tro g e n ic o th e r

NWFP  Population

constitutes 13.40% of the population of Pakistan as per 1998 Census.  The Population of this Province has increased at an average Annual Growth Rate of 2.82% as compared to National Growth Rate of 2.69%.3

BUNER one of the rural districts

www.nwfp.gov.pk

Buner  District

Buner takes its name from its headquarter town Buner which in Sansikrat mean ‘FOREST”.  north: Swat and Shangla  west: District Mardan and Malakand agency  South: Swabi District  East: River Indus, Haripur and Manshera.

BASIC INDICATORS Basic Indicators

Buner

NWFP

Pakistan

Total population (thousands)

506

17736

154000

Area in sq. km

1865

74521

796096

Population urban/rural ratio

0/100

17/83

34/66

Sex ratio(number of males over 100 females) at birth

100

105

108

Population density (person per sq. km)

271

238

166

Population annual growth rate

3.85

2.67

1.9

Provincial Census Report of N.W.F.P October 2000:85

Population structure: Population Groups

Standard Demographic Percentages

Estimated Population (2005)

Under 1 year

2.4

12,145

Under 5 years

17.7

89,570

Under 15 years

49.14

248,695

Women in child bearing age (1549 years)

21.7

109,812

49-65 years

8.4

425,080

Above 65 years

3.6

182,177

Literacy status: Literacy rate

Buner

NWFP

Pakistan

Total

26

40

49

Adult male

44.1

57.5

62

Adult female

7.2

21

35

Multiple Indicators Cluster Survey of N.W.F.P,May 2002.

Indicators on Women and Fertility Behaviors: Women & fertility behavior Total fertility rate

Buner NWFP

Pakistan

3.9

4

4.0

Contraceptive prevalence rate

7

31

36

Antenatal care coverage by any attendant (%)

48

47

43

Antenatal care coverage by skilled attendant (%)

27

34

35

29.1

28

20

Birth Care by any attendant

95

99

99

Post-birth Care by skilled attendant

59

30

24

Post-birth Care by any attendant

86

90

67

Birth Care by skilled attendant

Mean Children Ever Born to Married Women 1549 years

4.8

4.9

District Population Profile MSU N.W.F.P (Buner) Islamabad 2002.

Health facility availability: health facility 25

20

20 15 10 5

Series1

8 4

2

1

M CH C

BH U

RH C

ar ie s dis pe ns

ho sp ita ls

0

Conclusion These indicators don’t show a better picture than that of overall NWFP which suggests that health services in Buner needs improvement and coordinated efforts to meet national as well as millennium goals

POSSIBLE AREAS OF INTERVENTION Women NWFP

  

Buner Rural

 

Men

Intervention 

 

BCC Involving husbands to improve Maternal health Advocacy Female literacy

Illiterate Low socio class Lack of knowledge regarding health Follow cultural norms Non decision makers, dependant on the husbands or other family members

  



Literate comparatively Decision makers Un aware of the wives pregnancy related needs Lack of knowledge of access to andutilization of Emoc services

Intervention Family Planning

Intervention Prenatal care

PREGNANCY

POSSIBLE AREAS OF INTERVENTION

PREGNANCY

Abortion Miscarriage

Complications Intervention To improve Availability Accessibility & Affordability Of the services

Uncomplicated Pregnancy & delivery

Intervention Safe Abortion

Intervention Management Of PPH, Sepsis Eclampsia & other complications

Intervention Post natal care

REDUCING MATERNAL MORTALITY Primary prevention BCC •This is required for individuals, families, communities and providers if maternal health outcomes are to improve. • Effective health promotion and communications have contributed to better maternal health outcomes by reducing risky practices and promoting positive ones

PREVENTION OF UNWANTED PREGNANCY

PRIMARY PREVENTION ADVOCACY •e.g., to raise resources—is an important component it is often undertaken without a clear connection to actions that can actually help to reduce maternal deaths, such as to improve the retention and functioning of staff at rural health facilities. •We need advocacy directly aimed at crucial interventions, & at monitoring the implementation & outcome of programs .

PREVENTION OF UNWANTED PREGNANCY

PRIMARY PREVENTION FAMILY PLANNING •Address unwanted and poorly timed pregnancies and the health risks associated with them. •Access to voluntary, safe, affordable, and appropriate family planning information and services is critical to reducing unwanted pregnancies and to reducing the risks of maternal mortality

PREVENTION OF UNWANTED PREGNANCY

One flaw in this strategy is that it assumes that people do not use health facilities because they lack information or planning skills

SECONDARY PREVENTION: •SAFE BIRTH KITS

•Are small packets that are given or sold to pregnant women in developing countries •A study conducted in Bangladesh in 2005 suggested that not much reduction in maternal sepsis took place even after using such kits Furthermore, something that is not effective can never be costeffective.

Prevention of obstetric complications

SECONDARY PREVENTION: 1. One complication programs, PPH 2. One component programs, TRAINING 3.

One –cadre programs, SBA

4. Institutional deliveries 5. Private sector deliveries 6. Health centre intrepartum care 7. Skilled attendants at home 8. Community health workers at home 9. Relatives or traditional birth attendants at home 10. Emergency obstetric care strategies

Prevention of obstetric complications

Tertiary prevention This includes the 3 delays •Decision to seek care •Access to care •Quality of care and timeliness Safe abortion legally, politically, and culturally acceptable, medical abortions could potentially be delivered at the household level, and attain high coverage, thereby averting a substantial proportion of maternal deaths

Prevention of maternal deaths once complication has occurred.

Strategies: To decrease maternal mortality  Preventive:

BCC  Curative: Active management of complications of delivery.

GOAL: TO REDUCE MATERNAL MORTALITY IN DISTRICT BUNER THROUGH BEHAVIOUR CHANGE COMMUNICATION BY 50% IN 5 YEARS

Findings of a base line survey  Some

of the findings on which our objectives are based are as follows courtesy by PAIMAN project 2005 MATERNAL MORTALITY RATIO IS 201/100,000 LIVE BIRTHS

female literacy rate Buner

7.2

92.8

Illeterate

Literate

Total literacy rate

26

74

Illeterate

Literate

Age at Marriage 14 <19 yrs >19 yrs 86

Percentage of married women in Buner who know at least three danger sign

Knowledge of danger signs during pregnancy that requires medical attention

Percentage of married women by status of knowledge of danger signs during pregnancy

Distribution of respondents who had knowledge about complications during delivery

Percentage of married women who had knowledge of complications during post partum period

Percentage of women by their perception where delivery should take place

Percentage of women by place of delivery 80 60 40 20 0

65 19 H om e

TH Q/D H Q

Series 1

8 Pvt hos pitals /clinics

Percentage of women by delivery attendant

Knowledge of existence and importance of transport, blood and finances by the community at the time of delivery

Committee Services

%

Existence of transport by the community at delivery

1.6

Existence of blood by the community at time of delivery

1.0

Existence of money by community at the time of delivery

1.1

OBJECTIVES 1.

2.

3. 4. 5.

To increase awareness regarding nutritional status of women of reproductive age group. This includes anemia and protein energy malnutrition. To reduce early marriages by promoting female education To increase CPR Promoting antenatal visits at least 4 per pregnancy To give awareness regarding tetanus vaccination

OBJECTIVES contd…. 6.

7.

8. 9. 10.

To promote proper prior planning in order to decrease the three delays and prevent post partum complications. To council husbands about their wives’ pregnancy related needs and educate them regarding family planning. To improve knowledge of danger signs and life threatening conditions during pregnancy To council the influential members of the family about maternal health. To educate regarding personal hygiene and cleanliness

TARGET POPULATION:   



Women of reproductive age groups(15-49 yrs) Mother in laws and the influential family members Husbands: As husbands remain not well informed about their wives pregnancy related need and yet they are decision makers regarding family matters including pregnancy related care. Trained birth attendants and Dai’s

TOOLS AND MATERIALS:       

Involving LHW’s for( female counseling) Involving community leaders, counselors, nazims. Involving health personnel for services and referral system Male volunteers’ home visits (male counseling) To develop IEC material and booklets. Health camps quarterly Involvement of religious leaders Percentage of women who watch TV is 8.6% and those listen to radio is 12.7% so we are not using these for communication.

IMPLEMENTATION: Method Recruitment,Training and evaluation of LHW’s and male worker  Single LHW and male volunteer will be posted for 1000 houses. Training regarding the objectives will be carried out for a period of one month.  Availability of IEC material and pictorial booklets should be ensured at every health and MCH facility and is distributed by the LHW’s, male volunteers to every house hold during their visits. To enhance face to face communication  A schedule will be given to LHW’s and male workers for their daily, monthly visits and a target should be assigned to cover the required houses.  After 1 month of their services we will evaluate their performance by communicating with target audience through randomized sampling of that area.

Local religious leaders and counselors  Guidelines

regarding importance of women in society in vision of Islam can be communicated with the help of religious leaders. This can be done through radio, and religious gatherings, Friday prayers  It should include the importance of family planning and breast feeding.

Health personnel for services and referral system  Will

involve the staff of BHU and RHC, for providing proper and effective antenatal, natal and post natal services

A

proper referral system will be maintained in case of emergencies

Monitoring and evaluation: First monitoring will be done after 3 months of implementation of the services

Immediate Outcome indicators:       

Assessment of the knowledge of women and the husbands regarding importance of Maternal health Antenatal visits Knowledge regarding life threatening conditions during pregnancy Nutritional requirement in pregnancy Personal hygiene and cleanliness Family planning Women education and delay in early marriages

Late Outcome indicators:           

Percentage of maternal mortality in buner Percentage of women coming for antenatal checkups in health facility Percentage of health facility based deliveries Percentage of women utilizing family planning services Percentage indicating women who faced complications during delivery Percentage of referrals to tertiary care hospital Percentage of women who opted for home deliveries Percentage of women who had C/S Percentage of women who got vaccinated Percentage of pregnant women who were enrolled to LHW’s Percentage of females enrolled in schools

ASSUMPTIONS: 1 having the highest impact 1.

2.

3.

4. 5.

By involving husbands and other influential family members we can improve the decision making power and utilization of health facilities by women Pregnancy related complications are mainly due to poor identification of the danger signs during pregnancy as well as at the time of delivery. Awareness regarding this can reduce maternal mortality Female literacy rate is 7.2% in Buner. Promoting female education can lead to improved litracy rate which will prevent early marriages and hence better understanding of safe motherhood. To increase the number of antenatal visits can improve maternal outcome. CPR is 7% which is lowest in country, by improving their confidence on family planning, for child spacing and limitation we can improve maternal mortality.

Budgeting Training of Total LHW training days 3

Total LHWs= 400

Rs 200/day

240000 Rs

Rs 600

Visit/day 200*100 days= 20000

400 LHWs 20000* 400=

800000 Rs

Budgeting contd… Total cost of LHW/round

Total rounds in 3 years=6

240000+800000= Rs 1040000

1040000*6 =6240000Rs

Each evaluation round will cost 4 3200000Rs lakhs Total cost of LHWs rounds

Rs 9440000 Almost one crore

Budgeting contd… Cost of pamphlets

For one round For 6 rounds 20000 Pamphlets

1= Rs10

200000Rs

1 crore 20 lakhs

Budgeting contd… TA/DA of Trainer/day

Total training days 18

Rs 1000

Rs 18000

Per trainer 400/30= day will 14 training cover 30 spots LHWS 14*18000 =252000

Budgeting contd… Total cost Total cost Pamphlets Total of LHWs= of male cost volunteers 1 crore 50 1 crore 50 1 crore 20 4 crore 20 lakhs lakhs lakhs lakhs

Budgeting contd… Conferences of ulema

Rs 100000/year

Offices, salaries of 10lakhs /month staff, vehicles and fuel

For three years Rs 3000000 10*36 3 crore 60 lakhs

Budgeting contd… Total cost Total cost Cost of TA/DA of Conferen of LHWs of male pamphl Trainer ces of rounds volunteers ets ulema rounds one crore one crore 50 lakhs lakhs

1 crore 26 lakhs 30 lakhs 20 lakhs Total

5 crore 80 lakhs

Budgeting contd… 5 crore 80 lakhs

Offices, salaries of staff, 3 crore 60 vehicles and fuel lakhs

Final evaluation

9 crore 30 lakhs

70 lakhs Total

100million

DON’T assume that improved performance has to cost allot. Many countries have achieved better maternal health outcomes by using their existing resources more effectively by building strong political and grassroots support for improved maternal health outcomes. Finally reducing maternal mortality

Thank you