Afshan Bhatti

Good on paper: the gap between programme theory and real‐world context in Pakistan's Community Midwife programme

To understand why skilled birth attendance—an acknowledged strategy for reducing maternal deaths—has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory‐driven approach to evaluating implementation of maternal healthcare interventions.

Maternal deaths in Pakistan: intersection of gender, caste, and social exclusion

BackgroundA key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available.MethodsUsing a critical ethnographic approach, two case studies of women who died during childbirth were pieced together from information gathered during the first six months of fieldwork in a village in Northern Punjab, Pakistan.FindingsShida did not receive the necessary medical care because her heavily indebted family could not afford it. Zainab, a victim of domestic violence, did not receive any medical care because her martial family could not afford it, nor did they think she deserved it. Both women belonged to lower caste households, which are materially poor households and socially constructed as inferior.ConclusionsThe stories of Shida and Zainab illustrate how a rigidly structured caste hierarchy, the gendered devaluing of females, and the reinforced lack of control that many impoverished women experience conspire to keep women from lifesaving health services that are physically available and should be at their disposal.

Improving Maternal Health in Pakistan: Toward a Deeper Understanding of the Social Determinants of Poor Women’s Access to Maternal Health Services

Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May 2010-February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion

BackgroundPakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay.Methods/DesignData will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW’s in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan.DiscussionThe findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.

Addressing invisibility, inferiority, and powerlessness to achieve gains in maternal health for ultra-poor women.

1—concerns have arisen that this focus has often been diluted in eff orts to translate the Millennium Development Goals (MDGs) into actions. 2 Nowhere is this more apparent than in relation to MDG 5. Analyses of national survey data and local programme assessments show that policy directives and interventions often fail to reach the poorest women within local populations. In Pakistan, for example, a ten-district intervention aimed at upgrading health facilities while simultaneously increasing demand through behavioural change resulted in a rise in institutional deliveries in the highest wealth quintile (from 62% to 74%), but no change in the poorest (remaining at roughly 18%). 3 Meanwhile, a crossnational analysis 4 identifi ed large inequalities between wealth groups in access to skilled birth attendance 5 and antenatal care uptake in many countries. Thus, despite repeated assertions that reducing inequity is a top priority, international organisations, donor agencies, and country-level policy makers continue to fail to address the obstacles to care faced by the poorest women. Furthermore, despite reductions in maternal mortality in several countries, comprehensive reviews 6,7

Signalling, status and inequities in maternal healthcare use in Punjab, Pakistan.

Despite rising uptake of maternal healthcare in Pakistan, inequities persist. To-date, attempts to explain and address these differentials have focused predominantly on increasing awareness, geographic and financial accessibility. However, in a context where 70% of healthcare is private sector provided, it becomes pertinent to consider the value associated with this good. This study examined patterns of maternal healthcare use across socioeconomic groups within a rural community, and the meanings and values attached to this behaviour, to provide new insight into the causes of persistent inequity. A 10-month qualitative study was conducted in rural Punjab, Pakistan in 2010/11. Data were generated using 94 in-depth interviews, 11 focus group discussions and 134 observational sessions. Twenty-one pregnant women were followed longitudinally as case studies. The village was comprised of distinct social groups organised within a caste-based hierarchy. Complex patterns of maternal healthcare use were found, linked not only to material resources but also to the apparent social status associated with particular consumption patterns. The highest social group primarily used free public sector services; their social position ensuring receipt of acceptable care. The richer members of the middle social group used a local private midwife and actively constructed this behaviour as a symbol of wealth and status. Poorer members of this group felt pressure to use the afore-mentioned midwife despite the associated financial burden. The lowest social group lacked financial resources to use private sector services and opted instead to avoid use altogether and, in cases of complications, use public services. Han, Nunes, and Drezes (2010) model of status consumption offers insight into these unexpected usage patterns. Privatization of healthcare within highly hierarchical societies may be susceptible to status consumption, resulting in unforeseen patterns of use and persistent inequities. To-date these influences have not been widely recognised, but they deserve greater scrutiny by researchers and policy-makers given the persistence of the private sector.

Successful Community Midwives in Pakistan: An Asset-Based Approach.

In response to the low levels of skilled birth attendance in rural Pakistan, the government introduced a new cadre of community midwives (CMWs) in 2006. Assessments to-date have found that these CMWs have yet to emerge as significant providers for a number of sociocultural, geographic and financial reasons. However, a small number of CMWs have managed to establish functional practices in the private sector in conservative, infrastructure-challenged rural contexts. With an objective to highlight “what are the successful CMWs doing right given their context?” this paper adopts an asset-based approach to explore the experiences of the Pakistani CMWs who have managed to overcome the barriers and practice. We drew upon ethnographic data that was collected as part of a larger mixed methods study conducted in 2011–2012 in districts Jhelum and Layyah, Pakistan. Thirty eight CMWs, 45 other health care providers, 20 policymakers, 78 women, 35 husbands and 23 older women were interviewed. CMW clinics and practices were observed. Our data showed that only eight 8 out of 38 CMWs sampled were active providers. Poverty as a push factor to work and intrinsic individual-level characteristics that enabled the CMWs to respond successfully to the demands of the midwifery profession in the private sector emerged as the two key themes. Household poverty pushed the CMWs to work in this perceived low-status occupation. Their families supported them since they became the breadwinners. The successful CMWs also had an intrinsic sense of what was required to establish a private practice; they exhibited professionalism, had strong business sense and provided respectful maternity care. The study provides insight into how the program might improve its functioning by adapting its recruitment criteria to ensure selection of right candidates.

Saving mothers and newborns in communities: strengthening community midwives to provide high quality essential newborn and maternal care in Baluchistan, Pakistan in a financially sustainable manner.

BackgroundTo address its persistently high maternal mortality rate of 276/100,000 live births, the government of Pakistan created a new cadre of community based midwives (CMW). One expectation is that CMWs will improve access to maternal health services for underserved women. Recent research shows the CMWs have largely failed to establish midwifery practices, because CMWs lack of skills, both clinical and entrepreneurial and funds necessary to develop their practice infrastructure and logistics. Communities also lack trust in their competence to conduct safe births. To address these issues, the Saving Mothers and Newborn (SMNC) intervention will implement three key elements to support the CMWs to establish their private practices: (1) upgrade CMW clinical skills (2) provide business-skills training and small loans (3) generate demand for CMW services using cellular phone SMS technology and existing women’s support groups.Methods/DesignThis 3-year project aims to investigate whether CMWs enrolled in this initiative are providing the essential maternal and newborn health care to women and children living in districts of Quetta, and Gwadar in a financially self-sustaining manner. Specifically the research will use quasi-experimental impact assessment to document whether the SMNC initiative is having an impact on CMW services uptake, financial analysis to assess if the initiative enabled CMWs to develop financially self-sustainable practices and observation methods to assess the quality of care the CMWs are providing.DiscussionA key element of the SMNC initiative - the provision of business skills training and loans to establish private practices - is an innovative initiative in Pakistan and little is known about its effectiveness. This research will provide emperic evidence of the effectiveness of the intervention as well as contribute to the body of evidence around potential solutions to improve sustainable coverage of high impact Maternal, Neonatal and Child Health interventions in vulnerable populations living in remote rural areas.