Shamsa Zafar

Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice.

Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.

Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach

Maternal psychosocial well‐being (MPW) is a wide‐ranging concept that encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem solving) and social (e.g., family and community support, empowerment, culture) aspects of motherhood. Evidence‐based MPW interventions that can be integrated into large‐scale maternal and child health programs have not been developed. Building on several years of research in Pakistan, we developed and integrated a cognitive behavioral therapy–based MPW intervention (the five‐pillars approach) into a child nutrition and development program. Following formative research with community health workers (CHWs; n = 40) and families (n = 37), CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioral activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The success of the approach can be attributed to (1) mothers being the central focus of the intervention, (2) using local CHWs whom the mothers trust, (3) simplified training and regular supervision, and (4) an approach that facilitates, not adds, to the CHWs’ work.

Understanding care and feeding practices: building blocks for a sustainable intervention in India and Pakistan

Undernutrition and inadequate stimulation both negatively influence child health and development and have a long‐term impact on school attainment and income. This paper reports data from India and Pakistan looking at how families interact, play with, and feed children; their expectations of growth and development; and the perceived benefits, consequences, opportunities, and barriers of adopting recommended feeding and developmental behaviors. These data were collected as part of formative research for the Sustainable Program Incorporating Nutrition and Games (SPRING) trial. This trial aims to deliver an innovative, feasible, affordable, and sustainable intervention that can achieve delivery at a scale of known effective interventions that maximize child development, growth, and survival and improve maternal psychosocial well‐being in rural India and Pakistan.

Cognitive-Behavioral Counseling for Exclusive Breastfeeding in Rural Pediatrics: A Cluster RCT

OBJECTIVE: To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant’s life compared with routine counseling. METHODS: A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed. RESULTS: At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27–0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34–0.78]). CONCLUSIONS: Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.

Non-Life Threatening Maternal Morbidity: Cross Sectional Surveys from Malawi and Pakistan

Background For more accurate estimation of the global burden of pregnancy associated disease, clarity is needed on definition and assessment of non-severe maternal morbidity. Our study aimed to define maternal morbidity with clear criteria for identification at primary care level and estimate the distribution of and evaluate associations between physical (infective and non-infective) and psychological morbidities in two different low-income countries. Methods Cross sectional study with assessment of morbidity in early pregnancy (34%), late pregnancy (35%) and the postnatal period (31%) among 3459 women from two rural communities in Pakistan (1727) and Malawi (1732). Trained health care providers at primary care level used semi-structured questionnaires documenting signs and symptoms, clinical examination and laboratory tests which were bundled to reflect infectious, non-infectious and psychological morbidity. Results One in 10 women in Malawi and 1 in 5 in Pakistan reported a previous pregnancy complication with 1 in 10 overall reporting a previous neonatal death or stillbirth. In the index pregnancy, 50.1% of women in Malawi and 53% in Pakistan were assessed to have at least one morbidity (infective or non-infective). Both infective (Pakistan) and non-infective morbidity (Pakistan and Malawi) was lower in the postnatal period than during pregnancy. Multiple morbidities were uncommon (<10%). There were marked differences in psychological morbidity: 26.9% of women in Pakistan 2.6% in Malawi had an Edinburgh Postnatal Depression Score (EPDS) > 9. Complications during a previous pregnancy, infective morbidity (p <0.001), intra or postpartum haemorrhage (p <0.02) were associated with psychological morbidity in both settings. Conclusions Our findings highlight the need to strengthen the availability and quality of antenatal and postnatal care packages. We propose to adapt and improve the framework and criteria used in this study, ensuring a basic set of diagnostic tests is available, to ensure more robust assessment of non-severe maternal morbidity.

A randomized controlled trial comparing Pentazocine and Chamomilla recutita for labor pain relief

BACKGROUND Traditional birth attendants in Pakistan sometimes use a homeopathic remedy, Chamomilla for labor pain relief. Our study compares this homeopathic remedy for pain relief in labor with a commonly used parenteral analgesic in a hospital setting. No systematic study has been conducted previously to study the effect of chamomile, which may be affordable and available in community settings. METHODS A double blind randomized controlled trial was carried out at Islamic International Medical College Trust. Ninety-nine normal pregnant women were randomly assigned into three groups. Each group received one of the three trial drugs; Chamomile, Pentazocine or placebo. The efficacy of labor analgesia was assessed by using Visual Analogue Scale (VAS) for pain intensity. Indicators of maternal and child health were recorded as were adverse effects of the drugs. RESULTS Mean pain scores in the three groups were calculated and compared. The difference in mean VAS scores in Pentazocine and Chamomilla recutita group as compared with placebo was not statistically significant. No significant adverse effects were noticed in any group except slight headache and dizziness in three parturients in Pentazocine group. CONCLUSION Neither Pentazocine, or Chamomilla recutita offer substantial analgesia during labor.

Impact of essential surgical skills with an emphasis on emergency maternal, neonatal and child health training on the practice of doctors: A cluster randomised controlled trial in Pakistan

INTRODUCTION Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non-clinical or traditional testing manner. Such surrogate outcomes may not necessarily reflect vital changes in practice. The aim of this study was to determine if and to what extent, specific training in the management of life threatening emergencies resulted in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan. METHODS A cluster randomised controlled trial was conducted in three districts hospitals in three cities (Khairpur, Vehari and Peshawar) of Pakistan. Thirty-six doctors, 18 in intervention (trained in ESS-EMNCH training) and 18 in control (untrained), were enrolled and 248 life threatening emergency events, 124 in each group, were observed for the correct use of the Airway, Breathing, Circulation (ABC) structured approach. The outcome measure was structured approach defined a priori. Data was analysed by using STATA software. RESULTS At individual level, 79 (63.7%) life threatening episodes were managed according to the structured approach in the intervention group and 46 (37.1%) were managed according to the structured approach in controls (OR 2.98, 95%CI 1.78-4.99, p-value=0.0001). At cluster level, the mean percentage (95% CI) of the structured approach used by doctors in the intervention group [62.9% (50.4-75.3%)], was significantly higher than those in the control group, [36.3% (26.3-46.4)] (p-value=0.001). CONCLUSIONS 5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan.

A proposed new international convention supporting the rights of pregnant women and girls and their newborn infants

For a multitude of eminently modifiable reasons, death rates for pregnant women and girls and their newborn infants in poorly resourced countries remain unacceptably high. The concomitant high morbidity rates compound the situation. The rights of these vulnerable individuals are incompletely protected by existing United Nations human rights conventions, which many countries have failed to implement. The authors propose a novel approach grounded on both human rights and robust evidence-based clinical guidelines to create a ‘human rights convention specifically for pregnant women and girls and their newborn infants’. The approach targets the ‘right to health’ of these large, vulnerable and neglected populations. The proposed convention is designed so that it can be monitored, audited and evaluated objectively. It should also foster a sense of national ownership and accountability as it is designed to be relevant to local situations and to be incorporated into local clinical governance systems. It may be of particular value to those countries that are not yet on target to meet the Millennium Development Goals (MDGs), especially MDGs 4 and 5, which target child and maternal mortality, respectively. To foster a sense of international responsibility, two additional initiatives are integral to its philosophy: the promotion of twinning between well and poorly resourced regions and a raising of awareness of how some well-resourced countries can damage the health of mothers and babies, for example, through the recruitment of health workers trained by national governments and taken from the public health system.

Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi

Introduction For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity. Methods Descriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis. Results 11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries. Conclusion Women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

Dynamics of evidence-informed health policy making in Pakistan

&NA; Incorporating evidence is fundamental to maintaining the general acceptance and efficiency in public policies. In Pakistan, different actors—local and global—strive to facilitate the development of evidence‐informed health policies. Effective involvement however, requires knowledge of the country‐context, i.e. knowing the intricacies of how policies are formulated in Pakistan. Obtaining this knowledge is one of the key steps to making interventions impactful. We carried out a qualitative study to explore the environment of evidence‐informed health policy in Pakistan. The study involved 89 participants and comprised three phases including: (1) literature review followed by a consultative meeting with key informants to explore the broad contours of policy formulation, (2) in‐depth interviews with participants belonging to various levels of health system to discuss these contours and (3) a roundtable with experts to share and solidify the findings. Policy development is a slow, non‐linear process with variable room for incorporation of evidence. Political actors dominate decisions that impact all aspects of policy, i.e. context, process and content. Research contributions are mostly influenced by the priorities of donor agencies—the usual proponents and sponsors of the generation of evidence. Since the devolution of health system in 2012, Pakistans provinces continue to follow the same processes as before 2012, with little capacity to generate evidence and incorporate it into health policy. This study highlights the non‐systematic, nearly ad hoc way of developing health policy in the country, overly dominated by political actors. Health advocates need to understand the policy process and the actors involved if they are to identify points of impact where their interaction with policy brings the maximum leverage. Moreover, an environment is needed where generation of data gains the importance it deserves and where capacities are enhanced for communicating and understanding evidence, as well as its incorporation into policy.