Prof. Dr. Syeda Batool Mazhar. FRCOG ( U.K ), FCPS (PK)

1. Health services availability in WHO Multi country survey hospitals of Pakistan and its association with obstetric outcomes Prof. Dr. Syeda Batool Mazhar. FRCOG ( U.K ), FCPS (PK) Dr. Afshan Batool, Dr Qurratulain Rizwan. MCH center, PIMS, Islamabad

2. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes BACKGROUND • MDGsprovide a framework for the entire international community to work together towards a common end. – Ensuring that human development reaches everyone, everywhere. • Health system strengthening is a crucial preliminary step for addressing the MDG 4 & 5. • Pakistan has a low coverage of institutional births although a substantial proportion of maternal deaths take place in hospitals.

3. WHO MULTICOUNTRY SURVEY: 2010 -2011

4. SELECTED COUNTRIES IN WHO MULTICOUNTRY SURVEY

5. WHO MULTICOUNTRY SURVEY: 2010 -11

6. Maternal Mortality Ratio Pakistan

7. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes • Primary objective: To determine the availability of essential and comprehensive obstetric care at referral level government facilities selected for WHO MCS for maternal and newborn health 2011.

8. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes • Secondary objective: To correlate the availability of services for emergency and comprehensive obstetric care with maternal and neonatal mortality and morbidity in the respective facilities

9. MATERIALS AND METHODSSETTING *Rawalpindi Medical College comprised of 3 physically separate facilities namely BBH, HFH and DHQ and 4 professorial units resulting in 19 facilities in some subanalyses.

10. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes Hospital Selection Criteria • Hospitals able to conduct ≥1000 deliveries annually • With the capacity to provide cesarean section • From provinces of Sind, Punjab and Federal Capital Random selection through a stratified multistage cluster sampling technique among a list of government hospitals provided by federal MNCH cell.

11. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes Materials and Methods • Study duration: The survey was conducted from 1st March 2011 to 30th May, 2011

12. Materials and Methods • Each facility filled an institutional form regarding hospital structure, various facilities as well as staffing available in the hospital. • Medical records of all women delivering in the selected hospitals for study period were entered on individual forms. • Women admitted within 7 days of delivery or abortion with maternal near miss also had individual forms entry . • Subsequently data from forms was entered online at central office in MCH Center, PIMS, Islamabad.

13. Health services availability in WHO Multicountry survey hospitals of Pakistan and its association with obstetric outcomes RESULTS

14. Participating facilities:WHO MultiCountry Survey, Pakistan

15. Referral Level Of Hospitals

16. Characteristics of the participating hospitals 1 non teaching facility=THQ Muredke

17. Characteristics of the participating hospitals

18. MaternalCharacteristics Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000

19. Number of beds and deliveries

20. Number of beds and deliveries

21. AVAILABILITY OF BASIC SERVICES INCLUDINGINFRASTRUCTURE

22. AVAILABILITY OF MEDICAL FACILITIES

23. EMOC SERVICES AVAILABLE IN ALL THE HOSPITALS • Administration of parenteral antibiotics • Administration of oxytocin • Manual removal of placenta • Removal of retained products of conception • Vacuum and forceps delivery • Blood transfusion • Hysterectomy • Oxygen supplementation by mask or catheter • Neonatal resuscitation

24. EMOC SERVICES NOT AVAILABLE IN ALL HOSPITALS

25. ADULT AND NEONATAL ICU

26. Health Professionals Availability for EMNOC

27. Health Professionals Availability

28. Availability of Laboratory tests

29. Maternal morbidity and mortality among Pakistan hospitals in the WHO Multicountry survey • Severe maternal outcome Incidence 8.25 ± 11 per facility (maternal deaths+ maternal nearmiss) range 0-34 • Total Complications Rate 72.3 ± 100 per facility abortion, pregnancy, childbirth, postpartum range 0-293 Lowest levels in a secondary facility verses Highest rates in a tertiary care facility

30. Maternal morbidity and mortality in the WHO Multi-country survey Hospitals, Punjab

31. Maternal morbidity and mortality in the WHO Multi-country survey Hospitals,Sind

32. Maternal morbidity and mortality in the WHO Multi-country survey Hospitals, Islamabad

33. Who MC Survey: Hospital Perinatal mortality rates Mean PNMR 17.1/1000 Range 0-30

34. Perinatal mortality rate among different hospitals included in the Who Multi-country survey

35. Correlation Of Maternal And Neonatal Outcome With The Availability Of Resources In The Facilities

36. Adult ICU and Severe Maternal Outcome(SMO)

37. Laboratory tests and SMO

38. Senior EMOC staff availability and SMO

39. Maternal access to adult ICU care and SMO

40. Correlation of level of care with the proportion of severe maternal outcome and no of deliveries

41. Correlation of drug availability with maternal severe outcome(SMO) No correlation was found with SMO for • Administration of misoprostol and other uterotonics • Administration of magnesium sulphate • Dialysis

42. Diagnostic services and SMO No correlation of the following was found with SMO: • Laboratory services and blood bank • Blood gas analysis/gasometry • Creatinine • Bilirubin • Lactate • Screening of blood donor for HIV, HBV, Syphilis • Radiological services

43. Gender inequality indexand WHO MC survey Maternal mortality (299)* Adolescent fertility (4%)* Parliamentary representation Education Sec & above (38.4%)* Labour force participation 5 INDICATORS REPRODUCTIVE HEALTH EMPOWERMENT LABOUR MARKET 3 DIMENSIONS GENDER INEQUALITY INDEX *Evidence based policies for improving maternal health in Pakistan, Human Development Report, 2011. *WHO MCS findings

44. Correlation of Neonatal mortality with Neonatal ICU No correlation of neonatal mortality with availability of pediatrician was found.

45. Summary of Results • Tertiary care hospitals with high delivery rates had higher SMO and complication rates • Availability of ICU, 24/7 OBGYN, pediatrician & anesthetist encourages high risk referrals to such facilities with overburden. • It seems paradoxical yet lower facilities report better outcomes as referral rates are high.

46. Discussion • WHO MC Survey shows severe maternal outcome in Secondary facilities was 50% less compared to tertiary facilities. • Five districts of Punjab study in 2010 reported that none of the facilities at Tehsil level had maternal deaths in 2009*. • Complicated cases were referred or reported directly to tertiary care centers*. • Maternal mortality and obstetric complications in the tertiary care facilities is much higher due to higher referral rates.** *Mir AM, Gull S. countdown to 2015: a case study of maternal and child health service delivery challenges in five districts of Punjab..J Pak Med Assoc. 2012 Dec;62(12):1308-13 **Mbassi SM, Mbu R, bouvier-Colle MH. Use of routinely collected data to assessmaternal mortality in seven tertiary maternity in seven tertiary maternity centers in Cameroon. Int J Gynaecol Obstet. 2011 Dec;115(3):240-3

47. Discussion Absence of trained doctors in the evening at the secondary health facilities results in: • Poor utilization of medical facilities and Low delivery rates in THQs and DHQs. • Lack of confidence of general population on medical services at the secondary health care facilities. • Bypassing secondary health facilities resulting in overburdening of tertiary centers.* * Fikree F, Mir A,Haq IU. She may reach a facility but still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan. J Pak Med Assoc. 2006;56:156-63.

48. Discussion • Jafary et al. report that women are mishandled by local TBAs and in smaller health facilities due to lack of personnel and supplies with delayed referrals to tertiary care when the condition is moribund.* • WHO MC survey also shows a relative high delivery and complication rates in tertiary care hospitals due to high risk referrals. • Jafary SN, Rizvi T, Koblinsky M, Kureshy N. verbal autopsy of maternal deaths in two districts • of Pakistan – filling information gaps.J Health Popul Nutr. 2009 April;27(2):170-83.

49. Gender inequality index andWHO MCS Survey Pakistan Results • Only 38.9% of the women had more than secondary level education. • Adolescent fertility rate was 4%. • Our data is in agreement with the GII in the Human development report 2011( 3 out of 5 indicators and 2 out of 3 dimensions). • Pakistan ranks 115 out of 145 countries of the world in gender inequality. • Gender inequality remains an important cause of high maternal mortality in Pakistan.

50. Strengths and Limitations Strengths: • It is a large scale study exploring the coverage of essential obstetric care in 16 secondary and tertiary government health facilities in Punjab, Sind and Islamabad • The study could assist the policy makers regarding the deficiencies. Interventions to improve maternal health can include • ensuring availability of trained personnel for emergency obstetric care at primary and secondary level. • provision of intensive care units in tertiary care.