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
P e rp s e p
10% 5%
33% e c la m p s ia
7%
AP H
O b s tr la b
7%
3% a b o rtio n
7%
12% 16% e m b o lis m
ia tro g e n ic
o th e r
 NWFP
 Populationconstitutes 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
 DistrictBuner 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 506 17736 154000
(thousands)
Area in sq. km 1865 74521 796096
Population 0/100 17/83 34/66
urban/rural ratio
Sex ratio(number of 100 105 108
males over 100
females) at birth
Population density 271 238 166
(person per sq. km)

Population annual 3.85 2.67 1.9

growth rate
Provincial Census Report of N.W.F.P October 2000:85
Population structure:
Population Groups Standard Estimated
Demographic Population (2005)
Percentages

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 (15- 21.7 109,812

49 years)
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 Buner NWFP Pakistan

Total fertility rate 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

(%)
Birth Care by skilled attendant 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
Mean Children Ever Born to Married Women 15- 4.8 4.9
49 years

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

Health facility availability:
health facility

25
20
20
15
Series1
10 8
4
5 2 1
0
C

C
ls

RH

BH

CH
ie
ita

ar
sp

M
ns
ho

pe
dis
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  Illiterate
 Low socio class Intervention Intervention
 Lack of knowledge Family Prenatal care
regarding health Planning
Buner
Rural  Follow cultural norms
 Non decision makers,
dependant on the
husbands or other family
members PREGNANCY
Intervention Men
 BCC Involving  Literate comparatively
husbands to improve  Decision makers
Maternal health
 Un aware of the wives
 Advocacy
 Female literacy pregnancy related needs
 Lack of knowledge of
access to andutilization
of Emoc services
POSSIBLE AREAS OF INTERVENTION

Intervention
PREGNANCY Abortion Safe
Abortion

Miscarriage Intervention
Management
Of PPH,
Sepsis
Complications Eclampsia
& other
complications
Intervention
To improve
Availability Uncomplicated Intervention
Accessibility & Pregnancy & Post natal care
Affordability delivery
Of the
services
 REDUCING MATERNAL
MORTALITY
Primary prevention
BCC
•This is required for PREVENTION OF
individuals, families,
UNWANTED
communities and providers if
maternal health outcomes PREGNANCY
are to improve.
• Effective health promotion
and communications have
contributed to better maternal
health outcomes by reducing
risky practices and promoting
positive ones
PRIMARY PREVENTION

ADVOCACY
•e.g., to raise resources—is an
important component it is often
PREVENTION OF
undertaken without a clear
connection to actions that can UNWANTED
actually help to reduce maternal PREGNANCY
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 .
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

Prevention of
obstetric
complications
•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 cost-
effective.
SECONDARY PREVENTION:
1. One complication
programs, PPH
2. One component programs,
TRAINING
3. One –cadre programs,
SBA Prevention of
4. Institutional deliveries obstetric
5. Private sector deliveries
complications

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
Tertiary prevention
This includes the 3
delays
•Decision to seek care
•Access to care Prevention of
•Quality of care and maternal deaths
timeliness once complication
Safe abortion has occurred.
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
 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
65
20
19 8
0
H om e TH Q/D H Q Pvt
hos pitals /clinics

Series 1
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. To increase awareness regarding nutritional status
of women of reproductive age group. This includes
anemia and protein energy malnutrition.
2. To reduce early marriages by promoting female
education
3. To increase CPR
4. Promoting antenatal visits at least 4 per pregnancy
5. To give awareness regarding tetanus vaccination
OBJECTIVES contd….
6. To promote proper prior planning in order to decrease
the three delays and prevent post partum
complications.
7. To council husbands about their wives’ pregnancy
related needs and educate them regarding family
planning.
8. To improve knowledge of danger signs and life
threatening conditions during pregnancy
9. To council the influential members of the family about
maternal health.
10. 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

 Willinvolve 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. By involving husbands and other influential family members we
can improve the decision making power and utilization of health
facilities by women
2. 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
3. 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.
4. To increase the number of antenatal visits can improve maternal
outcome.
5. 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 Total Visit/day 400
LHW training LHWs= 200*100 LHWs
days 3 400 days= 20000*
20000 400=

Rs 240000 800000
200/day Rs 600 Rs Rs
 Budgeting contd…
Total cost of LHW/round Total rounds in 3
years=6

240000+800000= 1040000*6
Rs 1040000 =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 Total training Per trainer 400/30=
Trainer/day days day will 14 training
18 cover 30 spots
LHWS

Rs 1000 Rs 18000 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 Rs 100000/year For three
ulema years Rs
3000000
Offices, salaries of 10lakhs /month 10*36
staff, vehicles and 3 crore 60
fuel 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 1 crore 26 lakhs 30 lakhs

50 lakhs lakhs 20
lakhs

Total 5 crore
80 lakhs
 Budgeting contd…
5 crore 80
lakhs

Offices, salaries of staff, 3 crore 60 9 crore 30

vehicles and fuel lakhs lakhs

Final evaluation 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