With a measured maternal mortality rate of 297/100,000 live births; Pakistan is one of the six countries that contribute to more than 50% of all maternal deaths worldwide. Pakistan is also characterized by difficult terrain and political unrest in a number of provinces. Balochistan province in particular poses problems for health services delivery given its vast area (44% of Pakistan’s territory) with only 5% of the nation’s population. The government of Pakistan created a new cadre of community based midwives (CMW) with the expectation that CMWs will improve access to skilled antenatal and intra-partum care for the women living in these underserved areas.
However, research has shown that these CMWs have largely failed to establish midwifery practices and attract patients. A number of reasons have been identified for this failure which include, but are not limited to: 1) communities’ (particularly women’s) lack of trust in the CMWs’ capacity to conduct safe births; 2) the CMWs’ lack of interest in pursuing midwifery practice, partly because they are unable to meet its professional demands in terms of time and resources. In some areas, the young CMWs cannot travel to patients’ homes without a chaperone, a woman during daytime and at least two additional men during night visits. 3) The CMWs’ lack of business skills necessary to establish a private practice; and 4) the CMWs’ lack of essential financial support to develop their practice infrastructure and logistics.
The Balochistan Department of Health requires urgent technical assistance to develop and test a model that utilizes this resource (the CMW cadre), and to incorporate lessons learned into a budgeted five-year strategic plan for the MNCH program. The Government of Balochistan, other provincial governments in Pakistan, UN agencies, international NGOs, and the donor community (including USAID) are keen to understand whether or not the new cadre of CMWs can be part of the solution addressing Pakistan’s high maternal and neonatal mortality rates. Specifically, these actors are interested to identify and document a successful model that has been able to equip CMWs to be quality providers of essential maternal and newborn care in a financially sustainable manner.
Therefore, to address some of these issues, USAID through Mercy Corps has launched an initiative titled Improving Mother and Newborn Health (IMAN) in districts Quetta, Gwadar, and Kech in Balochistan. The strategic objective of the IMAN initiative is to seek increased use of quality essential maternal and newborn care through private-sector community midwives through increased availability of quality maternal and newborn care in communities (IR1); improved knowledge and demand for essential maternal and newborn care (IR2); improved access to emergency transport in remote communities (IR3) and; improved policy environment for improved maternal, newborn and child healthcare based on evidence from the Operations Research (IR4).
The intervention will consist of four elements that support these CMWs to become quality and sustainable providers: (1) a 4-week clinical skills upgrading course; (2) provision of business-skills training and small loans offered by a micro-finance institute to enable CMWs to establish self-sustaining private practices; (3) generation of demand for and acceptance of CMW services through an awareness-building campaign using cellular phone SMS technology and existing women’s support groups; (4) increase access to emergency transport services via a revolving transport fund called the Mamta Fund. The CMWs will work with their communities to establish this fund.
Under the IR4 of the Operations Research, USAID through Mercy Corp has collaborated with Real Medicine Foundation through the University of Alberta to implement a research study aimed to investigate whether the CMWs enrolled in the IMAN initiative have increased coverage of essential maternal and newborn health care to women and children living in remote Balochistan districts of Quetta, Gwadar, and Kech Districts in a financially self-sustaining manner.
Specifically the research will investigate: (1) whether the SMNC initiative is having an impact on CMW services uptake; (2) if any increased CMW service uptake is attributable to the SMNC initiative; (3) whether the SMNC initiative will enable the CMWs to develop financially self-sustainable practices; and (4) the level of quality of care the CMWs are providing.
Data will be collected in four interlinked modules over a 42-month period:
1. Module 1 will consist of a quasi-experimental impact assessment in Quetta and Gwader and a simple pre-post survey in Kech. Proportions of births attended by SMNC CMWs will be compared with non-SMNC CMWs (matched controls) at baseline (2013) and three years later (2016) to determine: (1) if CMWs have improved their coverage, and (2) if this increase can be attributed to the SMNC initiative. The data will be collected using survey methods around intermittent preventative treatment during pregnancy, clean cord cutting, active management of third stage of labour, post-partum visit for the mother, thermal care (immediate drying and wrapping), immediate breastfeeding of newborns, and patient satisfaction levels with their maternity care provider.
2. Module 2 will explore if the SMNC initiative has enabled SMNC CMWs to establish self-sustaining practices. Organizational, social, and financial challenges faced by CMWs to establishing and running their practices and attracting new clientele will be explored. The size, sustainability and effectiveness of the Mamta Fund will also be assessed. A quantitative financial tool will be used to assess the direct and indirect monetary costs as well as opportunity costs and benefits.
3. Module 3 will explore the quality of care provided by SMNC CMWs. In-depth interviews with CMWs, women of child-bearing age, mothers-in-law and older women and other community members will be conducted. CMW patient-provider interactions during antenatal visits and childbirth will be observed to document CMWs’ quality of care.
An extensive knowledge dissemination plan will facilitate uptake of research findings to both inform on-going positive developments in the SMNC initiative and contribute to the body of evidence around potential solutions to improve sustainable coverage of high impact MNCH interventions in vulnerable populations. The plan will include knowledge sharing primarily with SMNC policymakers and planners in the Government of Balochistan, Mercy Corps and USAID. In addition, research findings will be shared with other provincial MNCH programs, civil society advocacy groups, the community midwives, bilateral donors and international organizations.
Module 1 of the research study is complete. The household survey tool was developed, translated into local language and pilot tested. Pilot data collection was done by enumerators selected by Mercy Corps Balochistan office in Hudda, Quetta. Results of the pilot testing were incorporated and the questionnaire was finalized. Following this sampling for the quasi experimental was carried out where 19 out of the 22 SMNC CMWs in Quetta, 7 out 8 CMWs in Gawadar, while in Kech 7 out of 20 were selected due to extremely volatile security concerns in this district.
Household survey data collection in Quetta was collected from 38 clusters; 19 controlled and 19 intervention clusters. The data was collected over 19 days with two teams each composed of 12-13 enumerators. In Gwadar, the household survey data collection was carried out in 14 clusters over 14 days, equal for control and intervention with the help of one team of 6 enumerators. Similarly in Kech, the same was collected again in 14 clusters over 7 days using two teams, a total of 14 enumerators.
Within Module 1, the financial sustainability tool was also developed, pilot tested with the first batch of the SMNC CMWs and modified to the final version. Data for financial sustainability was collected from 20 CMWs from Quetta and Gwadar; 6 from Gwadar and 14 from Quetta were interviewed. As this was the baseline of financial sustainability, the data coming out was limited. The Mamta Fund has not yet been established yet so no focus group discussion was conducted.
Report: Analysis of the data collected in Module 1 was conducted and the final draft of the report has been shared with Mercy Corps for their review. Following their input, the study will then implement Module 2.
A shrine site in the middle of the desert.
A typical view of Balochistan small town — arid desert and sparsely populated.
The arid desert ends suddenly in the Indian Ocean.
The average living style of a rural inhabitant of Balochistan.