Health services availability in WHO Multi country survey hospitals of Pakistan and its association with obstetric outcomes

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
• MDGs provide 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
Group I Low MMR Group II Moderate MMR Group III High MMR Group IV Very High MMR
(MMRlt20) (MMR 20-99) (MMR 100-299) (MMR 300)
Japan Qatar Argentina Brazil China Jordan Lebanon Sri Lanka Mexico Mongolia Nicaragua Occupied Palestinian T Peru Philippines Paraguay Thailand Viet Nam Ecuador India Cambodia Nepal Pakistan Afghanistan Angola Democratic Republic of the Congo Kenya Niger Nigeria Uganda
5
WHO MULTICOUNTRY SURVEY 2010 -11
6
Maternal Mortality Ratio Pakistan
Period MMR Study source
1990-1991 533 National reproductive family planning survey
1988-1993 392 MIMS
2000-2001 279 MIMS
2000 500 WHO,UNICEF, UNFPA
2005 320 WHO, UNICEF, UNFPA, World Bank
2006-2007 267 PDHS
2011 299 WHO MCS
MDG 5 in 2015 140 Ministry of health, 2005
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 facilitiesWHO MultiCountry
Survey, Pakistan
15
Referral Level Of Hospitals
16
Characteristics of the participating hospitals
1 non teaching facilityTHQ Muredke
17
Characteristics of the participating hospitals
18
Maternal Characteristics
Characteristics All women n13175 N (age) SMO n132 N(age)
Age
lt20 years 529(4) 5(3.8)
20 35 years 12092(92) 116(88)
gt35 years 554(4.2) 11(8.3)
Schooling years
lt 5 years 4511(34) 75(57)
5 8 years 3600(27) 29(22)
9 11 years 3169(24) 21(16)
gt 11 years 1892(14) 7(5.3)
Statistically sig diff b/w SMO and non-SMO group
for maternal education p 0.000
19
Number of beds and deliveries
Hospitals NO of beds Deliveries 2009 Deliveries in Study period 2011( 2-3 mths)
PIMS 125 6379 1706
Polyclinic 150 7709 931
DHQ Toba Tek Singh 16 1580 349
THQ Muredke 10 1437 321
Services Lahore 125 10972 371
BBH Rwp 66 6057 705
HFH Unit I, Rwp 88 8949 967
HFH Unit II, Rwp 94 7635 1155
DHQ Rwp 64 5420 799
20
Number of beds and deliveries
Hospitals No of beds Annual deliveries in 2009 Deliveries in study period 2011 (2-3 mths)
Nishtar H Multan 194 10798 622
Bahawalpur Victoria H 120 11976 962
Shiekh zaid Lahore 25 1809 364
Civil Hosp Karachi 65 5520 763
Sobhraj H Karachi 110 5087 823
Korangi H Karachi 20 2728 497
Qatar H Karachi 55 5680 1204
Taluka H Rohri 11 5287 161
Civil H Jacobabad 12 2283 151
Civil H Badin 20 1326 369
21
AVAILABILITY OF BASIC SERVICES
INCLUDINGINFRASTRUCTURE
SERVICES NO OF HOSPITALS N 19 AGE
Electricity, water, sewerage system, Generator, Ambulance 19 100
Refrigerator, telephone, radio 17 89.5
Email/internet 13 68.4
Incinerator 9 47.4
22
AVAILABILITY OF MEDICAL FACILITIES
services No of hospitals N 19 age of hospitals
Blood bank, High risk pregnancy consultation service, Radiology dept 18 94.7
Screening of blood donor for HIV, HBV and Syphilis 12 63.2
High risk pregnancy beds 13 68.4
Ultrasound services, Biochemical/Clinical laboratories, Sterilization equipment 19 100
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
Services No of hospitals (N19) age
Administration of misoprostol 18 94.7
Uterine artery embolisation 1 5.3
Administration of MgSO4 16 84.2
Mechanical ventilation 12 63.2
Dialysis 17 89.5
25
ADULT AND NEONATAL ICU
Facility(n19) Present Absent
Adult intensive care unit 13(68.4) 6(31.6)
Neonatal intensive care unit 10(52.6) 9(47.4)
Other newborn care unit with incubator 11(57.9) 8(42.1)
26
Health Professionals Availability for EMNOC
Professionals Availability No of hospitals(n19) of hospitals
Obstetrician 24h/day, 7 days/week in facility 13 68.4
24h/day, 7 days/week on call 6 31.6
Pediatrician 24h/day, 7 days/week in facility 9 47.4
24h/day, 7 days/week on call 8 42.1
Partial availability 2 10.5
Anesthetist 24h/day, 7 days/week in facility 12 63.2
24h/day, 7 days/week on call 6 31.6
Partial availability 1 5.3
27
Health Professionals Availability
Professionals Availability No of hospitals(n19) of hospitals
Internal medicine specialist 24h/day, 7 days/week in facility 10 52.6
24h/day, 7 days/week on call 6 31.6
Partial availability 1 5.3
Not available 2 10.5
Critical care specialist 24h/day, 7 days/week in facility 10 52.6
24h/day, 7 days/week on call 4 21.1
Partial availability 0 0
Not available 5 26.3
28
Availability of Laboratory tests
Tests No of hospitals N 19 age
Blood gas analysis/gasometry 11 57.9
Creatinine, Bilirubin 18 94.7
Lactate 7 36.8
Hemoglobin, Platelet count 19 100
Coagulation tests 17 89.5
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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

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Maternal morbidity and mortality in the WHO
Multi-country survey Hospitals, Punjab
Hospital Total Deliveries (n13175) n () Maternal Severe Outcome (n132) n () Maternal Complications (n1158) n ()
DHQ Toba Tek Singh 349 (2.6) 7 (5.3) 12 (1)
THQ Muredke 321 (2.4) 0 1 (0.1)
Services H Lahore 371 (2.8) 1 (0.8) 10 (0.9)
RMC, Rawalpindi 3481 (26) 34 (25.8) 293 (25.3)
Nishtar H Multan 622 (4.7) 30 (22.7) 75 (6.5)
Bahawalpur Victoria H 962 (7.3) 25 (18.9) 159 (13.7)
Shiekh Zayed H Lahore 364 (2.8) 1 (0.8) 60 (5.2)
31
Maternal morbidity and mortality in the WHO
Multi-country survey Hospitals,Sind
Hospital Total Deliveries (n13175) n () Maternal Severe Outcome (n132) n () Maternal Complications (n1158) n ()
Civil H Karachi 763 (5.8) 13 (9.8) 52 (4.5)
Sobhraj H Karachi 823 (6.2) 5 (3.8) 16 (1.4)
Korangi H Karachi 497 (3.8) 0 4 (0.3)
Qatar H Karachi 1204 (9) 6 (4.5) 155 (13.4)
Taluka H Rohri 161 (1) 0 0
Civil H Jacobabad 151 (1) 1 (0.8) 2 (0.2)
Civil H Badin 369 (2.8) 0 2 (0.2)
32
Maternal morbidity and mortality in the WHO
Multi-country survey Hospitals, Islamabad
Hospital Total Deliveries (n13175) n () Maternal Severe Outcome (n132) n () Maternal Complications (n1158) n ()
PIMS Islamabad 1706 (12.9) 6 (4.5) 294 (25.4)
Poly clinic H Isb 931 (7) 3 (2.3) 23 (2.0)
33
Who MC Survey Hospital Perinatal mortality rates

Hospital name Total deliveries N13175 Peri-natal mortality rate/1000 births
DHQ Toba Tek singh 349 (2.6) 9.1
THQ Muredke 321 (2.4) 3.2
Services H Lahore 371 (2.8) 19.2
RMC, Rawalpindi 3481 (26) 30
Nishtar H Multan 622 (4.7) 30
Bahawalpur Victoria H 962 (7.3) 30
Shiekh Zayed H Lahore 364 (2.8) 10
Civil H Karachi 763 (5.8) 30
Mean PNMR 17.1/1000
Range 0-30
34
Perinatal mortality rate among different
hospitals included in the Who Multi-country
survey
Hospital name Total deliveries N 13175 Peri-natal mortality rate/1000 births
Sobhraj H Karachi 823 (6.2) 10
Korangi H Karachi 497 (3.8) 0
Qatar H Karachi 1204 (9) 20
Taluka H Rohri 161 (1) 20
Civil H Jacobabad 151 (1) 10
Civil H Badin 369 (2.8) 2.92
PIMS Islamabad 1706 (12.9) 20
Poly clinic hp Isb 931 (7) 30
35
Correlation Of Maternal And Neonatal Outcome With
The Availability Of Resources In The Facilities
36
Adult ICU and Severe Maternal Outcome(SMO)
Adult intensive care unit Facilities N16 Maternal severe outcome N 132 P value
Available adult ICU 10 (62) 119 (90) 0.006
Not available adult ICU 6 (38) 13 (10)
Mechanical ventilation Facilities N16 Maternal severe outcome N 132 P value
Available 9 (56) 113 (86) 0.01
Not available 7 (44) 19 (14)
37
Laboratory tests and SMO
Coagulation tests Facilities N16 Maternal severe outcome N 132 P value
Available 14(87) 132(100) 0.01
Not available 2(12) 0(0)
38
Senior EMOC staff availability and SMO
Availability of anesthesiologist Facilities N16 Maternal severe outcome N 132 P value
Available 24h/day, 7 days in facility 9(56) 113(86) 0.01
Not available 24h/day, 7 days in facility 7(44) 19(14)
availability of nurse/paramedics Facilities N16 Maternal severe outcome N 132 P value
Available 24h/day, 7 days in facility 12(75) 124(93) 0.03
Not available 24h/day, 7 days in facility 4(25) 8(6)
39
Maternal access to adult ICU care and SMO
Appropriate adult/maternal ICU? Facilities N16 Maternal severe outcome N 132 P value
Available 8(50) 107(81) 0.01
Not available 8(50) 25(18.9)
If a woman needs intensive care, she has to be referred to another hospital Facilities N16 Maternal severe outcome N 132 P value
Yes 7(44) 19(14) 0.01
No 9(56) 113(86)
40
Correlation of level of care with the proportion
of severe maternal outcome and no of deliveries
Level of facilities No of deliveries N13175 Maternal severe outcome N 132 P value
Secondary 1848(13.6) 8(6.1) 0.012
Tertiary 11327(86.4) 124(94)
Level of facilities No of deliveries N13175 Maternal complication N 1158 P value
Secondary 1848(13.6) 21(1.8) 0.0001
Tertiary 11327(86.4) 1137(98.2)
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
Parliamentary representation
Adolescent fertility (4)
Maternal mortality (299)
Labour force participation
Education Sec above (38.4)
5 INDICATORS
REPRODUCTIVE HEALTH
LABOUR MARKET
EMPOWERMENT
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
Neonatal ICU Facilities N16 Neonatal mortality P value
Available 7 219 0.01
Not available 9 74
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 Dec62(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 Dec115(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.
200656156-63.
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 April27(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.

51
Limitations

• As the WHOMCS was conducted in secondary and
  tertiary facilities it does not represent
  maternal outcomes and coverage of essential
  interventions in smaller facilities or in the
  community.
• The primary and secondary delays in seeking
  health care are not addressed in the survey which
  may be a cause of higher number of obstetric
  complications in the tertiary care centers.
• Ongoing strike of resident doctors for service
  structure during the study period affected care.

52
Recommendations

• Ensuring round the clock availability of skilled
  staff for emergency obstetric care services.
• Proper referral system
• Training/refresher courses for medical and
  paramedical staff.
• Provision of fully equipped intensive care units
  to tertiary care centers.
• Regular audits

53
References

• Souza JP, Gülmezoglu AM, Joshua Vogel, Carroli
  G, Lumbiganon P et al. Beyond the coverage of
  essential interventions the next challenge for
  reducing global maternal mortality findings of
  the World Health Organization Multi-country
  Survey on Maternal and Newborn Health. Lancet,
  May 2013.
• 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 Dec62(12)1308-13
• Mbassi SM, Mbu R, bouvier-Colle MH. Use of
  routinely collected data to assess maternal
  mortality in seven tertiary maternity in seven
  tertiary maternity centers in Cameroon. Int J
  Gynaecol Obstet. 2011 Dec115(3)240-3
• 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. 200656156-63.
• 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 April27(2)170-83.
  

54
Thank you