Abstract
BackgroundPakistan’s maternal and child health indicators remain unacceptably high, with a maternal mortality ratio of 276 per 100,000 live births and a neonatal mortality rate of 55 per 1,000 live births. Provision of basic and comprehensive emergency obstetric and newborn care is mandated by the government; however, coverage, access, and utilisation levels remain unsatisfactory, with the situation in Sindh province being amongst the worst in the country. This study attempted to assess access to comprehensive emergency obstetric and newborn care (C-EmONC) facilities and barriers hampering access in Sindh.MethodsOne public sector hospital in each of three districts in Sindh province providing C-EmONC services were selected for a facility exit survey. A cross-sectional household survey and focus group discussions were conducted in the catchment population of these hospitals.ResultsOverall, 82% and 96% of those who utilised a public or private C-EmONC facility, respectively, incurred out-of-pocket expenditure. As expected, those living more than 5 km from the facility reported higher mean expenditure than those living within 5 km of the facility. More than half of the respondents (55%) among public sector users and the majority (71%) of private sector users could not afford travel costs. More than one third (35%) of public sector users and about two thirds (64%) of private sector users who could not afford travel costs took loans. The proportion of respondents who took loans was higher among those living more than 5 km of the health facility compared to those living within a 5 km distance. The majority of respondents (70%) in the community survey chose to go to a private sector C-EmONC facility. In addition to poverty, in terms of sociocultural access, religious and ethnic discrimination and the poor attitude of facility staff were amongst the most important barriers to accessing a C-EmONC facility.ConclusionsC-EmONC facilities in both the public and private sectors may simply not be accessible and affordable for the vast majority of poor and marginalised women in targeted districts.
Highlights
Pakistan’s maternal and child health indicators remain unacceptably high, with a maternal mortality ratio of 276 per 100,000 live births and a neonatal mortality rate of 55 per 1,000 live births
Private sector facilities providing comprehensive emergency obstetric and newborn care (C-EmONC) services are mostly present within the catchment area of public sector secondary care facilities
A previous situation analysis of public sector emergency obstetric care facilities in Sindh province depicted stark deficiencies in service availability, distance, transport accessibility to reach facilities, and capacity of facilities to extend requisite 24-hour C-EmONC services at the secondary level: 12% of facilities did not provide services after 2:00 p.m. and 24-hour coverage for complicated deliveries was provided in only 88% of secondary care hospitals
Summary
Study setting The study was conducted in three districts of Sindh province, namely Ghotki, Jamshoro, and Tharparkar, representing northern, central, and southern parts of Sindh and chosen because they had a higher proportion of the population with lower economic profiles. Sample size A sample size of 690 for the community survey was calculated on the assumptions of known prevalence of 36% of mothers and 34% of newborns likely to utilise public sector health facilities for maternal and newborn morbidity [8]. The first FGD was conducted with male elders and community notables, the second with prominent females and women’s groups, and the third with married women who went to a public or private health facility for an emergency health problem for herself or her newborn baby. These women were identified through hired community resource persons and social mobilisers with the help of the local population.
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