assessing the feasibility of using community informant networks to estimate maternal mortality in...

Assessing the Feasibility of Using Community Informant Networks to Estimate Maternal Mortality in Pakistan Sharing Findings of a Pilot Study March 31, 2014

of 56 Alternative Approaches to Measure Maternal Mortality Methods: Civil registration with medical certification of cause of deaths Sample Vital Registration with Verbal Autopsy (SAVVY) Sisterhood method using Household surveys Direct estimation (sibling method ) using Household surveys Census data Health facility reporting of Maternal deaths Reproductive Age Mortality Studies (RAMOS) Informant Listing and Follow-up Technique (Made-in-Made-for)

of 56 Informant Listing and Follow-up Through Verbal Autopsy Technique (Made-In Made-For) A research tool that identifies pregnancy-related deaths in communities. Can be used as a basis for estimating mortality at any level of sufficient size from community to district, and national. Provides information on the causes of mortality.

of 56 Informants listing of deaths(MADE-IN ): Village-level informants identify deaths of women of reproductive age (WRA) (aged 1549 years) in their communities. Follow-up with verbal autopsies (MADE-FOR ): Follow- up interviews conducted with family members of deceased women to confirm if deaths are maternal or non-maternal and to explore cause of death. Two-Step Process

of 56 Limitations of the Technique Cannot be used if there are no suitable networks of informants Relies on the memory of the family in describing the circumstances of a death. Deaths early in pregnancy, and sensitive deaths (e.g. in unmarried women, or following induced abortion) likely to be missed.

of 56 Pilot Study to Test the Feasibility of Applying the Technique in Pakistan Primary Objective: To assess the feasibility of applying the Community Informant Network Listing and Follow-up with verbal autopsies (MADE-IN MADE-FOR) methodology in a typical Pakistani district

of 56 Secondary Objectives: To identify the networks available within rural and urban communities which can be key informants for information on maternal deaths. To assess mechanisms that can be employed at the community level to determine the cause of deaths. To determine the differential characteristics and geographical pattern of maternal deaths. Pilot Study to Test the Feasibility of Applying the Technique in Pakistan

of 56 Timeline Activity 20132014 NovDecJanFebMarApr Options Appraisal Field team selection & training Roll-out Data entry and analysis Report Writing and Dissemination

of 56 Methodology Study Site: District Chakwal in Punjab Province. Chakwal comprises four tehsils and has an estimated population of nearly 1.4 million. 85 percent rural population.

of 56 Map of District Chakwal

of 56 Key RH Indicators Chakwal District and Punjab Indicator MICS 2011 PunjabChakwal Total Fertility Rate for women age 15-19 3.582.51 Percentage of currently married women age 15-49 years who are using (or whose husband is using) a contraceptive method 35.225.6 Percentage of currently married women aged 15-49 years with an unmet need for family planning 17.118.5 Percent distribution of delivery by a skilled attendant (SBA) 58.574.9 Infant mortality rate 8261

of 56 Chakwal (30 UCs) Chakwal (30 UCs) Talagang (23 UCs) Talagang (23 UCs) Choa Saidan Shah (7 UCs) Choa Saidan Shah (7 UCs) Kallar Kahar (8 UCs) Kallar Kahar (8 UCs) 1.LHWs 2.Religious Leaders 1.LHWs 2.Religious Leaders 1.Religious Leaders 2.Lady Councilors 1.Religious Leaders 2.Lady Councilors 1.LHWs 2.Religious Leaders 1.LHWs 2.Religious Leaders LHWs The Networks for Identifying WRA Deaths by Tehsil LHWs 1.Nikah Registrars 2.Religious Leaders 1.Nikah Registrars 2.Religious Leaders Nikah Registrars

of 56 Preliminary Findings

of 56 Participation of Key Informants in Listing Meetings: Made-In Step Type of Informant No. of Informants No. of Listing Meetings Attendance Rate % Refusal Rate% LHW114361960 Lady Councilors2005850 Nikah Registrars130121000 Religious Leaders157768623

of 56 Glimpses of Network Listing Meetings to Identify Deaths Among Women of Reproductive Ages

of 56 Glimpses of Follow-up Through Verbal Autopsy Sessions

of 56 Number of Cases Found Cases Identified by Village informant networks (MADE-IN) Recorded 2001 WRA deaths (including 210 PRDs) Address not found: 94 Refused: 25 Duplicate: 74 Out of criteria Year: 135 Out of criteria Age: 249 Cases followed up by Home visits and verbal autopsies (MADE-FOR) Total number of WRA death cases interviewed: 1808 Final list of cases identified Total number of WRA deaths followed up: 1424 Total number of PRD cases: 169

of 56 Measures of Validity and Agreement Between Cases Identified and Confirmed Through Verbal Autopsies MADE- FOR PRDsNon- PRDs MADE- IN PRDs16618184 PPV 90% Non- PRDs 312371240 NPV 99% Total16912551424 Sensitivity 98% Specificity 99%

of 56 Ranking (%) of Major Causes of Deaths in Women of Reproductive Age (n=1424)

of 56 Pregnancy Related Deaths by Tehsil Name of Tehsil Number of Cases Population Case per Population Chakwal83603,465 7270 Talagang46479,771 10429 Kallar kahar22154,7777035 Choa Saidan Shah18133,2167400 Total1691,371,2298113

of 56 Geographical Distribution of Pregnancy Related Deaths

of 56 Estimating Total Pregnancy Related Deaths through the Capture and Re-capture Technique in Tehsil Chakwal and Talagang 3428 M 10 LHW (N1= 62) RL (N2 38) RL (N2 26) LHW (N1= 37) 1918 M Chakwal Talagang T=N1xN2/M Total cases recorded in Chakwal:72 The estimate based on CRC is 84 Total cases recorded in Talagnag: 45 The estimate based on CRC is 53 8

of 56 Tehsil Probability of LHWs capturing deaths 95% CI Probability of RLs capturing deaths 95% CI Chakwal73%62-8245%34-56 Talagang70%56-8247%33-61 Probability of LHWs vs. Religious Leaders Capturing Deaths in Chakwal and Talagang

of 56 Probability of Capturing Deaths in Kallar Kahar and Choa Sayeden Shah Tehsil Number of cases recorded Adjusted number Choa Sayeden Shah1521 Kalarkahar2028

of 56 Probability of Reporting a Case by LHWs Comparing Routine Reporting vs. Pilot Study Routine Reporting by LHW Probability of LHWs in capturing a case in routine record 53% 95% CI: (46 60) Reporting by LHW in Pilot Study Probability of LHWs in capturing a case in pilot study 73% 95% CI: (66 79) Added value of reporting deaths by Religious Leaders= 18%

of 56 MMR Estimates for District Chakwal PopulationnUnadjusted95% CI nAdjusted95% CI PRMR 58521169289 247 - 336 186318274 - 367 MMR (2 years) 58521165282 241 328 181309266 358 PMDF142416512% 10% - 13% 18113%11% - 15%

of 56 Age Specific Maternal Mortality Ratio Age GroupPilot Study MMRPDHS 2006-7 15-19346242 20-24152210 25-29248267 30-34375246 35-39604657 40-44525855 45-49225234

of 56 Socio-Demographic Characteristics of PRDs Mean age of respondents = 29 years

of 56 Proportion of Pregnancy Related Deaths by Socio- Economic Status of Households with Deaths

of 56 Proportion of Pregnancy Related Deaths by Level of Education of Women Who Died

of 56 Proportion of Pregnancy Related Deaths by Cause

of 56 Distribution of Direct Causes of Maternal Deaths

of 56 Care Seeking Behavior

of 56 Distribution of Antenatal Care Visits

of 56 Distribution of Type of Provider Giving Antenatal Care

of 56 Distribution of those Who Received Antenatal Care, by Type of Facility

of 56 Whether Certain Antenatal Care Services Availed

of 56 Referral Advice During Antenatal Care

of 56 Distribution of Place of Referral

of 56 The Delay that Led to The Death Was it the first, second, third or fourth delay?

of 56 Decision Making for Seeking Care

of 56 Time Taken to Make a Decision

of 56 Time Taken to Reach Health Facility

of 56 Proportion of Respondents Who Thought Treatment Cost was Prohibitive

of 56 Perception whether Cost of Treatment was Prohibitive by Socio-economic Status of Women

of 56 Difficulty in Arranging Funds for Treatment

of 56 Proportion of Pregnancy Related Deaths by Location

of 56 The Tragedy Unfolding The Fourth Delay She was first taken to the RHC from where they referred her to DHQ hospital Chakwal. She reached the DHQ at 1.00 pm in the afternoon but according to the family members she was not given attention by the medical staff of the hospital till 7.00 pm. Then they were advised to have an ultrasound from a private clinic. She was taken to the labour room around 11.00 pm for a cesarean section. After cesarean section she was again not cared for and she died in the morning.

of 56 The Tragedy Unfolding The Fourth Delay She was having her antenatal checkups done regularly from a lady doctor. Her pregnancy was normal. She was taken to RHC for delivery. They tried for normal delivery and then they did an Episiotomy but she couldnt deliver. She was than referred to DHQ but without stitches being applied and still bleeding. She died upon reaching DHQ hospital.

of 56 The Tragedy Unfolding The Fourth Delay She was 9 months pregnant. Suddenly, she started bleeding. A local female practitioner (nurse) was called who referred her to RHC. The staff at RHC further referred her to DHQ after giving first aid. She was bleeding continuously and in the same condition she was taken to the DHQ hospital. The medical staff at DHQ referred her to Rawalpindi. She died in transit.

of 56 The Tragedy Unfolding The Fourth Delay When labor pains started, she was taken twice to the BHU. The LHV of the BHU sent her back saying that there was still time for delivery. When she was taken to the same facility a third time, she delivered a dead baby girl and later died. According to the husband and other people of the community, she died due to the carelessness of the LHV.

of 56 The Tragedy Unfolding The Fourth Delay She delivered in a private hospital. Placenta was not removed properly. She kept on bleeding. She was referred to a tertiary care hospital in Rawalpindi where she died.

of 56 Unfolding the Tragedy The Fourth Delay She delivered at a private clinic. Episiotomy was in process when load-shedding started. Generator was out of order. The torch of the mobile phone was used for completing the surgery. She was bleeding continuously and was taken to another facility but the bleeding did not stop. Eventually, she died the same night.

of 56 Conclusions and Recommendations Maternal mortality remains a major public health issue for Pakistan - the problem may be much larger than we anticipate Reaching the appropriate facility in the first place could have avoided the unnecessary fourth delay LHWs are the best available source for collecting maternal mortality data on a sustainable basis. A dual model for collecting information on maternal deaths can enhance accuracy, especially for areas not covered by LHWs.

of 56 Conclusions and Lessons Learnt The following can be considered as good informant networks: -- Religious leaders universally available need to be motivated. Nikkah Registrars a good network but limited in numbers. Lady Councilors a good source of information but few and not recently elected. For sustainability, district administration should make it mandatory for the Union Councils Secretaries to routinely collect data on vital events including pregnancy related deaths.

of 56 Thank You!

assessing the feasibility of using community informant networks to estimate maternal mortality in...

Documents