prof. dr. syeda batool mazhar. frcog ( u.k ), fcps (pk)

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

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.

WHO MULTICOUNTRY SURVEY: 2010 -2011

SELECTED COUNTRIES IN WHO MULTICOUNTRY SURVEY

Group I Low MMR

Group II Moderate MMR

Group III High MMR

Group IV Very High MMR

(MMR<20) (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

WHO MULTICOUNTRY SURVEY: 2010 -11

Maternal Mortality Ratio PakistanPeriod 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


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.


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

MATERIALS AND METHODS

SETTING

*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.

Health services availability in WHO Multicountry survey

hospitals of Pakistan and its association with obstetric

outcomesHospital 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.



outcomes

Materials and Methods

• Study duration:The survey was conducted from 1st March 2011 to 30th May, 2011

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.



outcomes

RESULTS

Participating facilities:WHO MultiCountry Survey, Pakistan

Referral Level Of Hospitals

Characteristics of the participating hospitals

16

3

institutions providing free of charge caren=19 hospitals

yes

no

Proprtion of women delivering free of charge:PIMS Islamabad= between 25 and 50%Sobhraj hsp Karachi= less than 25%Shiekh Zayed Lahore= less than 25%

1 non teaching facility=THQ Muredke

Characteristics of the participating hospitals

Maternal CharacteristicsCharacteristics % All women n=13175

N (%age) SMO n=132

N(%age)Age

<20 years 529(4%) 5(3.8%)

20 – 35 years 12092(92%) 116(88%)

>35 years 554(4.2%) 11(8.3%)

Schooling years

< 5 years 4511(34%) 75(57%)

5 – 8 years 3600(27%) 29(22%)

9 – 11 years 3169(24%) 21(16%)

> 11 years 1892(14%) 7(5.3%)

Statistically sig diff b/w SMO and non-SMO group for maternal education p= 0.000

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

Number of beds and deliveriesHospitals 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

AVAILABILITY OF BASIC SERVICES INCLUDINGINFRASTRUCTURE

SERVICES NO OF HOSPITALSN= 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%

AVAILABILITY OF MEDICAL FACILITIES

services No of hospitalsN= 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%

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

EMOC SERVICES NOT AVAILABLE IN ALL HOSPITALS

Services No of hospitals (N=19) %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%

ADULT AND NEONATAL ICUFacility(n=19) Present AbsentAdult 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%)

Health Professionals Availability for EMNOCProfessionals Availability No of hospitals(n=19) % 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%


8 42.1%

Partial availability 2 10.5%

Anesthetist 24h/day, 7 days/week in facility

12 63.2%


6 31.6%


Health Professionals AvailabilityProfessionals Availability No of

hospitals(n=19)% of hospitals

Internal medicine specialist

24h/day, 7 days/week in facility

10 52.6%


6 31.6%


Not available 2 10.5%

Critical care specialist

24h/day, 7 days/week in facility

10 52.6%


4 21.1%

Partial availability 0 0

Not available 5 26.3%

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%

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 facilityverses

Highest rates in a tertiary care facility

Maternal morbidity and mortality in the WHO Multi-country survey Hospitals, Punjab

Hospital Total Deliveries (n=13175)

n (%)

Maternal Severe Outcome(n=132)n (%)

Maternal Complications(n=1158)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%)

Maternal morbidity and mortality in the WHO Multi-country survey Hospitals,Sind

Hospital Total Deliveries

(n=13175) 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%)

Maternal morbidity and mortality in the WHO Multi-country survey Hospitals, Islamabad

Hospital Total Deliveries

(n=13175)n (%)



PIMS Islamabad 1706 (12.9%) 6 (4.5%) 294 (25.4%)

Poly clinic H Isb 931 (7%) 3 (2.3%) 23 (2.0%)

Who MC Survey: Hospital Perinatal mortality rates Hospital name Total deliveries

N=13175Peri-natal mortality rate/1000 births

DHQ Toba Tek singh 349 (2.6%) 9.1THQ Muredke 321 (2.4%) 3.2Services H Lahore 371 (2.8%) 19.2RMC, Rawalpindi 3481 (26%) 30Nishtar H Multan 622 (4.7%) 30Bahawalpur 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

Perinatal mortality rate among different hospitals included in the Who Multi-country survey

Hospital name Total deliveriesN= 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

Correlation Of Maternal And Neonatal Outcome With The Availability Of

Resources In The Facilities

Adult ICU and Severe Maternal Outcome(SMO)

Adult intensive care unit

FacilitiesN=16

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

FacilitiesN=16


P value

Available 9 (56%) 113 (86%) 0.01

Not available 7 (44%) 19 (14%)

Laboratory tests and SMO

Coagulation tests FacilitiesN=16


P value

Available 14(87%) 132(100%) 0.01

Not available 2(12%) 0(0%)

Senior EMOC staff availability and SMOAvailability of anesthesiologist

FacilitiesN=16


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

FacilitiesN=16


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%)

Maternal access to adult ICU care and SMOAppropriate adult/maternal ICU?

FacilitiesN=16


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

FacilitiesN=16


P value

Yes 7(44%) 19(14%) 0.01

No 9(56%) 113(86%)

Correlation of level of care with the proportion of severe maternal outcome and no of deliveries

Level of facilities No of deliveriesN=13175


P value

Secondary 1848(13.6%) 8(6.1%) 0.012

Tertiary 11327(86.4%) 124(94%)

Level of facilities No of deliveriesN=13175

Maternal complication N= 1158

P value

Secondary 1848(13.6%) 21(1.8%) 0.0001

Tertiary 11327(86.4%) 1137(98.2%)

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

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

Gender inequality indexand WHO MC survey

Parliamentary representation

Adolescent fertility

(4%)*

Maternal mortality

(299)*Labour force participation

EducationSec & above

(38.4%)*

REPRODUCTIVE HEALTH LABOUR MARKETEMPOWERMENT

5 INDICATORS

GENDER INEQUALITY INDEX

3 DIMENSIONS

*Evidence based policies for improving maternal health in Pakistan, Human Development Report, 2011.*WHO MCS findings

Correlation of Neonatal mortality with Neonatal ICU

Neonatal ICU FacilitiesN=16

Neonatal mortality P value

Available 7 219 0.01

Not available 9 74

No correlation of neonatal mortality with availability of pediatricianwas found.

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.

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 Dec;62(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 Dec;115(3):240-3

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. 2006;56:156-63.

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 April;27(2):170-83.

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.

Strengths and LimitationsStrengths:

• 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.

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.

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

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 Dec;62(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 Dec;115(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. 2006;56:156-63.

• 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 April;27(2):170-83.

Thank you

prof. dr. syeda batool mazhar. frcog ( u.k ), fcps (pk)

Documents

availability of services

selected hospitals

newborn health

ministry of health

availability of essential

multicountry surveygroup

obstetric outcomesmaterials

obstetric outcomesprof