Transcript 5. S. BATOOL facility3

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
Large cross-sectional
survey
Worldwide network of
357 health facilities
• May 2010 to December
2011
• 14 WHO sub-regions
selected based on levels of
child and adult mortality
• in 29 countries from Africa,
Asia, Latin America and the
Middle East
• 314,623 observations
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
Afghanistan
Angola
Democratic Republic
of the Congo
Kenya
Niger
Nigeria
Uganda
Pakistan
WHO MULTICOUNTRY SURVEY: 2010 -11
29 countries, 357 health
facilities
Americas - 8 countries
Africa - 7 countries
Asia - 14 countries
314,623 women
PAKISTAN
16 FACILITIES
2 FEDERAL CAPITAL
7 SINDH
7 PUNJAB
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
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.
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
MATERIALS AND METHODS
SETTING
4 urban
7 from Sindh
3 periurban
*16 referral level
govt. hospitals
7 from Punjab
5 urban
2 periurban
2 Federal capital
*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 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.
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
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.
Health services availability in WHO
Multicountry survey hospitals of Pakistan
and its association with obstetric outcomes
RESULTS
Participating facilities:
WHO MultiCountry Survey, Pakistan
FEDERAL CAPITAL
PUNJAB
SINDH
• PIMS
• POLYCLINIC
• DHQ Toba Tek Singh
• THQ Muredke
• Services H Lahore
• RMC(BBH,HFH DHQ)
• Nishtar H.Multan
• Bahawalpur Victoria
• Sh. Zayed H Lahore
• Civil H Karachi
• Sobhraj H Karachi
• Korangi H Karachi
• Qatar H Karachi
• Taluka H Rohri
• Civil H Jacobabad
• Civil H Badin
Referral Level Of Hospitals
Secondary
Health Care
Facilities
• DHQ H ,Toba Tek Singh •Taluka hp. Rohri
• THQ Muredke
•Civil H Jacobabad
• Korangi H. Khi
•Civil H Badin
Tertiary
Health Care
Facilities
•
•
•
•
•
PIMS, Islamabad
POLYCLINIC, Isb
Services H Lahore
RMC, Rawalpindi
Qatar H Karachi
•Bahawalpur Victoria H
•Shiekh Zayed H Lahore
• Nishtar H Multan
•Civil H Karachi
•Sobhraj H Karachi
Characteristics of the participating hospitals
institutions providing free
of charge care
n=19 hospitals
3
yes
16
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 Characteristics
Characteristics %
All women n=13175
N (%age)
SMO n=132
N(%age)
Age
<20 years
529(4%)
5(3.8%)
12092(92%)
116(88%)
554(4.2%)
11(8.3%)
< 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%)
20 – 35 years
>35 years
Schooling years
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
Deliveries in Study
2009 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
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
Services Lahore
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
AVAILABILITY OF BASIC SERVICES INCLUDING
INFRASTRUCTURE
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%
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%
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 ICU
Facility(n=19)
Adult intensive
care unit
Present
13(68.4%)
Absent
6(31.6)
Neonatal
intensive care
unit
Other newborn
care unit with
incubator
10(52.6)
9(47.4%)
11(57.9%)
8(42.1%)
Health Professionals Availability for EMNOC
Professionals
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%
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%
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%
Pediatrician
Anesthetist
Health Professionals Availability
Professionals
Availability
No of
hospitals(n=19)
% 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%
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%
Critical care
specialist
Availability of Laboratory tests
Tests
Blood gas
analysis/gasometry
No of hospitals
N= 19
%age
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
range 0-34
(maternal deaths+ maternal nearmiss)
• 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
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 (%)
12 (1%)
DHQ Toba Tek Singh
349
(2.6%)
7
(5.3%)
THQ Muredke
321
(2.4%)
0
Services H Lahore
371
(2.8%)
1
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
60
1
(0.8%)
(0.8%)
(0.1%)
10 (0.9%)
(5.2%)
Maternal morbidity and mortality in the WHO
Multi-country survey Hospitals,Sind
Hospital
Total Deliveries
(n=13175)
n (%)
Maternal Severe
Outcome
(n=132)
n (%)
Maternal
Complications
(n=1158)
n (%)
Civil H Karachi
763 (5.8%)
13 (9.8%)
52
(4.5%)
Sobhraj H Karachi
823 (6.2%)
5
16
(1.4%)
Korangi H Karachi
497
0
4
(0.3%)
Qatar H Karachi
1204 (9%)
6
Taluka H Rohri
161
(1%)
0
Civil H Jacobabad
151
(1%)
1
Civil H Badin
369
(2.8%)
0
(3.8%)
(3.8%)
(4.5%)
155 (13.4%)
0
(0.8%)
2
(0.2%)
2
(0.2%)
Maternal morbidity and mortality in the WHO Multicountry survey Hospitals, Islamabad
Hospital
Total Deliveries
(n=13175)
n (%)
Maternal Severe
Outcome
(n=132)
n (%)
Maternal
Complications
(n=1158)
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=13175
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
Shiekh Zayed H
Lahore
962
(7.3%)
30
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 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
30
(7%)
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
Facilities
N=16
Maternal severe
outcome N= 132
P value
Available adult ICU
10 (62%)
119
(90%)
0.006
Not available adult
ICU
6
13
(10%)
Mechanical
ventilation
Facilities
N=16
Maternal severe
outcome N= 132
P value
Available
9
(56%)
113 (86%)
0.01
Not available
7
(44%)
19
(38%)
(14%)
Laboratory tests and SMO
Coagulation tests
Facilities
N=16
Maternal severe
outcome
N= 132
P value
Available
14(87%)
132(100%)
0.01
Not available
2(12%)
0(0%)
Senior EMOC staff availability and SMO
Availability of
anesthesiologist
Facilities
N=16
Maternal severe
outcome N= 132
P value
Available 24h/day, 7 9(56%)
days in facility
113(86%)
0.01
Not available
24h/day, 7 days in
facility
7(44%)
19(14%)
availability of
nurse/paramedics
Facilities
N=16
Maternal severe
outcome N= 132
P value
Available 24h/day, 7 12(75%)
days in facility
124(93%)
0.03
Not available
24h/day, 7 days in
facility
8(6%)
4(25%)
Maternal access to adult ICU care and SMO
Appropriate
adult/maternal
ICU?
Facilities
N=16
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
N=16
Maternal severe
outcome N= 132
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 deliveries
N=13175
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
N=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 index
and WHO MC survey
Maternal
mortality
Adolescent
fertility
(299)*
(4%)*
REPRODUCTIVE
HEALTH
Parliame
ntary
represen
tation
Education
Sec & above
(38.4%)*
EMPOWERMENT
Labour force
participation
LABOUR
MARKET
5 INDICATORS
3 DIMENSIONS
GENDER INEQUALITY INDEX
*WHO MCS findings
*Evidence based policies for improving maternal health in
Pakistan, Human Development Report, 2011.
Correlation of Neonatal mortality with Neonatal ICU
Neonatal ICU
Facilities
N=16
Neonatal mortality
P value
Available
7
219
0.01
Not available
9
74
No correlation of neonatal mortality with availability of pediatrician
was 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 and
WHO 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 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.
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