Development & Management of the Reproductive Health Program to Reduce the High Maternal Mortality in District Haripur, N.W.F.P.

Dr Dr Dr Dr Haris Habib Nida Liaquat Fariha Fatima Muhammad Bilal Khan

MSPH 2009-10 Health Services Academy Islamabad

Background
Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. 6 priority components of RH: Safe motherhood Ante-natal care Obstetric care Post-natal care Newborn care Family planning These services were devised to address the issues of maternal & neonatal deaths. Other Components of RH: Control of STIs, HIV/AIDS, Cancers of genital tract, Reproductive health in adolescence & post-menopausal, Pre-marital & genital counseling.

Background
Maternal mortality is the death of the women during the pregnancy or within 42 days after the termination of pregnancy by the maternal causes and absence of the accidental or other causes. 1800 Women are dying /day globally due to maternal causes. 78% of these deaths are occurring during the perinatal period. 90% of the deaths occurring in the SSA & SEA including Pakistan. MMR in Pakistan is 276/100000 live births 82% of these deaths are preventable

Causes of Maternal Deaths World Wide

History of Haripur
Hari Singh Nalva,General of Ranjit Singhs army

Introduction of District Haripur

Founded in 1822 by Hari singh Nalva Diverse Landscape Administrative boundaries touching Punjab and Federal Capital. District Health system under the administration of EDO Health consists of very vast infrastructure. Other Vertical Programs for reproductive health ;
National Program for PH & FP District Population Office District MNCH program.

Map of Haripur and the Beautiful Khanpur Dam

Urban-Rural Population Distribution in Distt. Haripur

12%

Rural Population %
88%

Urban Population%

Source DCR (1998), District Population Office (2008), National Programme (2008) , FD
(2008)

Demographic and Reproductive Health Indicators of District Haripur

Population Rural/ Urban % Male / Female % Growth Rate Health Facilities TFR IMR MM Ratio Deliveries in Health Facilities % Deliveries by skilled in HF CPR 0.8 Millions 88/12% 49/51% 2.19 54 4.7 36/1000 170/100000 34223 11.7% 28.5

Public Sector Health Staff in Haripur (Current Status) Designation No. Presently Working Medical Officers(male) 45 Women Medical Officer 6 Gyneacologist 1 Medical Assistants 84 LHVs 43 Health Technician 33 LHWs 475 Traditional Birth Attendants 44

Target Population
Our Target population is all Pregnant women in Haripur which constitutes 3% of the total population. This population is spread over 1,725 sq. km, with population density of 401.3 persons per sq. km. The average household size of the district is 6.6 persons per household.

Literacy Rate in Distt. Haripur

The overall literacy rate for Haripur district is 53.7%. The female literacy rate is dismally low at 37.4% as against male literacy of 70.5 percent. The urban: rural break down show that rural literacy is lower (51.4 percent) than the urban literacy (69.7 percent).

Why Private Sector?

80%
72 %

Urban
6 7% 64%

70% 60%

Rural Overall
50% 40% 30%
2 0 % 2 1% 2 1%

20% 10% 0% Private Disp/ Hosp Public Disp/ Hosp RHC/BHUs Hakeem Homeopath Chemist Others

5%

7% 4% 2% 2% 2% 2% 2% 3% 1% 1%

5% 1% 2% 1%

Aim and Objectives

Aim:
To improve the quality of life through provision of better reproductive health services to the women of Pakistan. To reduce the maternal mortality in the district Haripur by 75% in 03 years. To achieve the availability of skilled birth attendants 24/7 in 100% of the facilities of the district Haripur in 03 years

Objectives:

Preventive Interventions
Short Term Interventions Long Term Interventions

Community awareness sessions regarding reproductive health approach. Involvement of influential people of district like religious and political leaders as well as family heads & establishment of community groups. Community based transport system on subsidized rates, make available for 24/7.

To improve knowledge, attitudes and their beliefs regarding family planning. To provide comprehensive family planning services Eradicate poverty and hunger To improve employment status Promote gender equality and women empowerment. Intersectoral approach Involvement of men in the reproductive health issues.

Curative Interventions
Short term interventions Availability of the female staff at the facilities 24/7 Hands on training to existing doctors, midwives and LHWs. Provide kits and teach them how to greet patients. Improving access to health facility by providing ambulance to the district. Functionalize birthing centers Provision of ante-natal care services. Provision of post-natal care services. Long Term Interventions To improve the health care system by increase the number of health personnel of the district. To provide cEmoC at BHUs level. Develop public/private partnership. To develop working relationship among the CPSP, Federal MoH and DHMT for sustainability of the program intervention.

New Concept
The Risk of the death in the women of child bearing is un predicted. We always talk of 3 Ds. What is the limit of these delays??? We should not delay in understanding the magnitude of the problem! We would introduce 3 Ts concept
Terrain Type of transport Travel Time

Selected Internvetions
Curative; short term
We as a DHMT selected the strategy of availability of skilled birth attendants 24/7 in the BHUs.

Preventive;
Community awareness through the multifaceted approach for the sustainability of program intervention.

Steps Towards Better Future

We made the 10 clusters of 40 BHUs along with the 6 RHCs. For every cluster, gynecologist will be hired with large monetary incentives; 24/7. Training of the trainers for skilled birth attendant will be done in Teaching Hospital. Skilled development Training of the staff working in the health facilities by the master trainers. Making of support groups in the targeted communities.

Steps Towards Better Future (contd)

Community awareness sessions will be conducted at the regular intervals in order to emphasize the importance of reproductive health. To involve the influential people of the district regarding the decision and policy making about the service provision and service utilization in the public sector health facilities. To involve the community transporter through the community support group for providing the ambulatory facilities to the referral cases on subsidized rates. Purchase of the delivery equipments for the BHUs.

Activity Plan for one Whole Year(Revised Every Year)

Ist month:
Sensitization of the DHMT and stakeholders about the program through series of meetings.(1st Weeks) Hiring of the master Trainers in the teaching hospitals.(1st & 2nd Week). Formulation of training manuals (3rd & 4th week). Printing & revising the TMs (4th Week).

Activity Plan
IInd Month:

(Cont)

Hiring and inducting the gynecologists & other necessary staff(5th Week) Training of the trainers at selected teaching hospital outside the district(6th 7th & 8th Weeks).

Activity Plan
IIIrd Month:

(Cont)

Training of rest of concerned female staff by the trainers within the district(9th, 10th, 11th Weeks) Evaluation of the trained staff through role plays & hands on activity.(12th Week)

Activity Plan
IV & V Months:

(Cont)

Purchase of the equipments and other necessary items for the facilities.(13th & 14th Week) Hiring of the social mobilizers & their training(14th & 15th Weeks) Serial meetings with the community members & identification of local influential people(16th, 17th,18th, 19th Weeks) Printing & revision of the social mobilization material like pamphlets, posters ,banners etc(20th week).

Activity Plan
VI Month:

(Cont)

Formation of community support groups(21st week) Start of community awareness sessions about the provision & utilization of reproductive health services in the area.(21st week & it is an ongoing activity).

Activity Plan
VI------XII Months:
Evaluation:

(Cont)

Ongoing , for every cluster twice in a month and for every facility once in a month visit. Feedbacks from the community support groups regularly once in a month & continuously through cellular phone. Every facility & every cluster will report its performance in written every month and cross checking of these reports by the DHMT.

Revised Activity Plans

As it is a 3 years program, activity plans may be revised every year according to the feedbacks by the community and evaluation by DHMT. Rotation of the gynecologist may be done after every six months. Budgeting adjustment according to the need may be done.

Budgeting
Total Budget 100 Millions only

1 Training Expenses
Training of trainers (3 days course) 0.1 million Rupees

Training of WMOs+LHVs+Nurses(6 Days with 3batches)

Training of Social mobilizers

0.3 million
0.2 million

2 Printing Expenses
Printing of training mannuals+Pamphlets+Multimedia & Other Stationary Items 6 million

3 Transport Expenses
Trainers & social mobilzers Transport
Community Transporters

4 million
2 million

Budgeting
4 Awareness campaign
Community awareness sessions+formation of community groups

(Conti...)
5.0 Millions

Purchase of Equipment
Delivery tables, O2 Cylinder, 4 Ambulances, 4 Ultrasound Machines & other surgical equipments 10 Millions 35 Millions 20 Millions 10 Millions

6 7 8

Salaries & Overtime Construction Charges Repair and maintenance

Miscellaneous

5 Millions

Assumptions
1
2 3
Promote primary /secondary education Comprehensive family planning services as well as Nutrition interventions for women.

Accessibility to hospitals by the provision of ambulatory services and Hands on training of TBAs /midwives and LHWs to deal with minor cases.

4 5

Reinforce the knowledge base about reproductive health among the community through involvement of influential personalities (political, religious & family heads)as well as mass media.

Availability of skilled birth attendant by 24/7 and give them high incentives.

Way Forward
Sustainability: Program suggests following steps to be taken for the sustainability of the interventions
Working relationship among CPSP, Fed. MoH & DHMT. Formulation of the policy regarding the trainee doctors . Formulation of the policy regarding induction of the doctors in the basic health units and revision of their pay /salary especially NWFP.