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SMART Practices in
Pakistan
According to UNICEF, a woman in Pakistan has a
one-in-31 lifetime risk of death from causes related to pregnancy and
childbirth. Although the country has made important progress recently,
it ranks 183rd out of 220 countries in terms of infant mortality.
The Safe Motherhood Applied Research and Training
(SMART) project was developed by Council researchers to investigate ways
to reduce maternal and perinatal mortality in the Pakistani province of
Punjab. (Perinatal mortality figures include both stillbirths and
neonatal deaths.) The three-year project, launched in 2003, tested the
effects of introducing two service-delivery methods. For the
experimental interventions, 120 rural communities with a total
population of about 600,000 were divided at random into a control group,
a group that would receive improved health-care systems only, and
another group with improved systems plus community-based interventions.
Strengthening the health-care systems primarily
involved training of district health managers, medical specialists,
physicians, and paramedics in the public sector. This training included
technical aspects of maternal and newborn health care and the Council’s
“client-centered approach” (CCA) to care, which emphasizes the
assessment of clients’ needs and negotiated solutions to reproductive
health problems.Community-based interventions included involvement
of community leaders, education of close to 34,000 women and men by
means of support groups, improved transport systems, and better linkages
with the health-care system. In addition, community-based providers,
including government-paid community health workers and dais
(traditional birth attendants), were given both technical and CCA
training.
Less than two years later, the perinatal mortality
rate had declined by 22 percent in the areas with an improved
health-care system plus community-based interventions. No change was
found in the communities that received only health-care system
improvement or in the control district. The primary factors in the
decline appear to have been the community education and dai training
components.
The SMART project has broken the barrier between
the traditional dais and modern health workers in a way that respects
the dais’ important position in Pakistan’s traditional culture but also
takes advantage of the life-saving skills of modern practitioners. As a
result, the dais are increasingly bringing emergency cases to the
regional hospitals. SMART also has increased awareness among mothers of
danger signs during pregnancy, delivery, and the postnatal period, and
improved understanding of when they should seek medical help.
In January, the Population Council hosted a seminar
to present the SMART project findings to health-care professionals,
academics, policymakers, and health-care managers. Pakistan’s
Director-General of Health, Shahida Malik, said that training dais in
accordance with the study’s “lessons learned” is vital to reducing
maternal and neonatal mortality and to reaching the Millennium
Development Goals, a major objective for Pakistan.At least eight Pakistani newspapers covered the
release of a report of the European Commission–funded research. The
results from the study, including specific project innovations, are now
being used more widely in Pakistan to strengthen maternal and neonatal
health programs. For example, the Council’s dai training package is
currently being implemented in three large-scale interventions, and the
client-centered methodology is being incorporated into the government’s
new community midwife training project. Publication of the results of
the project in several international medical journals is helping to
ensure dissemination beyond Pakistan’s borders.
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