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October 2007, Vol. 13, No. 2Reproductive Health A Population Council project has succeeded in significantly reducing perinatal deaths (including stillbirths and neonatal deaths) in Dera Ghazi Khan, a predominantly rural district in Pakistan’s Punjab province. The project addresses multiple factors that contribute to maternal and infant deaths. “This project shows that simple actions, such as educating women about danger signs that can arise in newborns and in women before, during, and after pregnancy; improving access to emergency care; and changing age-old practices can lead to considerably better health outcomes for babies and their mothers,” said Zeba A. Sathar, director of the Population Council’s Pakistan office. Maternal and infant death and illness remain serious public health problems 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 progress recently, it ranks 183rd out of 220 countries in terms of infant mortality. Three delays The first delay occurs at the household level, as lack of knowledge and other factors impede the decision to seek emergency care. The second delay occurs at the community level because of the absence of telephones and regular ambulance services, a particularly acute problem in rural areas. The third delay occurs at the hospital or health facility, and is largely due to a lack of trained staff, lack of supplies and equipment, and poorly organized emergency services. The main objective of the SMART project was to test the hypothesis that reducing all three delays through a concerted effort is significantly more effective than reducing any of the delays individually, as had been tested in prior studies. The project was developed with the expectation that the results would be used, replicated, adapted, and scaled up nationally in Pakistan, as well as in other developing countries facing similar challenges of reducing maternal and infant mortality. The SMART project was implemented in three sites. Two intervention strategies, one involving a community-based intervention plus a health services intervention (“site 1”), the other involving the health services intervention only (“site 2”), were compared against a control site (“site 3”) with no intervention. The community-based intervention included community organization, education for women and men, and the training of community health workers and traditional birth attendants (dais). The health services intervention included training in technical skills and client-centered counseling for relevant public sector physicians and paramedics. The ultimate goal of the project was to reduce maternal and neonatal mortality. However, it was impossible to measure declines in maternal mortality with statistical certainty given the relatively small number of people involved in the project. (Each of the three sites consisted of 60 communities, with an average of roughly 5,000 people in each community.) Thus, the researchers chose perinatal mortality (stillbirths plus early neonatal deaths per 1,000 live births) as their key indicator. In less than two years, perinatal mortality declined by a statistically significant 22 percent (from 81.7 deaths per thousand births to 63.4 deaths per thousand births) in site 1, where the community-based and health services interventions took place. This decline applied to both stillbirths and early neonatal deaths. There was no decline in such deaths in sites 2 or 3. “It is not clear which particular components of the intervention caused this decline, but it appears likely that the innovative program of dai training had an important effect,” states Council public health expert Peter C. Miller, a researcher on the study. On the other hand, in-service training of doctors and paramedics in both technical skills and client-centered counseling in site 2 did not in itself have a substantial effect in reducing perinatal mortality. Although maternal deaths were reduced in all three areas, the numbers were too small to be statistically meaningful. “Addressing all three delays is necessary to improve maternal and neonatal health,” said project director Gul Rashida, a Population Council researcher. “The results of the SMART project present a useful blueprint for how to address these delays in a poor and vulnerable area of Pakistan. We suggest that if this can be done in a setting such as Dera Ghazi Khan, with its logistical, cultural, and other challenges, it can be replicated in most other places in Pakistan.” Sources Wajid, Abdul, Zakir H. Shah, Ashfa Hashmi, Zeba Tasneem, and Lubna Shireen. 2006. “Safe Motherhood Applied Research and Training (SMART) Report 2: The interventions,” Islamabad: Population Council. (PDF) Arif, Muhammad Shafique, Peter C. Miller, Nayyer Munir, and Irfan Masood. 2006. “Safe Motherhood Applied Research and Training (SMART) Report 3: Changes in knowledge and behavior of women and families,” Islamabad: Population Council. (PDF) Shah, Zakir Hussain and Saima Pervaiz. 2006. “Safe Motherhood Applied Research and Training (SMART) Report 4: Knowledge and behavior of service providers.” Islamabad: Population Council. (PDF) Outside funding Related Projects
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