Maternal mortality ratio of Pakistan

Abstract:

Background:

It has been estimated that 350-550 women die per 100,000 live births in Pakistan. Over all Maternal Mortality Ratio of Pakistan is 276 deaths per 100,000 live births being highest in Balochistan which is 785 maternal deaths per 100,000 live births. Traditional birth attendants (TBAs) had been the main source for the provision of delivery care in rural areas of Pakistan but failed in reducing the pregnancy related deaths especially the complicated cases due to adherence to traditional practices. Government of Pakistan has launched a Community Based Midwife (CMW) program to fill the gaps and tackle maternal mortality problem in order to achieve the targets of Millennium Development Goals.

Objectives:

The objectives of this study are to explore the expectations and willingness of the community along with the Traditional Birth Attendants (TBAs) regarding acceptance of the new role of Community based Midwifes (CMWs) in the reduction of pregnancy related deaths in District Lasbela, Balochistan Province during July-September, 2010.The study will also explore willingness of Community based Midwifes to work at community level independently and the issues and challenges that might be faced by these midwives.

Methodology:

This will be an Exploratory Qualitative Study. In-depth interviews with Community based Midwifes and Traditional Birth Attendants will be conducted through semi structured guides. Focus Group Discussions (FGD) will be conducted with respective communities by using the FGD guidelines.

Outcome:

The perceived role of these Community based midwives by the community and Traditional Birth Attendants will help in understanding the readiness to accept the entry of new player at community level. We will also understand that either community consider CMWs as a valuable strategy for the delivery of reproductive health services at doorstep for provision of emergency obstetric services in the presence of TBAs. The performance of these midwives will be improved by resolving the challenges that might be faced during their work and service provision which will ultimately strengthen their role.

Introduction:

Background

Each year over 500,000 women die from obstetric complications worldwide. Estimated total of 536000 maternal deaths occurred in 2005, developing countries accounted for 99 %( 533000) of these deaths. The maternal mortality ratio was 490 maternal deaths /100000 live births in South Asia in 2005.[1] The Millennium Development Goal (MDG-5) calls for the reduction of maternal mortality ratio (MMR) by three quarters between 1990 and 2015.[2]An estimated 16,500 maternal deaths occur every year in Pakistan. MMR for Pakistan ranges from 276 to 700 per 100,000 live births and it is high in rural areas of the country.[3] Results of a study revealed the Khuzdar district of Balochistan had the highest MMR significantly higher than other districts including Pishin, Loralai and Lasbela.[4] According to another report, the overall MMR was 276 maternal deaths per 100,000 live births in Pakistan while the MMR in Balochistan was 765 highest among other three provinces.[5] According to Pakistan Demographic and Health Survey 2006-07 the Maternal Mortality Ratio is 785 maternal deaths per 100,000 live births in the Balochistan province. Direct causes for maternal deaths in Pakistan are postpartum hemorrhage, hypertension, sepsis, unsafe abortion and ruptured uterus, which constitutes 80% of maternal deaths.[6] The PDHS 2006-07 showed that 61% of mothers receive prenatal care from skilled birth attendants, while the deliveries occurring at health facilities were only 34.2% (56% urban, 25% rural). On the other hand 52% of the births are assisted by the TBAs while 57% believe that it is not necessary to give birth in a health facility.10

The World Health Organization (WHO) has defined Traditional Birth attendant (TBA) as a person who assists the mother during childbirth and who initially acquires her skills by delivering babies herself or by working with other TBAs.[7] TBAs are often older women over 40 years of age and are usually uneducated and untrained.[8] Mostly these are community member often chosen by community for assistance in childbirth. These are highly regarded by community. These TBAs acquire skills through observation rather through professional training.[9]

In spite of this fact, data reveals that 81% of pregnant women were delivered at home in Balochistan out of which 50.6% were assisted by Dai/TBAs.[10]

Traditional birth attendant (TBA) training has been promoted for a long time in order to expand the attainment of health services by underserved populations and to reduce the preventable maternal morbidity and mortality in developing countries.[11] It has been observed that historically, traditional birth attendants (TBAs) have been the key personnel for women during childbirth. Despite the variation of tasks and positions across cultures, still the majority of deliveries are attended by these TBAs in rural areas of developing countries. They are considered as culturally fit for the provision of comfort, sympathy and psychosocial support to the mothers, newly born child and families at the time of delivery. Different strategies and initiatives have been taken for the improvement of maternal and a neo natal outcome in many countries but the training of TBAs has been an important part of all these. However, recent analysis has shown that training of TBAs has not been effective in reducing the maternal mortality and the impact of training on maternal mortality is low.[12] Though models have been developed and proposed for improvement in maternal health and reduction of maternal mortality through training and integration of the Traditional birth attendants in health care system of developing countries.[13] It has been realized that interventions at community level may be useful in improving the prenatal care practices that may be helpful in declining the maternal mortality[14] and delivery assisted by a skilled birth attendant (SBA) became an indicator for progression towards reduction in pregnancy related maternal mortality around the globe.[15] The Safe Motherhood Initiative (SMI) of 1987 became a bench mark that provided new direction for the research defining the policies and strategies required to combat the long-lasting high levels of maternal deaths focusing on increasing access to skilled birth attendants and obstetric emergency care.[16] WHO has defined an skilled birth attendant (SBA) as an accredited health professional such as midwife, doctor and nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated)pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.[17],[18]

The trend of delivery care and assistance by untrained or improperly trained traditional birth attendants/dais is prevalent in Pakistan. In spite of the fact that these are highly valuable and culturally deep rooted service provider but their persistent attitude and non adherence to modern and safe birth practices has been observed as one of the contributing factor in high maternal and neonatal mortality rates in Pakistan. one study conducted in Pakistan recommended that there is dire need of training midwifes having strong links with community and formal health system in order to bring the change. [19] A study conducted to assess care provided by Indonesian village midwifes from a clinical perspective considering the health system and social factors which might have affected the care provision. The results showed that midwifes facilitated referral effectively and reduced the delays in accessing the health facilities. The success depended upon the integration with communities, enabling environment like infrastructure, training, supervision, policy and political support.[20] To combat this alarming situation and recognizing the importance of community based midwife, Government of Pakistan decided to launch National Community Midwife Program (NCMP) designed to significantly reduce Maternal and Infant Mortality rates by introducing a modern and safe service for child delivery along with the provision of skill-based education, income generation, and gender empowerment opportunities for enrolled midwifes.[21] The major objective of NCMP program include delivery of safe maternal care, provision of readily accessible reproductive and family planning services at the community level, creation of network of institutionally trained reproductive health workers throughout Pakistan and provision of micro-credit for establishment of village-based reproductive centers owned and operated by Midwifes. Improved maternal health and reproductive indicators is one of the expected outcomes of the program.[22], 21 Impact of the program will be measured by improvement in health indicators like maternal and infant mortality.21 Independent midwifery practice has been legalized and approved by the government.[23]

One of the focus areas of the strategic plan of Pakistan Initiative for Mothers and Newborns (PAIMAN) was community based access to maternal and neonatal health services by introducing, training and deploying community midwifes as long term goal to reduce the maternal mortality due to non availability of skilled attendants in rural areas of Pakistan. This strategy was named as National Skilled Birth Attendant Strategy for the improvement of community access to care being the important part of National Program on Maternal, Newborn and Child Health (MNCH). As a part of SBA strategy, Traditional birth Attendants (TBAs) have been given the orientation trainings as their inclusion and integration into the SBA strategy was considered important. It was decided that until launching and operalization of the strategy in whole Pakistan, TBAs will remain the initial and first point of contact in rural areas. For this purpose the PAIMAN has oriented 1400 out of 1900 TBAs in the selected districts regarding clean delivery practices, enhancing the ability for recognizing the danger signs. The increase in referral rate of complicated deliveries is the main focus of strategy.[24]

Goal of the study:

To reduce the Maternal Mortality by minimizing the pregnancy related maternal deaths through strengthening and improving the role of Community based Midwifes (CMWs)

Research Questions:

  1. What are the expectations and readiness of the community in accepting the emerging role of trained community based mid wives (CMW) in reducing the pregnancy related maternal deaths in Lasbela District, Balochistan?
  2. What are the perceptions of Traditional Birth Attendants (TBAs) about accepting the new role of Community based Midwifes (CMWs) in the reduction of pregnancy related deaths in District Lasbela, Balochistan?

Study Objectives:

  1. To explore the expectations and willingness of the community to accept the new role of trained community based midwifes in district Lasbela, Balochistan in the reduction of pregnancy related deaths in District Lasbela, Balochistan Province during July-September, 2010.
  2. To explore the Community based Midwifes (CMWs) readiness and willingness to work independently in their respective communities in district Lasbela, Balochistan during July-September, 2010.
  3. To explore the perceptions of Traditional Birth Attendants (TBAs) about accepting the new role of Community based midwifes (CMWs) in the reduction of pregnancy related deaths in District Lasbela, Balochistan Province during July-September, 2010.

Hypothesis:

  1. The community will have higher expectations from these trained community based midwifes in the presence of TBAs in term of knowledge and skills in emergency obstetrics care provision and saving the lives of mothers during pregnancy.
  2. The community may not be willing to accept these CMWs due to their less experience.
  3. The Traditional Birth Attendants (TBAs) will not accept the presence of community Based midwives (CMW) and perceive them as rivals.
  4. The community based midwifes may also face barriers in the provision of services related to maternal health at community level

Rationale of the study and selection of study site:

The government of Pakistan has launched the National Community Midwifes Program (NCMP). The community based midwifes have been trained through midwifery schools established all over the country in selected districts to tackle the mounting maternal mortality ratio and to attain the targets of MDGs related to maternal mortality through safe delivery, readily accessible reproductive health and family planning services at the community level. Training to the 1st batch of midwives has been completed in 10 focal districts of Balochistan. These trained community based mid wives have been deployed in two district of province while process will be completed in other districts very soon. This study will explore that the community readiness to accept the CMWS along with the readiness and willingness of these CMWs to work independently in their respective catchment areas. By conducting this study we will also understand that either the communities consider this strategy as a valuable addition in the delivery of reproductive health services at door step for provision of emergency obstetric services in the presence of TBAs. In addition to this, we will also analyze that to what extent reduction can be brought by these CMWs in maternal mortality. Lasbela District is one of the districts of Balochistan where high pregnancy related mortality has been established by studies. As per my knowledge, no such study has been conducted in Balochistan.

Methodology

Study Setting:

The study will be conducted in District Lasbela. It is one of the coastal districts of Balochistan province.[25] It is bounded in the North by district Khuzdar, in the East by Malir and Karachi (West) districts of Sindh province, in the South by the Arabian Sea and in the West by Gawadar and Awaran districts.[26]

Research Design:

This study will be based on the exploratory research design and qualitative methods will be used in order to meet the study objectives. The Qualitative Exploratory research design is very useful when we know little about the topic or issue to be explored[27] as no information regarding the perceived expectation and readiness of community about community based midwifes is available. Furthermore the perceived barriers which these community based Midwifes face during their routine work and service provision are also unknown. It help will help to generate hypothesis for further research. Exploratory research is a type of research conducted since a problem has not been clearly delineated. [28]

Rationale for choice of design:

An exploratory research design is appropriate to explore these perceptions which have not yet been explored.[29] Based on the principles and characteristic of an exploratory research, this design has been considered to be most apt to answer the study research questions, as well as to address the purpose of this study which is to reduce the maternal mortality by minimizing the pregnancy related maternal deaths through strengthening the role of community based Midwifes in the province. The other reason for preferring the qualitative research design is that it serves the basis for the study when there is no sound knowledge in the form of facts or themes available and the topic has to be explored in-depth due to unavailability of research done in the local context.[30]

Study Population:

The study population is comprised of following primary respondents

Primary Respondents

The primary respondents/participants will be comprised of all the Community based Midwifes, Traditional Birth Attendants and the General population residing in the catchment areas of these primary respondents in the district.

  • Community based Mid wives(CMWs)
  • Traditional Birth Attendants(TBAs)
  • Respective Community Members (Male and Female)

List of Community Midwifes (CMWs) containing the residential addresses will be obtained from the District Focal Person (PAIMAN) and Executive District Officer Health (EDO-H) office. Information about Traditional Birth Attendants (TBAs) will be obtained from the respective community and EDO (Health) office for those who will be serving in the Government facilities. Both male and female community members will be identified from the respective catchment areas of Community Midwifes (CMWs).

Selection Criteria

Inclusion and Exclusion Criteria for CMWs

  • Those CMWs who have completed their TBAs preliminary training, have successfully cleared the examination and have been deployed in the community regardless of age, period of experience, ethnicity and area of residence will be included in the study.
  • Those CMWs who fulfill all the inclusion criteria but not present in district during the study period will not be included in the study.
  • Those CMWs who will not agree to participate in the study will also be excluded
  • Those CMWs who will be involved during the pilot testing of the guides will also be excluded

Inclusion and Exclusion Criteria for TBAs

  • TBAs either trained or not trained regardless of age, period of experience, ethnicity and area of residence will be included in the study.
  • Those TBAs who fulfill all the inclusion criteria but not present in district during the study period will not be included in the study.
  • TBAs who will not agree to participate in the study will be excluded.
  • The TBAs who will participate in the pilot testing selected through convenient and purposive sampling will be excluded.

Inclusion and exclusion Criteria for FGDS

  • Community members over the age of 18 residing in the catchment areas of CMWS and TBAs regardless of their sex, ethnicity, education status and area of residency will be included in the study
  • All among these community members who will be the close relatives of the CMWs and TBAs will not be included in the study.
  • The community members who will be part of the pilot testing of the FGD guide will be excluded.

Study Duration:

The total duration of the study will be three months. Data will be collected, transcribed and analyzed. The final draft with results and recommendations will be submitted within this period. The study will be conducted during July 2010 to September 2010.

Sampling Strategy:

Purposive sampling approach will be used as in most of the qualitative studies this sampling strategy has been applied by researchers.[31] Therefore the participants for in depth interviews and for Focus Group Discussion (FGDs) will be selected by adopting purposive sampling strategy. After taking information from the EDO-Health office and District Focal Person (DFP) for PAIMAN regarding the Community Based Midwifes and Traditional Birth attendants, the study participants will be approached at their homes according to the residential address for enrolment in the study. Male and female community members will be enrolled from the respective catchment area of Community based Midwifes (CMWs). Those participants who will fulfill the inclusion criteria will be involved in the study

Data Collection and Management:

Research tools/ Methods:

Semi Structured in depth interviews with Community based Midwives and Traditional birth Attendants will be conducted through semi structured interview guide. Focus group discussions (FGDs) will be conducted with respective communities including men and women by using the FGD guide.

  • Semi structured in depth interviews with TBAs, CMWs
  • Focus group discussion (FDGs) with community( both men and women)

Pilot Testing

Semi structured guides for in depth interview with Community Based Midwife (CMW), Traditional Birth Attendants (TBAs) and Focus Group Discussion with community members will be developed based on literature search. These guides will be modified according to local context. In order to test content appropriateness, these guides will be pilot tested on purposively selected participants before starting the study. After pilot testing, the guides will be modified. The questions will be rephrased to make them simple and clear. Sequence of the questions will be changed if required. Finally, these edited guides will be used for data collection after consultation and getting approval from the thesis supervisor and thesis committee member.

Data Management

The principal investigator (PI) will be responsible for data management. He will be responsible to take consent forms, notes and recorded interviews in his custody during the field work. Each interview will be transcribed into text form at the end of each day. During the process of transcription, original meaning of the interview will be maintained. Data pertaining to each participant will be kept in separate files for future analysis and report writing.

Data Analysis (Plan of Analysis):

The analysis of interview transcripts and field notes will be based on an inductive approach. Inductive analysis means that the patterns, themes, and categories of analysis come from the data; they emerge out of the data rather than being imposed on study participants prior to data collection and analysis.[32] Analysis will be done manually. The data will be tape recorded and transcribed. After transcription the interview will be typed in Microsoft Word. The data will be categorized as Nodes and Sub Nodes. Themes will be extracted by analyzing these sub nodes. Similar themes emerging from different interviews will be incorporated to come up with some results. After the analysis the results will be shared as a detailed report to the EDO Health, Provincial Coordinator PAIMAN, and thesis committee.

Triangulation:

In order to get clear picture in the district, following two types of triangulation will be used in this study:

  • By Source: Data will be collected from different sources including CMWs, TBAs and Community members (primary respondents).
  • By Methods: Data will be collected by two methods including In depth interviews and Focus Group Discussion.

Standards for Quality Control / Quality Assurance/ Rigor for Data Analysis:

All the in depth interviews and FGD will be conducted by Principal investigator except the Focus Group Discussion with female community members. One female moderator to conduct FGD with female community members will be identified and hired in the district. One female and one male note taker will also be identified and hired. Both will be used for taking notes and writing the important information during in depth interviews and Focus Group Discussion during the study. All study personals will be trained by principal investigator before conducting the study. The criteria for quality of qualitative research are Credibility, Conformability, and Transferability.30 The study will adopt the triangulation measure for the maintenance of Credibility (internal validity). The Principal investigator will maintain reflective notes for self reflexivity on the daily basis for retaining the Conformability (Objectivity). Up to my knowledge, this is the first study being conducted in Balochistan province using the Qualitative Exploratory research design, involving participants from one setting (District Lasbela) to gather in-depth information on the investigated topic. Though the study findings will reveal the description on the perceived role of CMWs by the community in reducing the maternal mortality along with the perceived barriers by these CMWs during the service provision but the findings will be contextual. The results may have potential for transferability (external validity) to other settings (districts) of Balochistan province and other settings with the same context in Pakistan having the same demographic and socio-cultural characteristics. The results may not be transferable to the settings with different context.

Ethical consideration: The Ethic Review Committee (ERC) of Community Health Sciences Department and the Institutional Review Board of Aga Khan University Karachi will review the study. After getting approval from both, the process of data collection will be started.

Human Subjects Consideration:

Human subjects involvement and characteristics

The study participants are Community based Midwifes, Traditional Birth Attendants and Community members. These will be enrolled in the study to explore the expectations and willingness of community to accept the new role of community based midwifes along with the Traditional birth attendants. Besides this the willingness of community based Midwifes to work in their respective communities will also be explored.

Recruitment

After taking information from the EDO-Health office and District Focal Person (DFP) for PAIMAN regarding the Community Based Midwifes and Traditional Birth attendants, the study participants will be approached at their homes according to the residential address for enrolment in the study. Male and female community members will be enrolled from the respective catchment area of Community based Midwifes (CMWs).The study participants fulfilling the eligibility criteria will be included in the study. The interviews will be conducted at the ease of study respondents with respect to time and place. The principal investigator will be bound to revisit the respondent provided that any of participants refuse to participate at the time of visit.

Source of Materials

The related information from the participants will be collected through Semi Structured in depth interview guides and Focus Group Discussion (FGDs) guide.

Informed Consent

The participation in this study will entirely be voluntary. The informed consent will be translated in Urdu. Principal Investigator will read the consent form and will take the signature of each participant after explaining the contents of the form. The informed consent form will describe the purpose of this study, its risk and benefits. The participants will be encouraged to ask questions and queries regarding the study. A copy of the informed consent form will be provided to each study subject.

Risks to the Subjects/ Risks and Adequacy of Protection against Risks

There is no chance of any direct and indirect harm or risk to the Community based Midwifes, Traditional Birth Attendants and community members by answering the asked questions

Potential Benefits of the Proposed Research to the Subjects and Others

This study has direct benefit to the study participants and other stakeholders at district and provincial level. The ultimate aim of this study is to reduce the maternal mortality ratio by minimizing the pregnancy related maternal deaths through strengthening and improving the role of Community based midwifes in Balochistan Province.

Confidentiality

All the data will be kept confidential and no one except the principal investigator will have access to it. Names of the participants will not be used in study. Codes will be assigned to each participant and responses will be noted against assigned codes during the analysis. All the interviews will be conducted in privacy.

Vulnerable population

The study participants comprised of Community based midwifes, Traditional Birth attendants and Community members do not fall in the category of vulnerable population by definition.

Capacity to consent

As all the study participants are adults and have capacity to consent, so the written consent will directly be taken from them.

Compensation

No monetary or non monetary compensation will be offered to the study participants. The participation will be on voluntary basis.

Refusals

The participants will have complete right to refuse the participation in the study and will have freedom to withdraw from the study at any point in time.

Importance of the Knowledge to be gained

The recommendations made on the basis of the results of this study will be communicated to the higher authorities. These recommendations will play a pivotal role in formulations of strategies and policies at managerial level to reduce the pregnancy related maternal deaths by maximally fulfilling the expectations of general population of setting. These recommendations will help the higher authorities to take appropriate steps to resolve the problems, issues and challenges which Community based midwifes will be facing during service provision that will ultimately improve and strengthen their position and role. The community based Midwifes may prove to be the bridging force filling the gap between community based service provision and health care system in case of complicated obstetric cases in future which may reduce the maternal mortality in Pakistan.

Manual of Operation:

Study preparation

This is an Exploratory Qualitative Study and no Physical examination, Measurement, Equipments, Sample Collection Procedure and transportation of samples to any laboratory is involved in the study. This study involves following preliminary steps and processes during the preparation period.

  • Final review of the thesis research proposal by the supervisor and the committee member
  • Submission of the proposal to ethical review committee ERC (CHS) and University research council (URC) of the AKU University for approval of the study.
  • Prior written approval from the relevant District Health Manager (EDO-H) and Provincial Health Department.
  • Pilot testing of the Focus Group Discussion and In depth interview Guides and modification in phrasing and sequence of questions if required.
  • Identification, recruitment and training of the note takers both male and female. Besides this one female moderator for Focus Group Discussion (FGD) with female community members will also be identified, recruited and trained.

Study Organization:

The thesis Supervisor and Committee Member will be providing technical in puts regarding the study during the process of drafting.

Description of data collection personnel

Personnel

One female moderator for conducting the focus group discussion with female members of community will be identified belonging to the district Lasbela. It will be ensured that female moderator will have at least Master degree in Social Works or Sociology. Good communication skill of local language, Urdu and English will be the selection criteria for the female moderator. It will be priority that she should have prior experience of conducting at least 2 studies or at least having the experience of such procedures. Female moderator will be responsible for conducting the FDG according to sequence of the questions included in the guidelines. She will also be responsible to supervise the recruitment of participants in accordance to inclusion and exclusion criteria.

Two note takers including one male and one female will be identified by the principal investigator. Both note takers will be experienced, having graduate degree and permanent residents of district Lasbela. Good writing skills will be criteria for selection of Note takers. They will be responsible for taking the note during the process of the FDG and in depth interviews. They will also help the moderators during the process of Focus Group Discussion and will keep an eye on the whole process so that no question may not be missed.

Training of study personnel

The female moderator and two note takers will be trained by the principal investigator before conducting the study and data collection process. The training of female moderator will include details of FGD guidelines, explanation of the question along with probes, administration of the questions, approaching study participants, recruitment process and taking informed consent. After completion of the training she will be asked to conduct a mock focus group discussion.

The training of the note taker will be on how to take important notes during the FDG and in depth interviews. They will be trained regarding the operation of tape recorder. They will also be trained about the comprehension of the questions along with probed included in the Focus Group discussion and in depth interview guides. They will be told to take special care of information noting during the process so that important information may not be missed. They will be asked to repeat note taking process repeatedly. Mock interviews will be conducted and their writing skills will be evaluated.

Sampling strategy

The participants for in depth interviews and Focus Group Discussion (FGDs) will be selected by adopting Purposive sampling approach. Those participants who will fulfill the inclusion criteria will be enrolled in the study.

Enrolment of study participants:

List of Community Midwifes (CMWs) containing the residential addresses will be obtained from the District Focal Person (PAIMAN) and Executive District Officer Health (EDO-H) office. Information about Traditional Birth Attendants (TBAs) will be obtained from the respective community and EDO-H office for those who will be serving in the Government facilities. After taking this information, the study participants will be approached at their homes according to the residential address for enrolment in the study. The community members both male and female will be enrolled from the respective catchment areas of Community Midwifes (CMWs).

Informed consent

The informed consent form will be translated in Urdu. The principal investigator will read the consent form and will take the signature of each participant while female moderator will perform this duty before starting the Focus group discussion with female members of community. In both cases, the contents of consent form will be explained to each study participant specially the purpose of the study and its risks and benefits. A copy of the informed consent form will be provided to each study participant and a copy will be kept in a predefined separate file for personal record.

Refusals

Study participant will be free to choose to participate and will not be pressurized to participate in the study. Participant may refuse to participate before or during the process. The study participant may also refuse to answer some or all the questions if he / she do not feel comfortable with questions. In case of the refusal during the data collection, it will be noted and recorded in the notebook. The principal investigator will be bound to revisit the respondent provided that any of the participants refuse to participate at the time of visit but agrees for interview at some other time. Another appropriate substitution will be identified on the same day as compensation and to avoid the wastage of time.

Confidentiality

The study participants will be ensured that their names will not be recorded on the guide and all the information obtained from them will be kept secret. They will also be ensured that nobody except principal investigator will have access to it. It will also be ensured that their names and identity will not be disclosed at any time.

Description of data collection procedure:

Semi structured in depth interviews with the Community based Midwifes (CMWs) and Traditional Birth Attendants (TBAs) while Focus Group Discussion (FGD) with community members will be the data collection tools in this study. Following point will be focused while conducting in depth interviews:

  • All the in depth interview will be conducted by the principal investigator
  • All the interviews will be tape recorded
  • Maximum two interviews will be conducted in a day in order to generate, maintain and ensure good quality data
  • Semi-structured guide will be administered to each consenting participant in their respective area of residence
  • If the participant will refuse for tape recorded interview, then the note taker will take the notes and will write down all the important and relevant information in detail.
  • Informed written consent will be obtained from each participant to ensure confidentiality and privacy
  • The principal investigator will start the interview by introducing himself and note taker. Purpose, objectives and intended outcomes will briefly be shared with study participants
  • 45-60 minutes will be the total duration of each interview.
  • The prime importance will be given to the place of interview. A suitable place will be chosen as per participants comfort as interviews will be conducted at the residence of interviewee.
  • The interview will be conducted in calm and quiet environment to avoid unnecessary disturbance and break during the interview
  • The note taker will be responsible to check the functioning status of tape recorder along with batteries in advance before starting the interview.
  • The principle investigator will phrase the questions in understandable tone so that the study participant may comprehend the questions.
  • Maximum consideration will be given to the feelings and view of the study participants.
  • The note taker will be responsible to note pauses, changes in tone, laughter and comments
  • The principal investigator will maintain his own reflective journal
  • Identification tag or number will be allotted to each participant.
  • The interviews will be stopped at the point of saturation when it will be not possible to get additional information

Following point will be focused while conducting Focus Group Discussion (FGD):

  • All the FGDs will be conducted by the principal investigator except with female members of community that be conducted by the female moderator.
  • There will be 6-8 participants in each FGD
  • FGDs will be conducted with both male and female community members
  • Consent will be obtained from each participant before FGD.
  • The total duration of each FGD will be about 60-90 minutes
  • FGD will be conducted at a suitable place in the selected community.
  • The place will be selected after seeking permission from the community and considering participants comfort and privacy.
  • The note taker will be responsible to check the functioning status of tape recorder along with batteries in advance before starting the FGD.
  • The participants will sit in circle to facilitate interaction among participants and between moderator and participants.
  • The moderator will start the FDG by introducing himself/herself and note taker. Purpose, objectives and intended outcomes will briefly be shared with participants.
  • The note taker will be responsible to note important information, pauses, changes in tone, laughter and comments
  • The FGD will be stopped at the time of saturation when it will not be possible to get additional information.

Focus Group Checklist:

Following material and supplies will be required for focus group discussion (FGD). Both note taker and female moderator will be responsible to check the availability of these things before starting the Focus Group Discussion with female community members and will be responsible to return back to Principle investigator at the end of process.

  1. Equipment:

    1. 2 tape recorder (Check working of tape recorder)
    2. 2 blank 90- minutes audiocassette tapes per focus group
    3. 2 spare batteries
    4. 2 field notebooks and 2 pens
  2. Focus group packet:

    1. 1 large envelope
    2. 1 copy of focus group guide ( for moderator)
    3. 8-10 Informed consent forms (3 extra copies)
    4. Note taking form
  3. What to place in the envelope at the end of FGD:

    1. Draw a diagram of seating arrangement
    2. Listen to tape to ensure proper recording
    3. Signed informed consent forms
    4. Labeled focus group guide with notes (moderators copy)
    5. Labeled cassette tapes / written notes

Administrative and reporting requirements

Supervision of focus group discussion and in depth interviews

The principal investigator will be responsible for the supervision of all the focus group discussions and in depths interviews except the focus group discussion with the female community members. The female moderator will be responsible to supervise these focus group discussions. However the principle investigator will have the authority to check the accuracy of the information by asking some random questions of the guide to ensure good quality data provided that if allowed by the male community members.

Material and Supplies:

Audio Cassettes, batteries, tape recorder and stationary will be the main supplies that will be used during the data collection process of this study. The tape recorder and cassettes will be checked before moving to the field if provided as loan by the CHS department, otherwise it will be purchased from the market using the existing standard procedure. Consent forms, in depth interview guide and Focus Group Discussion Guide will be photocopied as per requirement.

Data Analysis, Report writing and Dissemination

The analysis of interview transcripts and field notes will be based on an inductive approach. Analysis will be done manually. The data will be tape recorded and transcribed. After transcription the interview will be typed in Microsoft Word. The data will be categorized as Nodes and Sub Nodes. Themes will be extracted by analyzing these sub nodes. Similar themes emerging from different interviews will be incorporated to come up with some results. Final report of the study will be drafted in close coordination with the thesis supervisor and committee member. The results and findings of the study will be shared as a detailed report to the EDO Health, Provincial Coordinator PAIMAN, Provincial Coordinator MNCH Program and thesis committee.

Annexure 1: Informed Consent Form for in depth interview with Community Based Midwife (CMW)

Title of the Study: Emerging role of Community Based Midwife (CMW) in Pakistan: A case of District Lasbela, Balochistan Province.

Principal Investigator: Dr. Ghulam Mustafa

Institute: Department of Community Health Sciences, Aga Khan University.

Introduction:

Assalam-u-Allakum

I am Dr Ghulam Mustafa Khan from Community Health Sciences Department, Aga Khan University Karachi. I am conducting a research which is part of my MSc. Thesis. I am collecting information regarding your willingness to work independently in your respective community as Community based Midwife (CMW) in order to reduce the pregnancy related maternal death. I request your kind participation in this research. A copy of this consent form will be provided to you

Background information:

It has been estimated that 276 mothers / women die for every 100,000 live births in Pakistan. 785 mothers / women die for every 100,000 live births in Balochistan which is the highest Maternal Mortality Ratio in the country. Though Traditional birth attendants (TBAs) are main source for delivery care provision in rural areas of country but the Government of Pakistan has launched a National Community Midwives Program (NCMP). Through this program a new cadre of health professionals with the name of Community Midwife (CMW) has been introduced. These Community based Midwifes (CMWs) have been deployed at community level after getting training through midwifery schools in their respective communities in selected districts of Balochistan. Lasbela district is one of these districts.

Purpose of this research study:

The purpose of this research is to explore the expectations and willingness of the community and Traditional Birth Attendants(TBAs) regarding acceptance of the new role of Community based midwifes(CMWs) in the reduction of pregnancy related deaths in District Lasbela, Balochistan. The study will also explore willingness of Community based Midwifes to work at community level independently. It will explore the issues and challenges that these midwives might be facing during service provision at community level and in getting community acceptance. The ultimate aim of this study is to strengthen and improve the role of community based midwifes for reducing the pregnancy related maternal deaths.

Procedure:

I (Principal Investigator) will have an interview with you. I would like to ask you questions regarding your willingness to work independently in your respective community during this interview. The duration of the interview will be about an hour. Your interview will be tape recorded. If you do not allow for recording your interview then the note taker will write down your responses and views during the interview provided that you allow his/her presence. I want to tape record and write down your responses with the help of note taker in order to avoid missing any valuable details that you will share for the purpose of this study. The tape recorded interview will be discarded after transcription and final submission of thesis. Your participation during the process of interview will be voluntary.

Possible risks or benefits:

There is no chance of any harm to you by answering the asked questions except your valuable time. This study has direct benefit to you because recommendations based on the result of this study will ultimately help higher authorities and policy makers at District, Provincial and Federal levels in resolving the problems, issues and challenges which as Community based midwifes you are facing during service provision that will ultimately improve and strengthen your position and role in the community.

Financial Consideration:

There is no monetary or non monetary compensation for your participation in this research

Right of refusal to participate and withdrawal:

You are free to choose to participate in the study. You may refuse to participate without any loss of benefit which you are otherwise entitled to. You may also refuse to answer some or all the questions if you dont feel comfortable with those questions. If you want to ask any question right now or during interview please feel free to ask.

Confidentiality:

Your name will not be recorded on the Guide and all the information obtained from you will be kept secret. Your identity, audio tapes and other information provided by you will also not be disclosed at any time. Nobody except principal investigator will have an access to it. However the data may be seen by Ethical review committee and may be published in journal and elsewhere without giving your name or disclosing your identity.

Privacy:

The time and location will be subject to your ease in order to maintain privacy.

AUTHORIZATION

I have read and understand this consent form, and I volunteer to participate in this research study. I understand that I will receive a copy of this form. I voluntarily choose to participate, but I understand that my consent does not take away any legal rights in the case of negligence or other legal fault of anyone who is involved in this study. I further understand that nothing in this consent form is intended to replace any applicable Federal, state, or local laws.

Participants Name (Printed or Typed): Date:

Participants Signature or thumb impression: Date:

Principal Investigators Signature: Date:

Annexure 2: Informed Consent Form for Focus Group Discussion (FGD) with Community and In depth interview with Traditional Birth Attendants (TBAs)

Title of the Study: Emerging role of Community Based Midwife (CMW) in Pakistan: A case of District Lasbela, Balochistan Province.

Principal Investigator: Dr. Ghulam Mustafa

Institute: Department of Community Health Sciences, Aga Khan University.

Introduction:

Assalam-u-Allaikum

I am Dr Ghulam Mustafa Khan from Community Health Sciences Department, Aga Khan University, Karachi. I am conducting a research which is part of my MSc. Thesis. I am collecting information regarding your expectation and willingness to accept the role of Community based Midwife (CMW) in reducing the pregnancy related maternal death. I request your kind participation in this research. A copy of this consent form will be provided to you

Background information:

It has been estimated that 276 mothers / women die for every 100,000 live births in Pakistan. 785 mothers / women die for every 100,000 live births in Balochistan which is the highest Maternal Mortality Ratio in the country. Though Traditional birth attendants (TBAs) are main source for delivery care provision in rural areas of country but the Government of Pakistan has launched a National Community Midwives Program (NCMP). Through this program a new cadre of health professionals with the name of Community Midwife (CMW) has been introduced. These Community based Midwifes (CMWs) have been deployed at community level after getting training through midwifery schools in their respective communities in selected districts of Balochistan. Lasbela district is one of these districts.

Purpose of this research study:

The purpose of this research is to explore the expectations and readiness of the community and Traditional Birth Attendants(TBAs) regarding acceptance of the new role of Community based midwifes(CMWs) in the reduction of pregnancy related deaths in District Lasbela, Balochistan. The study will also explore willingness of Community based Midwifes to work independently at community level. It will also explore the issues and challenges that these midwives might be facing during service provision at community level and in getting community acceptance. The ultimate aim of this study is to strengthen and improve the role of community based midwifes for reducing the pregnancy related maternal deaths.

Procedure:

I (Principal Investigator) will have an interview with you. I would like to ask you questions regarding your expectations and willingness to accept the role of Community based Midwife during this interview. The duration of the interview will be about an hour/duration of focus Group Discussion will be one and half hour. Your interview will be tape recorded. If you do not allow for recording your interview then the note taker will write down your responses and views during the interview provided that you allow his/her presence. I want to tape record and write down your responses with the help of note taker in order to avoid missing any valuable details that you will share for the purpose of this study. The tape recorded interview will be discarded after transcription and final submission of thesis. Your participation during the process of interview will be voluntary.

Possible risks or benefits:

There is no chance of any harm to you by answering the asked questions except your valuable time. This study has no direct benefit to you but recommendations based on the result of this study will ultimately help higher authorities and policy makers at District, Provincial and Federal levels in resolving the problems, issues and challenges which Community based midwifes may be facing during service provision that will ultimately improve and strengthen their position and role in reducing the pregnancy related maternal deaths in your district.

Financial Consideration:

There is no monetary or non monetary compensation for your participation in this research

Right of refusal to participate and withdrawal:

You are free to choose to participate in the study. You may refuse to participate without any loss of benefit which you are otherwise entitled to. You may also refuse to answer some or all the questions if you dont feel comfortable with those questions. If you want to ask any question right now or during interview please feel free to ask.

Confidentiality:

Your name will not be recorded on the Guide and all the information obtained from you will be kept secret. Your identity, audio tapes and other information provided by you will also not be disclosed at any time. Nobody except principal investigator will have an access to it. However the data may be seen by Ethical review committee and may be published in journal and elsewhere without giving your name or disclosing your identity.

Privacy:

The time and location will be subject to your ease in order to maintain privacy.

AUTHORIZATION

I have read and understand this consent form, and I volunteer to participate in this research study. I understand that I will receive a copy of this form. I voluntarily choose to participate, but I understand that my consent does not take away any legal rights in the case of negligence or other legal fault of anyone who is involved in this study. I further understand that nothing in this consent form is intended to replace any applicable Federal, state, or local laws.

Participants Name (Printed or Typed):

Date:

Participants Signature or thumb impression:

Date:

Principal Investigators Signature:

Date:

Annexure 3: Guide for in depth Semi Structured Interview with Community Midwife (CMW)

Date:

Place:

Interviewer:

* Complete address of place where interview will be conducted:

Starting time of interview:

End time of Interview:

Key Instructions for study personals :

  • Brief introduction of study personals to study participant
  • Both written and verbal consent for tape recorded interview will be obtained before starting interview from each study participant
  • The aim and objectives of the study will be explained to each participant
  • The confidentiality of the participant will be ensured
  • The participants will be allowed to withdraw from the study at any time during the interview process
  • All interviews will be conducted by the principle investigator
  • The study participant will be allowed to listen to the tape recorded interview in the end if she will ask for it.
  • It will be ensured to the study participant that tape recorded interview will be discarded after transcription and final submission of thesis.
  1. Please tell me something about your working experience?
  2. Prompts:

    1. For how long you are working in community
    2. Education level-years of schooling
  3. What type of maternal health care does a midwife provides during pregnancy?
  4. Prompts:

    1. Before birth
      1. Monitors health of mother and baby
      2. Prenatal care
    2. At Birth
      1. Delivery care / Assists child birth
    3. After birth
      1. Post natal care
    4. Obstetrics services
    5. Any other aspect of care_________________
  5. Based on your personal thinking, what is the role of midwife while serving at community level?
  6. Prompts:

    1. Support to family
    2. Manages emergencies
    3. Provides guidance to family
    4. Informer
    5. Listener
    6. Advocate for safe delivery practices
    7. Antenatal care / Follow up
    8. Undertakes appropriate consultation and referral
  7. What are your experiences while working as midwife at community level?
  8. Prompts:

    1. Interaction
    2. Support from community
    3. Respected/ Disrespected
    4. Relationship with Traditional Birth Attendants (TBAs)
    5. Relationship with Lady Health workers (LHWs)
    6. Relations with Lady Health Visitors (LHVs)
    7. Acceptance as belonging to same community and culture
    8. Others___________
  9. What is your fee for antenatal, delivery and postnatal care (in Rupees)?
  10. Do you consider it?
    1. Reasonable
    2. Nominal
    3. High
  11. Do you have enough supplies and other support?
  12. Prompts:

    1. Equipments
    2. Separate specific clinic at your own residence
    3. Separate specific office or clinic to conduct delivery
    4. Transport to conduct delivery at distant place
  13. Where do you prefer to deliver?
  14. Prompts:

    1. At your own residence
    2. At your clinic
    3. At homes in community
    4. Others_________
  15. What type of constraints and challenges you are facing while working in community
  16. Prompts:

    1. Social
      1. Mobility in catchment area
      2. Communication with community members
      3. Support from family and relatives
      4. Support from community
      5. Support from other health care providers like doctors and paramedic staff
    2. Managerial
      1. Support from district health administration
      2. Support from district focal person of PAIMAN
    3. Financial
      1. Salary
      2. Employment opportunities
      3. Private practice
  17. Based on your experience do you think that you will be able to continue your service provision in your respective area?
  18. Prompts:

    1. If yes then how
    2. If No then why
  19. In your opinion are you prepared to serve in your respective community independently?
  20. Prompt:

    1. If yes then why
      • On the basis of competency
      • On the basis of community Support
    2. If No then why

Annexure 4: Guide for Focus Group Discussion (FGD)) with Community Members

ID NO

Date:

Place:

Moderator:

Note Taker:

Complete address of place where Focus Group Discussion will be conducted:

Key Instructions for Moderator and Note taker:

  • Brief introduction to study participant
  • Both written and verbal consent for tape recording will be obtained before starting focus group discussion from each study participant
  • Copy of informed consent will be provided to each participant
  • The principal investigator will read the consent form for the benefit of those who are unable to read
  • The aim and objectives of the study will be explained to each participant
  • The confidentiality of the participant will be ensured
  • The participants will have the right to ask questions during the interview
  • The participants will be allowed to withdraw from the study at any time during the interview process
  • The focus group discussion will be conducted by the principle investigator (where culturally not suitable or possible, then a female moderator along with a female note taker will conduct FGD.

Ground rules:

The Focus Group discussion will start by explaining the ground rules as follows:

  • Before we start, I would like to remind you that there is no right or wrong answer in this discussion.
  • Participation of all group members is required during this conversation.
  • Let's start by going around the circle and having each person introduce her / him.
  • Members of the research team will also introduce themselves and will describe their roles in study.
  1. Who assists in deliveries in your community generally?
  2. Would you like to tell whom do you prefer for maternal care in your area of residence?
  3. Prompts:

    1. What are the reasons for your preference
  4. How the pregnancy care with this new midwife is different as compared to traditional birth attendant?
  5. Prompts:

    1. In terms of Antenatal and post natal care
    2. In terms of Availability
    3. In terms of Accessibility
  6. How the delivery care with this new midwife is different as compared to traditional birth attendant?
  7. Prompts:

    1. In terms of skills
    2. In terms of Competency
    3. In terms of Cost
    4. In terms of Experience
    5. In terms of Education
    6. In terms of Equipments
  8. How much do you pay for delivery care?
  9. What is the usual mode of payment to delivery care provider for rendering services in your respective community?
  10. Prompts:

    1. Cash
    2. Kind
    3. Other
  11. Can you please describe what a midwife does to help you regarding maternal care during pregnancy?
  12. Prompts:

    1. Before birth
      1. Monitors health of mother and baby
      2. Prenatal care
    2. At Birth
      1. Delivery care / Assists child birth
    3. After birth
      1. Post natal care
    4. Any other aspect of care____
  13. What do you think about the general perception of midwife in your respective community?
  14. Do you know any specific care for which she has been trained to help you out during pregnancy and child birth?
  15. Prompts:

    1. Identification of high risk pregnancy
    2. Care for complicated delivery
    3. Prompt referral
  16. Why women like to see or seek mid wife care?
  17. Prompts:

    1. Access with respect to area and distance
    2. Safety and effectiveness
    3. Care at home
    4. Ability to handle a complicated case
    5. Satisfaction
  18. What type of constraints and challenges do you think she is facing while working in community?
  19. Prompts:

    1. Social
    2. Mobility in catchment area
      1. Communication with community members
      2. Support from family and relatives
      3. Support from community
      4. Support from other health care providers like doctors and paramedic staff
    3. Managerial
      1. Support from district health administration
      2. Support from district focal person of PAIMAN
    4. Financial
    1. Salary
    2. Employment opportunities
    3. Private practice
  20. What are your expectations from a midwife working in her respective catchment area?
  21. Prompts:

    1. Skilled care
    2. Provision of culturally accepted and appropriate care
    3. Advocacy
    4. Provision of information about expectations and possible realities
  22. How much you are willing to pay to Midwife for her services at community level?
  23. Do you think that you are willing to accept her role for service provision in your respective area of residence?
  24. Prompt:

    1. If yes why
    2. If No why
    3. Resistance by community
  25. Do you think that she should be allowed to work independently in your community?
  26. Prompts:

    1. If yes why
    2. If No why
    3. To what extent

Thank you for your cooperation, participation and giving time to talk to us on the topic

Annexure 5: Guide for in depth Semi Structured Interview with Traditional Birth Attendant (TBA)

ID NO

Date:

Place:

Interviewer:

Complete address of the place where interview will be conducted:

Starting time of interview:

End time of Interview:

Key Instructions:

  1. Brief introduction to study participant
  2. Both written and verbal consent for tape recorded interview will be obtained before starting interview from each study participant
  3. The aim and objectives of the study will be explained to each participant
  4. The confidentiality of the participant will be ensured
  5. The participants will be allowed to withdraw from the study at any time during the interview process
  6. All interviews will be conducted by the principle investigator
  7. The study participant will be allowed to listen to the tape recorded interview in the end if she will ask for it.
  8. It will be ensured to the study participant that tape recorded interview will be discarded after transcription and final submission of thesis.
  1. Please tell me something about your working experience?
  2. Prompts:

    1. For how long you are working in community as TBA
    2. Formal training received
    3. Informal training received
    4. Untrained
  3. What is your perception about Midwife?
  4. What type of maternal health care does a midwife provides during pregnancy?
  5. Prompts:

    1. Before birth
      1. Monitors health of mother and baby
      2. Prenatal care
    2. At Birth
      1. Delivery care / Assists child birth
    3. After birth
      1. Post natal care
    4. Obstetrics services
    5. Any other aspect of care
  6. What are your experiences while working with the Community Midwife (CMW) at community level?
  7. Prompts:

    1. Interaction
    2. Relationship with Community Midwife
    3. Acceptance as belonging to same community and culture
    4. Competitor
    5. Support at the time of need
  8. Do you think that community Midwife is facing constraints and challenges while working in community?
  9. Prompts:

    1. Social
      1. Mobility in catchment area
      2. Communication with community members
      3. Support from family and relatives
      4. Support from community
      5. Support from other health care providers like doctors and paramedic staff
    2. Managerial
      1. Support from district health administration
      2. Support from district focal person of PAIMAN
    3. Financial
      1. Salary
      2. Employment opportunities
      3. Private practice
  10. Do you think that Community Midwife will be able to continue her service provision in her respective catchment area?
  11. Prompts:

    1. If yes then how
    2. If No then why
    3. Will she be able to hold ground
  12. Are you willing to accept the presence of Community Midwife and the role she is playing for service provision regarding maternal health along with you at community level?
  13. Prompts:

    1. If yes then why
    2. If No then why

Annexure 6: Study Budget

Study Title: Emerging role of Community Based Midwife(CMW) in Pakistan: A case of District Lasbela, Balochistan

References

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  2. The Millennium Development Goals Report 2008: Goal 5: Improve Maternal Health; http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2008/MDG_Report_2008 accessed on 13th January 2010.
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  12. The role of traditional birth attendants in the reduction of maternal mortality: Staffan Bergstrm and Elizabeth Goodburn
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