Maternal deaths in Pakistan : intersection of gender, class and social exclusion.

Background: A key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available. Methods: Using a critical ethnographic approach, two case studies of women who died during childbirth were pieced together from information gathered during the first six months of fieldwork in a village in Northern Punjab, Pakistan. Findings: Shida did not receive the necessary medical care because her heavily indebted family could not afford it. Zainab, a victim of domestic violence, did not receive any medical care because her martial family could not afford it, nor did they think she deserved it. Both women belonged to lower caste households, which are materially poor households and socially constructed as inferior. Conclusions: The stories of Shida and Zainab illustrate how a rigidly structured caste hierarchy, the gendered devaluing of females, and the reinforced lack of control that many impoverished women experience conspire to keep women from lifesaving health services that are physically available and should be at their disposal

Not Managing Expectations: A Grounded Theory of Intimate Partner Violence From the Perspective of Pakistani People

Intimate partner violence (IPV) is a major social and public health problem affecting people from different cultures and societies. Much research has been undertaken to understand the phenomenon, its determinants, and its consequences in numerous countries. However, there is a paucity of research on IPV in many areas of the world including Pakistan. The present study aimed to develop a theory of the meaning and process of IPV from the perspective of Pakistani men and women living in and outside Pakistan

Women's leadership in the Asian Century: does expansion mean inclusion?

This paper draws on British Council commissioned research in response to concerns about women's absence from senior leadership positions in higher education in South Asia. The study sought existing knowledge from literature, policies, and available statistics and collected original interview data from 30 academics in Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka. A central finding was that gender is not a category of analysis in higher education policy, research or statistical data in the region. Our interview data suggest that leadership was frequently not an object of desire for women. Being associated with particular types of masculinities, leadership often carried a heavy affective load for those women who transgressed patriarchal socio-cultural norms and disrupted the symbolic order of women being led by men. Leadership was frequently perceived and experienced by women in terms of navigating a range of ugly feelings and toxicities that depleted aspirations, well-being and opportunities

Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme

Objective To understand why skilled birth attendance—an acknowledged strategy for reducing maternal deaths—has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions. Design Implementation research was conducted using an institutional ethnographic approach. Setting and population National programme and local community levels in Pakistan. Methods Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together. Main outcomes Alignment of programme theory with real-world practice. Results Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public–private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography. Conclusions Greater attention to programme theory and the ‘real-world’ setting during design of maternal health strategies is needed to achieve consistent results in different contexts

Addressing disparities in maternal health care in Pakistan: gender, class and exclusion

Background: After more than two decades of the Safe Motherhood Initiative and Millennium Development Goals aimed at reducing maternal mortality, women continue to die in childbirth at unacceptably high rates in Pakistan. While an extensive literature describes various programmatic strategies, it neglects the rigorous analysis of the reasons these strategies have been unsuccessful, especially for women living at the economic and social margins of society. A critical gap in current knowledge is a detailed understanding of the root causes of disparities in maternal health care, and in particular, how gender and class influence policy formulation and the design and delivery of maternal health care services. Taking Pakistan as a case study, this research builds upon two distinct yet interlinked conceptual approaches to understanding the phenomenon of inequity in access to maternal health care: social exclusion and health systems as social institutions. Methods/Design: This four year project consists of two interrelated modules that focus on two distinct groups of participants: (1) poor, disadvantaged women and men and (2) policy makers, program managers and health service providers. Module one will employ critical ethnography to understand the key axes of social exclusion as related to gender, class and zaat and how they affect women’s experiences of using maternal health care. Through health care setting observations, interviews and document review, Module two will assess policy design and delivery of maternal health services. Discussion: This research will provide theoretical advances to enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems in Pakistan. It will also provide empirical evidence to support formulation of maternal health care policies and health care system practices aimed at reducing disparities in maternal health care in Pakistan. Lastly, it will enhance inter-disciplinary research capacity in the emerging field of social exclusion and maternal health and help reduce social inequities and achieve the Millennium Development Goal No. 5

Are children with tuberculosis in Pakistan managed according to National programme policy guidelines? A study from 3 districts in Punjab

<p>Abstract</p> <p>Background</p> <p>The adherence to policies of National TB Control Programme (NTP) to manage a case of tuberculosis (TB) is a fundamental step to have a successful programme in any country. Childhood TB services faces an unmet challenge of case management due to difficulty with diagnosis and relatively new policies. For control of childhood TB in Pakistan, NTP developed and piloted its guidelines in 2006-2007. The objective of this study was to compare the documented case management practices of pediatricians and its impact on the outcome before and after introducing NTP policy guidelines.</p> <p>Findings</p> <p>An audit of case management practices of a historical cohort study was done in children below 15 years who were put on anti-tuberculosis treatment at all nine public hospitals in three districts in province of Punjab. The study period was two years pre-intervention (2004-05) and two years post-intervention (2006-07) after implementation of new NTP policy guidelines for childhood TB. There were 920 childhood TB cases registered during four years, 189 in pre-intervention period and 731 in post-intervention period. The practices changed significantly in post-intervention period for use of tuberculin skin test (63% of pulmonary cases, 19% of extrapulmonary cases and 67% for site unknown), and for the use of chest x-ray (69% of pulmonary cases, 16% of extrapulmonary cases and 74% for site unknown). Diagnostic scores were recorded for only a minority of cases (18%). The proportion of correct drugs pre- and post-intervention remained same. There were unknown treatment outcomes in 38 out of 141 cases (27%) in pre-intervention and in 483 out of 551 cases (87%) post-intervention, all among the 692 cases without documented treatment supporter.</p> <p>Conclusions</p> <p>The study has shown that pediatricians have started following parts of the national policy guidelines for management of childhood TB. The documented use of diagnostic tools is increased but record keeping of case management practices remained inadequate. This seems to increase case finding substantially but the treatment outcomes were poor mainly due to unknown outcomes. Development and implementation of standardized operational tools and regular monitoring system may improve the services.</p

Development and Testing of a Field Diagnostic Assay for Peste des Petits Ruminants Virus

We have developed an immunochromatographic test for the diagnosis of peste des petits ruminants (PPR) under field conditions. The diagnostic assay has been tested in the laboratory and also under field conditions in Ivory Coast, Pakistan, Ethiopia and Uganda. The test is carried out on a superficial swab sample (ocular or nasal) and showed a sensitivity of 84% relative to PCR. The specificity was 95% over all nasal and ocular samples. The test detected as little as 103 TCID50 (50% tissue culture infectious doses) of cell culture‐grown virus, and detected virus isolates representing all four known genetic lineages of peste des petits ruminants virus. Virus could be detected in swabs from animals as early as 4 days post‐infection, at a time when clinical signs were minimal. Feedback from field trials was uniformly positive, suggesting that this diagnostic tool may be useful for current efforts to control the spread of PPR

Perceptions of Pakistani medical students about drugs and alcohol: a questionnaire-based survey

BACKGROUND: Drug abuse is hazardous and known to be prevalent among young adults, warranting efforts to increase awareness about harmful effects and to change attitudes. This study was conducted to assess the perceptions of a group of medical students from Pakistan, a predominantly Muslim country, regarding four drugs namely heroin, charas, benzodiazepines and alcohol. RESULTS: In total, 174 self-reported questionnaires were received (87% response rate). The most commonly cited reasons for why some students take these drugs were peer pressure (96%), academic stress (90%) and curiosity (88%). The most commonly cited justifiable reason was to go to sleep (34%). According to 77%, living in the college male hostel predisposed one to using these drugs. Sixty percent of students said that the drugs did not improve exam performance, while 54% said they alleviated stress. Seventy-eight percent said they did not intend to ever take drugs in the future. Females and day-scholars were more willing to discourage a friend who took drugs. Morality (78%), religion (76%) and harmful effects of drugs (57%) were the most common deterrents against drug intake. Five suggestions to decrease drug abuse included better counseling facilities (78%) and more recreational facilities (60%). CONCLUSION: Efforts need to be made to increase student awareness regarding effects and side effects of drugs. Our findings suggest that educating students about the adverse effects as well as the moral and religious implications of drug abuse is more likely to have a positive impact than increased policing. Proper student-counseling facilities and healthier avenues for recreation are also required