RAF-RSPN Endline Report by Bilal Safdar

Addressing Delays for Access to EmONC 1 in Non-LHW Areas of Pakistan

A RESEARCH REPORT

Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme MAY 2014

2 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

DECLARATION: We have read the report titled ‘Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme’, and acknowledge and agree with the information, data and findings contained.

Principal Investigator Bashir Anjum

Co-Investigator Dr. Muhammad Sarwat Mirza

Edited By: Umme-laila Hussain (RSPN Communications) Design & Print DOT Advertising

ACKNOWLEDGMENT STATEMENT: ‘Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme is a research project funded by the Maternal and Newborn Health Programme Research and Advocacy Fund (RAF), and is implemented by the Rural Support Programmes Network (RSPN).

DISCLAIMER: This document is an output from a project funded by the UK Department for International Development (DFID) and the Australian Department of Foreign Affairs and Trade (DFAT) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, DFAT or the Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF), which can accept no responsibility or liability for such views, for completeness or accuracy of the information, or for any reliance placed on them.

IMPLEMENTING PARTNERS:

Addressing Delays for Access to EmONC 3 in Non-LHW Areas of Pakistan

A RESEARCH REPORT

Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care in Areas of Pakistan not Covered by the Lady Health Worker Programme

4 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Addressing Delays for Access to EmONC 5 in Non-LHW Areas of Pakistan

6 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

ACKNOWLEDGEMENTS We are thankful to our partners, the Thardeep Rural Development Programme (TRDP) and the Health and Nutrition Development Society (HANDS), who were an integral part of this research project. The programme staff of both these organisations deserves due appreciation. In addition, the Peopleâ&#x20AC;&#x2122;s Primary Healthcare Initiative, the District Health Departments and the management at the District Headquarter hospital of Dadu made valuable contributions to the project. At the provincial level, the Director General of Health Services, Department of Health, Sindh also extended support in overseeing the research project and coordinating with health personnel at the district level, for which we are deeply grateful. We were fortunate to have inputs from experienced health professionals and researchers; Dr. Shireen Bhutta, from JPMC Karachi, Dr. Shaikh Tanveer Ahmed, CEO of HANDS, Mr. Zaffar Junejo, CEO of TRDP, Dr. Huma Quraishi, Director of Pakistan Medical and Research Council, Dr. Zarifuddin Khan, National Coordinator MNCH- WHO, General (Rtd.) Usmani, Professor of Reproductive Health at Sarhad University Institute of Information Technology and Dr. Yasmeen Qazi, Senior Country Advisor to the David and Lucile Packard Foundation, who were part of the Project Advisory Committee. We would also like to acknowledge the efforts of our field team and research officers without whom we would not have been able to complete the daunting task of data collection, documentation and analysis. Apart from the authors, Ms. Shandana Khan, the Chief Executive Officer RSPN and Mr. Khaleel Ahmed Tetlay, the Chief Operating Officer of RSPN enriched this research project and report with their valuable input. We thank the National Programme for Family Planning and Primary Healthcare and the Maternal, Neonatal and Child Healthcare (MNCH) Programme for providing valuable input and coordination support at the district and provincial levels. Most of all we would like to express extreme gratitude to all the women and men of Khudabad and Kamal Khan, Dadu, who participated in the project, spared their time and shared their experiences with us. A research study like this is heavily indebted to the openness and honesty of the research participants as their experiences make way for learning and policy change.

Addressing Delays for Access to EmONC 7 in Non-LHW Areas of Pakistan

CONTENTS 1.

Executive Summary

Introduction and Literature Review

2.1

Outline of this Research

2.2

Aims, Objectives and Outcomes

2.3

Research questions

Study Design and Methodology

3.1

Target Population

3.2

Sampling Methodology and Sample size

Results and Findings

4.1

Demographic and Household Characteristics

4.2

OBJECTIVE 1: Community Resource Persons - Awareness about Health-seeking and EmONC

4.3

OBJECTIVE 2: Knowledge and involvement in decision making and access to health facilities

4.4

OBJECTIVE 4 & 5: Village Health Committees â&#x20AC;&#x201C; VHC, Community based financing and Access to EmONC Services and Facilities

4.5

OBJECTIVE 6: Readiness of staff and supplies and uptake of services

4.6

Health Facility Audit

4.7

Predictors of Facility Based Deliveries

Summary, Discussion and Conclusions

5.1

Key Findings

5.2

Limitations

5.3

Lessons Learned

5.4

Recommendations

6. References

7. Appendices

7.1

Geographical location (Map of the area, highlighting project districts)

7.2

Womenâ&#x20AC;&#x2122;s questionnaire (Quantitative Survey)

7.3

Birth audit questionnaire

7.4

Check list of Focus Group Discussions and Indepth Interviews

116

7.5

Focus Group Discussions and Indepth Interviews

117

7.6

CRP Model

119

8 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

LIST OF FIGURES Figure 1:

Inter-spousal communication for place of Delivery (Reported by Women)

Figure 2:

Perceived Impact of Post-partum Danger Signs on a Woman’s Life (Reported by Wives)

Figure 3:

Perceived Risks to the Life of a Newborn (Reported by Wives)

Figure 4:

Comparison of place of delivery at baseline with program women (Khudabad)

Figure 5:

Who conducted delivery

Figure 6:

Comparison of outcome of delivery for women in baseline study with program women

Figure 7:

CRP Visited (Reported by Women- Birth audit)

Figure 8:

Received IEC Material (Reported by Women- Birth audit)

Figure 9:

Information Gained from IEC Material (Reported by Women-birth audit)

Figure 10: Mechanism to Provide Financial Support (End line)

Figure 11: Knowledge of Community Mechanism to Provide Transport Support

Figure 12: Receive Community Support for EmONC Services

Figure 13: Avail VHC fund – Birth Audit (Reported by Women)

Figure 14: Mode of Transport – Birth Audit (Reported by Women)

Figure 15: Did you go to a Health Facility for a Post-partum Check-up (Reported by Wives)

Figure 16: Physical Examination within 24 Hours of Delivery (Reported by Women)

Figure 17: Women Who Were Examined Within the First Week (Reported by Women)

Figure 18: Display of Management and Clinical Protocols at BHU Aminani

Figure 19: Medicine supply and their storage in BHU Kamal Khan and Aminani respectively

Figure 20: Infant Weighing Scale at BHU Kamal Khan

Figure 21: Medical equipment at MCH Centre Khudabad

Figure 22: Record of supervisory visit by District Manager PPHI at BHU Aminani

LIST OF TABLES Table 1: Sample Size – Quantitative Survey with Men and Women

Table 2: Sample Size – Qualitative Component

Table 3: Sample Size – Birth Audit

Table 4: Mean Age of the respondents

Table 5: Household Characteristics across the intervention and control arm at baseline and endline

Table 6: Distance to Health Care- across the intervention and control arm at baseline and endline

Table 7: Age and Reproductive History of Program Women (N=846)

Table 8: Poor outcome of last pregnancy (Abortion, still birth, neonatal death, physical & mental abnormalities etc)

Table 9: Mean Age and Income of recent mothers

Table 10: Education Level and Employment Status

Addressing Delays for Access to EmONC 9 in Non-LHW Areas of Pakistan

LIST OF TABLES Table 11: Reproductive History of Women (Birth Audit)

Table 12: Number of ANC Visits a Pregnant Woman Should Make - Wife and Husband – Endline

Table 13: Number of Antenatal Care Visits a Pregnant Woman Should Make (Reported by wives)

Table 14: Sources of Information Regarding Antenatal Care – Wives

Table 15: Sources of Information Regarding Antenatal Care: Husbands

Table 16: Important Components of ANC – Husbands’ and Wives’ Opinion

Table 17: Antenatal care visits (Reported by Women, Quantitative survey)

Table 18: Antenatal care Visits (Reported by Program women)

Table 19: Type of provider for antenatal care (Reported by Wives)

Table 20: Practice for Birth Preparedness (Reported by Wives)

Table 21: Source of Knowledge of Respondents Regarding Birth Preparedness – Wives

Table 22: Knowledge of Birth Preparedness (Reported by Wives)

Table 23: Preferred Place for Giving Birth (Reported by Wives)

Table 24: Number of Pregnancy Related Complications Known

Table 25: What Pregnancy Related Complications Wives Know About

Table 26: Source of Information for Complications during Delivery (Reported by Women)

Table 27: Knowledge of Complications that Can Occur During Delivery

Table 28: Recognition of danger signs for post-partum period – Wives

Table 29: Sources of Information about Danger Signs during the Post-partum Period (Reported by Wives) 35 Table 30: Most Important Things to do with a Newborn – Wives

Table 31: Danger Signs for a Neonate (Reported by Women)

Table 32: Understanding of Exclusive breastfeeding (Reported by Women)

Table 33: Source of Information about New-borns (Reported by Wives)

Table 34: Decision-makers to Seek Treatment (Reported by Women)

Table 35: Did not Seek Treatment (Reported by Women)

Table 36: Time Taken to Seek Healthcare (Reported by Wives)

Table 37: Reasons for Delay (Reported by Women)

Table 38: Where was Treatment Sought (Reported by Women)

Table 39: What Prompted to Seek Healthcare? (Reported by Wives)

Table 40: Reason for delivery at selected place (Reported by Women)

Table 41: Source of Information for Financial Support Mechanisms (End line)

Table 42: Type of Support from Community for EmONC Services (Reported by women, End line)

Table 43: Source of Funds – Wives

Table 44: Who Examined the Woman immediately after birth (Reported by Wives)

Table 45: Who Were They Examined By (Reported by Women)

Table 46: Time Taken to be Seen at a Health Facility (Reported by Women)

Table 47: Summary table for Health facility audit

Table 48: Predictors of Having Facility Based Deliveries – Program Data

10 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

LIST OF ABBREVIATIONS ANC

Antenatal Care

BHU

Basic Health Unit

CMO

Community Mobilisation Officers

CMW

Community Midwives

CRP

Community Resource Persons

CPR

Contraceptive Prevalence Rate

DHQ

District Health Quarter

DSM

District Support Manager

EmONC Emergency Obstetric and Neonatal Care FGD

Focus Group Discussions

FMO

Female Medical Officer

Family Planning

HANDS

Health and Nutrition Development Society

IDI

In Depth Interviews

IEC

Information, Education and Communication

KAP

Knowledge, Attitude and Practices

LHW

Lady Health Workers

LSO

Local Support Organisation

MDG

Millennium Development Goals

MNH

Maternal and Neonatal Health

MCH

Maternal and Child Health

MWRA

Married Women of Reproductive Age

NGO

Non-Governmental Organisations

PNC

Postnatal Care

PPHI

Peopleâ&#x20AC;&#x2122;s Primary Care Health Initiative

RAF

Research and Advocacy Fund

Reproductive Health

RSPN

Rural Support Programme Network

TBA

Traditional Birth Attendant

THQ

Tehsil/ Taluqa Health Quarter

TRDP

Thardeep Rural Development Programme

Union Council

UCHC

Union Council Health Committee

VHC

Village Health Committee

WHO

World Health Organisation

Addressing Delays for Access to EmONC 11 in Non-LHW Areas of Pakistan

DEFINITIONS ANTENATAL CARE Antenatal refers to the period of pregnancy for a woman. Antenatal care includes medical check-ups to assess pregnant woman’s health status, identification of any maternal or child health risks; and counselling during pregnancy and for delivery. Important components of ANC include monitoring blood pressure, ultrasound, weight and examining for any other conditions that may put the mother and/or child at risk. The World Health Organization recommends a minimum of 4 ANC visits. BIRTH PREPAREDNESS Birth preparedness refers to the planning and management of maternal and child health from the beginning of the pregnancy till the child is born, as well as post-partum care for the mother and child. It involves making specific decisions regarding health seeking measures, finances, travel arrangements and any other unforeseen contingencies. INFANT MORTALITY RATE (IMR) Infant mortality rate is the number of deaths of children less than one year of age, per 1000 live births. The rate for a given region is the number of children dying under one year of age, divided by the number of live births during the year, multiplied by 1000. NEONATAL The neonatal period refers to the first 28 days of a child’s life after birth. During this period, the child is at risk and therefore requires extreme care. NEONATAL MORTALITY RATE (NMR) Number of deaths during the first 28 days of life per 1000 live births in a given year or period. Neonatal deaths may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before the 28th day of life. MATERNAL MORTALITY RATIO (MMR) Maternal mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births POSTNATAL / POST-PARTUM Postnatal refers to the period after childbirth. Postnatal care includes care for both the mother and child after birth. Postnatal care is defined as the first 6 weeks after childbirth; and is considered critical for maternal and child health. Early post-partum care is defined as health care provided to the woman within 48 hours of giving birth. In Pakistan, women hardly receive early post-partum care – the percentage being particularly low among poor and rural populations. Early post-partum care can save the lives of many women; while improving health of others. STILLBIRTH The definition recommended by WHO is a baby born with no signs of life at or after 28 weeks’ gestation.

1 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

1. EXECUTIVE SUMMARY BACKGROUND Pakistan with its current population of more than 180 million is the sixth most populous country in the world and fourth in Asia. Approximately two-thirds (65%) of the population is located in rural areas. Demographic trends indicate a continuously increasing growth in population. Presently the population growth rate is 1.9 per cent per annum. Pakistanâ&#x20AC;&#x2122;s population growth rate is thus very high as compared to 0.1 per cent for more developed countries. The Maternal Mortality Ratio (MMR) is 276 per 100,000 live births. The under 5 mortality rate is 89 per thousand live births, infant mortality rate is 72 per thousand live births and neonatal mortality rate is 54 per thousand live births. These figures are far higher in rural than in urban locations. Despite the deployment of a very large work force of Lady Health Workers (LHWs), 35% of the rural areas across the country remain un-served. The non-availability of LHWs in these areas is compounded by extreme poverty which further limits the access to essential health services.

METHODS RSPN in collaboration with HANDS and TRDP implemented a one year intervention in a non-Lady Health Worker covered area by attempting to reduce the delays in utilising emergency obstetric care that are known to contribute towards maternal mortality. The main interventions were community mobilisation through Community Resource Persons (CRPs) to address the first delay (male CRPs for male segments of the population and female CRPs for women), formation of Village Health Committees (VHCs) and the establishment of a transport fund and arrangement of vehicular transport for complicated delivery cases to address the second delay. The training and equipping existing public sector health facilities to address the third delay was a common component in both intervention and control areas. The intervention commenced in May 2012 (with the exception of the transport fund that was operationalised in November 2012) and continued until June 2013. The project research utilised mixed research methodologies to achieve the project objectives. The various approaches used for this project included 1. Baseline and end line quantitative surveys of MWRAs and their husbands to compare project intervention areas with non-intervention areas. 2. Pre-post quasi experimental design in the intervention areas with follow-up of enrolled participants. The participants were enrolled during pregnancy and follow-up was completed till the time of delivery and first post-natal and neonatal check-up during the first week postpartum. 3. A birth-audit survey for a subset of women (who had given birth during the last one year) as a mid-term assessment of project interventions in the intervention and non-intervention area. 4. Health facility audit to ascertain the functionality with reference to staff, infrastructure, services, equipment and materials, reporting and recording mechanism and facilities/amenities availability. Qualitative focus group discussions and in-depth interviews were conducted with MWRAs, husbands, TBAs, VHCs, village influencers and elders in the family. Two union councils in Dadu were selected â&#x20AC;&#x201C; UC Khudabad and UC Kamal Khan. The intervention area was the non-LHW covered rural population of UC Khudabad of district Dadu which had an estimated population of 27,188. The non-intervention UC Kamal Khan was also located in district Dadu and has an estimated 32,452 non-LHW covered population. The project compared two socio-demographically similar communities to see if the interventions increased skilled birth attendance through facility based deliveries or improved the uptake of EmONC in the intervention community (Khudabad) as compared to the non-intervention community.

Addressing Delays for Access to EmONC 2 in Non-LHW Areas of Pakistan

3 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

RESULTS CRPs and Knowledge Enhancement CRPs were effective in raising the knowledge of communities regarding antenatal care. When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). Regarding the components of antenatal care, husbands in Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed. Regarding the number of antenatal care visits, the base line and end line data comparison revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The programme data revealed that 92% of the program women had one antenatal check-up; 86%, 73% and 57% had a second, third and fourth antenatal visit. The CRPs visited nearly 91% of the households and were cited as the main source of information in intervention UC at the end line for antenatal care by 41% of the women and 35% of the husbands. The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to base line. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The CRPs helped to increase awareness regarding complications during pregnancy among husbands from 36% to 79% (an increase of 43%) and from 83% to 94% among women. With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications such as severe bleeding, convulsions, high fever, loss of consciousness, labour period longer than 12 hours and un-delivered placenta when compared to base line. When the women were inquired about the source of information for complications during delivery it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by trained health care providers (11%). Wives in Khudabad demonstrated an increase in their ability to recognise danger signs such as bleeding, blurred vision, convulsions, difficulty in breathing, severe weakness, severe abdominal pain and difficulty in breathing during the post-partum period. The perceived impact of post-partum danger signs on womenâ&#x20AC;&#x2122;s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad. The most common sources of information regarding danger signs during the post-partum period in Khudabad was family elders at base line, however, CRPs emerged as an important source of information at the end line. The perceived risk to the life of newborn increased from 76% at base line to 94% at end line among women in Khudabad. The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination; avoid feeding food, initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth. The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessively crying were correctly identified as signs of danger. The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% at end line, suggesting that children should only be breastfed for first six months of life. CRPs and Health Care Use As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. With regards to the decision makers to seek treatment, there was considerable increase in the proportion of women in Khudabad who were engaged in decision making at end

Addressing Delays for Access to EmONC 4 in Non-LHW Areas of Pakistan

line (10% at base line to 39% end line). The time taken to seek health care showed improvement for women in Khudabad with almost three-fifths seeking health care immediately (59%) at end line compared with 50% at base line. The utilisation of public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/ clinic remained the most sought health providers both at base line and end line. The place of delivery for last pregnancy among women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at public sector health facility. Comparing with programme data, a higher proportion of women (24%) gave birth at a public sector health facility while 28% delivered at home. The programme data for women revealed that for around 66% women, delivery was conducted by skilled health provider. For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed by advice from family, confidence in provider, costs and advice from provider. Around one-fifth of the women (22%) and husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line. Village Health Committees and Transport Mechanism A considerably higher proportion of women and their husbands (43% & 47% respectively) had knowledge of the community mechanism to provide transport support in Khudabad at end line compared to the base line (4% & 9%, respectively). A higher proportion of husbands (33%) in Khudabad received community support for EmONC services when compared with base line (23%). Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%). Around 28% of the women at base line in Khudabad went to a health facility for post-partum check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high during end line assessment. The overall trend remained the same for Khudabad at base line and end line with most of the women being examined immediately after birth by lady doctors and TBAs. However, there was an improvement in the proportion of women examined by trained TBAs from 0% at base line to 6% at end line. Regarding postnatal care, around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line. Health Facility Audit A third component of the intervention attempted to reduce the delays at health facilities and provided some basic medical equipment to public sector health facilities as well as training paramedical staff and TBAs. The operational hours of the MCH centre were extended from 2 pm to 8 pm. The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as the provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times. However, the qualitative findings repeatedly revealed high absenteeism, vacancies of key paramedical staff and unpleasant staff attitudes, especially towards the poor, as a major deterrent to institutional births. Community members frequently complained of poor treatment, being yelled at or scolded or being asked for a reference before they were treated adequately. The project however had little control over these problems. Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. It was found that the use of vehicles arranged through the VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/ stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery.

5 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

CONCLUSIONS AND RECOMMENDATIONS The project intervention period was very short while significant changes in behaviours require continuous long term efforts and repeated positive reinforcements through success stories and realisation of ‘good’ outcomes. Furthermore, in working with poor communities, the biggest challenge is to provide costeffective and user-friendly solutions to problems. Going forward, communities should be more integral to the design of such interventions and the duration of interventions that seek to change behaviours should be longer – several years as was seen in the case of the Matlab project in Bangladesh. Another key aspect of the intervention may be to use VHCs as means to provide oversight over public sector facilities that are meant to serve communities. Based on the research findings, the CRP model has shown effectiveness in mobilising communities in non-LHW covered areas to seek institutional healthcare. CRPs are an effective, community based solution for providing EmONC information and referrals to rural communities. As their monthly honorarium is one-sixth of the LHW salaries, the government and donors can use CRPs as an alternate to LHWs in un-covered areas till the government is able to deploy LHWs.

Addressing Delays for Access to EmONC 6 in Non-LHW Areas of Pakistan

7 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

2. INTRODUCTION AND LITERATURE REVIEW Pakistan has some of the highest maternal and neonatal mortality rates in the world. Despite a considerable investment of resources over the past decades, these rates have not improved sufficiently. While most interventions have been facility based and largely in the public sector, it appears that many of the factors that underlie this high mortality are social and have their roots in communities. It is well known that despite the presence of an extensive network of nearly 15,000 public sector health facilities, women turn to these for fewer than 10% births2.

Maternal and Neonatal Mortality in a Global Context Worldwide, more than 800 women die daily during pregnancy or childbirth. In fact, the average lifetime risk of a woman from a developing country dying from complications related to pregnancy or childbirth is over 300 times greater than for women from developed countries (State of the World’s Children, UNICEF 2009). Most such deaths would be preventable if critical but often ordinary resources were available. In particular, poverty – which restricts access to health services - adversely impacts maternal and neonatal health. For example, in Pakistan neonatal mortality is about 55% higher for the poorest as compared to the richest quintiles3 and similar inequalities also affect maternal health4. Beyond poverty, factors such as distance to healthcare facilities, lack of information and poor quality of services, the perception among poor people that they will be treated shabbily at health facilities and cultural barriers to health seeking limit women’s access to health services5;6. Sixty percent of the world’s births still take place without a skilled birth attendant, usually with Traditional Birth Attendants (TBAs), who are a common in rural communities; but also have poorer maternal outcomes due to unhygienic practices, inability to handle complications, lack of professional training and poor medical knowledge7-9. However, the absence of viable options such as quality professional providers and high costs force women in communities to seek these TBAs; and weak referral mechanisms further delay seeking of life saving emergency obstetric and neonatal care (EmONC) until it is too late.

The Situation in Pakistan In Pakistan maternal mortality is 276 per 100,000 live births and neonatal mortality is 54 per 1,000 live births. This situation is graver for rural areas – that comprise nearly two-thirds of the Pakistan’s population – where the MMR is 319, in contrast to 175 for urban areas1. The effects of rural poverty are further aggravated by socio-cultural norms, lack of female empowerment, male control of key assets and decisionmaking that limit a woman’s ability to negotiate for better health services or access services without their spouse’s consent10. Pakistan has made insufficient progress in reducing maternal mortality (MDG 5)11. The Lady Health Worker Programme was initially created to promote maternal health and family planning, but over the years has seen an expansion in the tasks assigned to LHWs and simultaneously diminishing efficacy at meeting reproductive health goals. Furthermore, the programme only covers around 65% of the country, and among the population that remains uncovered by the programme are the extremely poor, living in remote rural locations. The government then created a cadre of community midwives to provide skilled birth attendance to rural homes. However, poor planning, management and accountability have led to a largely ineffective programme. Similarly a number of donor funded programmes have also been implemented in various regions across Pakistan; however, there is no evidence that they have impacted maternal or neonatal mortality on the whole.

Addressing Delays for Access to EmONC 8 in Non-LHW Areas of Pakistan

The Three Delays Model and the need for EmONC Among women who die during maternity, most do so due to delays in seeking care12. These delays occur 1) in deciding to seek medical care when a woman encounters complications during pregnancy or labour, 2) during transport to a healthcare facility and 3) in receiving adequate and appropriate treatment once at a healthcare facility. These delays are grounded in socio-cultural structures, poverty, political will and institutional capacities of the healthcare system10. In addition to the three delays it is recognised that once complications arise during pregnancy or labour, in some women they will progress rapidly to become severe and life threatening and that it is often difficult to predict which woman will encounter these complications. Hence, the concept of emergency obstetric and neonatal care (EmONC) services was developed so that these women can receive emergency care by a trained provider as needed and there should be provisions made to transport women to higher level facilities should the need arise13. Numerous interventions to reduce three delays in access to EmONC have been devised and implemented globally. These interventions range from capacity building initiatives in local communities, improving access to skilled health care and service quality, promoting facility based births, providing transport facilities and scaling up of services. These interventions have included training of TBAs who far outnumber other providers7 and have had a moderately successful record in some developing countries14;15. However other evidence suggests that TBAs perhaps never unlearn their old ways and therefore there has been a shift16 to other cadres such as community midwives (CMWs) who receive more extensive training. Other means to improve maternal mortality have included improved referral systems so that women are transported to facilities on time17;18. This in turn has been one of the best options since improved access â&#x20AC;&#x201C; which includes readily available means of transport - to well-equipped hospitals has reduced maternal mortality19-27.

Examples of other Community Based Initiatives In Pakistan, over the past few years NGO driven initiatives have explored novel ways of improving access to maternal and child health and family planning or birth spacing services in remote rural areas that are not covered by LHWs. In the Marginalised Areas Reproductive Health and Family Planning Viable Initiatives (MARVI), conducted in non-LHW covered areas of district Umerkot by HANDS and the Thardeep Rural Development Programme, community-based MARVI workers mobilised communities and provided subsidised services and referral for reproductive health (RH) and family planning services. It resulted in an increase in Contraceptive Prevalent Rate (CPR) from 7% to 31% in a period of 5 years and a skilled birth attendance rate of 48%. Similarly the Rural Support Programmes Network (RSPN) carried out a project in non-LHW covered areas across 10 districts of Sindh where CRPs created awareness among the men and women of reproductive age about birth preparedness, antenatal care, danger signs during pregnancy and delivery, neonatal care, prevention of diarrhoea and pneumonia, immunisation and birth spacing. In the USAID funded Family Advancement for Life and Health (FALAH), the RSPN used a similar approach to help increase CPR from 14 to 36%. In the USAID funded PRIDE project, Health Management Committees (HMCs) were formed around each health facility in district Mansehra and Bagh; which raised awareness for health issues in the local communities, oversaw the functions of facilities and saw considerable improvements in the quality and uptake of services.

2.1 OUTLINE OF THIS RESEARCH For this study the research team conducted operational research to address issues related to three delays in

9 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

remote rural areas that are not covered by the LHW programme. The intervention was at three levels. First, male and female CRPs were trained to mobilise the communities. This mobilisation included formation of Village Health Committees and the institution of a community financed transport fund. The research team worked with local public sector facilities to upgrade their equipment, train their providers and to open their services for a second shift, i.e. from 8am to 8pm, rather than the customary 8am to 2pm. Finally CRPs worked with the community to provide health messages about recognising dangers during pregnancy and labour and to promote facility births. The team also trained local TBAs to recognise danger signs during pregnancy and to refer women to health facilities. The overall design was a quasi experimental community based study. The union council Khudabad was selected in the district Dadu because of its remoteness. UC Kamal Khan – also from district Dadu - was selected as control as it had similar indicators and health services profile and was not geographically contiguous. It is noted that following selection of the sites, Kamal Khan received a number of NGO interventions and experienced an improvement in its health profile.

2.2 AIMS, OBJECTIVES AND OUTCOMES The aims of this project were: • To develop and demonstrate a community based intervention model to remove the three delays in access to EmONC in areas not covered by LHWs. • To generate robust evidence to push for the scale-up of proven, cost effective community based interventions with a focus on improving EmONC services and access for poor and marginalised communities in non-LHW covered areas.

2.3 RESEARCH QUESTIONS Q 1. Do training community-level volunteers as Community Resource Persons improve awareness for health-seeking among married couples of reproductive age regarding EmONC? Q 2.

Does the knowledge and awareness of women, husbands and community members improve women’s involvement in decision-making and their mobility to access health facilities?

Q 3. Does the presence of trained Community Resource Persons contribute to timelier referral of complicated deliveries, or at least increase deliveries in facilities? Q 4. Does a community support mechanism in the form of a Village Health Committee (VHC) increase access to EmONC services/facilities? Q 5. How effective are community based financing mechanisms (such as community saving schemes to cover cost of transport) in improving access to facilities for complicated deliveries? Q 6. Do Community Resource Persons help improve neonatal care practices? The main outcomes of interest was improved skilled birth attendance or facility based deliveries

Addressing Delays for Access to EmONC 10 in Non-LHW Areas of Pakistan

11 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

3. Study Design and Methodology The present intervention project research utilised mixed research methodologies to achieve the project objectives. The various approaches used for this project included: 1. Base line and end line quantitative surveys of MWRAs and their husbands to compare project intervention areas with non-intervention areas. 2. Pre-post quasi experimental design in the intervention areas with follow-up of enrolled participants. The participants were enrolled during pregnancy and follow-up was completed till the time of delivery and first postnatal and neonatal check-up during the first week postpartum. 3. A birth audit survey for a subset of women (who had given birth during the last one year) as a mid-term assessment of project interventions in the intervention and non-intervention area. 4. Health facility audit to ascertain the functionality with reference to staff, infrastructure, services, equipment and materials, reporting and recording mechanisms and facilities/amenities availability. Qualitative focus group discussions and in-depth interviews with MWRAs, husbands, TBAs, VHCs, village influencers and elders in the family. Two union councils in Dadu were selected â&#x20AC;&#x201C; UC Khudabad and UC Kamal Khan. The intervention area was the non-LHW covered rural population of UC Khudabad of district Dadu which had an estimated population of 27,188. The non-intervention UC Kamal Khan was also located in district Dadu and has an estimated 32,452 non-LHW covered population. The interventions component of the project had the following key components: 1. Community mobilisation to address the causes of the first delay 2. A community support mechanism in the form of Village Health Committees to ensure transport to health facilities in emergency cases to address the causes of second delay 3. Training of health care providers to ensure delivery of quality EmONC services to address the third delay (common in both areas) The project compared two socio-demographically similar communities to see if the intervention increased skilled birth attendance through facility based deliveries or improved the uptake of EmONC in the intervention community (Khudabad) as compared to the non-intervention community.

3.1 TARGET POPULATION The target population were Married Women of Reproductive Ages (MWRAs) residing in the intervention (Khudabad) and non-intervention (Kamal Khan) UCs of district Dadu, located in the province of Sindh. Based on available demographic data, approximately 3,000 MWRAs were anticipated in both the intervention and non-intervention areas. Among these only MWRAs with children under the age of 3 years were recruited in the sampling, to address information accuracy and recall bias. For the birth audit, the target population was MWRAs who had given birth in the past 12 months. In addition to this, regular programmatic data were collected and validated throughout the intervention period. This was done through referral slips which were given to the Community Resource Persons (CRPs), which they would use to refer pregnant women to health facilities. Each referral slip had three parts; one for the client (i.e., the pregnant woman), the second to be given to the projectâ&#x20AC;&#x2122;s community mobilisation officers (CMOs) and the third to be retained by CRPs. CMOs would collect these slips from each CRP on a weekly basis, after which the projectâ&#x20AC;&#x2122;s research officers would visit the health facilities and meet with healthcare providers to track whether the referred clients had actually visited the facilities. Additionally, the research officers validated 5% of all clients (selected randomly) who availed services from health facilities through an interview and by tallying information with the CRP record.

Addressing Delays for Access to EmONC 12 in Non-LHW Areas of Pakistan

3.1.1

Census of both Union Councils

To have an updated sampling frame the research team conducted a brief but universal activity in the selected union councils. The census focused on updating information from both union councils of neonates, children under the age of 3 and 5 years, maternal deaths, neonatal deaths and total households in the village/UC.

3.2 SAMPLING METHODOLOGY AND SAMPLE SIZE There were 4 components in this study. The primary household survey sampling was done to detect a difference in facility births of 5%. Systematic sampling strategy with a simple random start was conducted to identify eligible women for the quantitative survey from a list of all eligible women in each of the union councils (the universe), to give a sample size of 389 women per UC and their respective husbands. We oversampled this number to include 550 women in order to have power for some sub-analyses. The household rosters of the project were used to list all households in each of UC and then divided them with sample size (n=550) to achieve the interval k. The first household was selected through simple random selection approach, and every kth household was approached for recruitment. If more than one eligible woman was encountered within a household, the first one was recruited. If there were no eligible women in that household, the house to its right was approached but the sampling frame resumed with the next kth household on the original list (i.e. the enumerators did not â&#x20AC;&#x153;frame-shiftâ&#x20AC;? if they had to resort to an alternative household). The birth audit was meant to provide supporting, in depth evidence for key variables. Since the research team had maintained a list of all births occurring in the area, every third birth was selected for the birth audit using the random number generator function in Microsoft Excel. For the qualitative assessment, respondents were recruited based on identification by key informants.

3.2.1

Base line Survey

After receiving the census data, the sampling frame was used to interview at least 550 couples from each union council, i.e. a total of 1100 participants (550 male and 550 female) from each UC. Table 1: Sample Size â&#x20AC;&#x201C; Quantitative Survey with Men and Women Union Council

Interview Category

Target Interviews

Achieved Target

Khudabad

Male

550

475

Female

550

536

Total

1100

1011

Male

550

526

Kamal Khan

Female

550

559

Total

1100

1085

The qualitative study set was planned separately to cover those villages where the number of maternal or neonatal deaths was high. For in-depth interviews, at least 5 people were targeted from each group i.e. women, in-laws, health care providers and local influential/political leaders/ social workers.

13 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 2: Sample Size â&#x20AC;&#x201C; Qualitative Component Union Council

Interview Category

Target Interviews

Achieved Target

Kamal Khan

FGDs

IDIs

Total

FGDs

IDIs

Total

Khudabad

3.2.2

Birth Audit

As per the given sampling frame, birth audit interviews were only conducted with mothers who had given birth in the past year. Details of the sample are given in Table 3. Table 3: Sample Size â&#x20AC;&#x201C; Birth Audit Union Council

Interview Category

Kamal Khan Khudabad

3.2.3

Target Interviews

Achieved Target

Women only

150

157

Women only

150

Total

300

307

Health Facility Audit

An audit was conducted of the BHUs in Kamal Khan, BHU Aminani and the MCH centre from Khudabad, as well as the district headquarters hospital Dadu.

3.2.4

Data Collection Tools

Data collection tools were prepared and finalised with inputs from the donor agency. All tools were pretested and changes incorporated. The tools were translated into the local language, which was Sindhi. All interviews were also conducted in the local language except for the health facility audit which was conducted in Urdu. The quantitative household survey tool included questions on socio-demographics, birth preparedness and antenatal care, skilled care at birth, skilled care for obstetric emergencies, post-partum and neonatal care and community support for obtaining emergency services. The birth audit similarly captured information on household characteristics, knowledge, attitude and practices regarding pregnancy, antenatal care, delivery location and procedures, postnatal care and decision-making. The qualitative tools gathered detailed and in-depth insight on delivery practices, knowledge about EmONC services, skills of health facility staff and community support mechanisms. Probes were used for each of the identified themes to congregate complete information and achieve saturation. The health facility audit tool was adapted from an instrument developed by the WHO

Addressing Delays for Access to EmONC 14 in Non-LHW Areas of Pakistan

3.2.5

Data Management

Data for all components of the project were collected on paper based forms. To computerise the quantitative forms, separate study specific data entry programs were developed in Epi Data software for each quantitative component of the project. Data from the paper based forms were computerised through a team of data entry operators. After computerisation, the data was coded, labelled, edited and cleaned by preparing a .dbf format file and exporting it into SPSS version 20 software. Completion of data entry was followed up with logical editing and cleaning of the dataset. This was done through execution of frequencies and cross-tabulations in SPSS version 20 software. Standard data management practices to deal with outliers and missing values were adopted to ensure completeness of the dataset. The same software was used for analysis of data. The qualitative information was translated into English and transcribed. Transcription was done under identified analysis themes in-line with the project objectives. Matrices were developed for the devised themes and the findings were summarised under each theme. The quantitative and qualitative data was analysed and triangulated based on key variables that included knowledge and practices regarding ANC, birth preparedness, safe birthing, neonatal care and postnatal care. The role of CRPs and VHCs was particularly assessed for creating awareness and reducing delays in access to EmONC.

3.2.6

Quality Assurance Mechanisms

To ensure the dataâ&#x20AC;&#x2122;s quality, the following steps were taken during the data collection process:

3.2.6.1

Hiring and Training of Enumerators

A total of 22 male and 22 female enumerators and 8 supervisors were hired through an interview process which was conducted by research team in Dadu. This team was then trained over a period of 4 days, where they were oriented on the background and objectives of the research, and the use of the quantitative and qualitative survey tools. During the training, the enumerators conducted practice interviews with each other and then in the field, after which each enumerator was evaluated.

3.2.6.2

Monitoring of the Survey

The data collection process was monitored by two research officers, two monitoring officers and a research quality coordinator, all of whom accompanied the research teams in the field and provided support when needed. In addition, the information on the qualitative and quantitative survey forms was verified by revisiting respondents on a random basis.

15 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

3.2.7

Research Objectives and Methodological Approach

The following tools were used for acquiring information and analysis: Research Question

Survey

Tools of Analysis

1. Does training community-level volunteers as community resource persons improve awareness for health-seeking among married couples of reproductive age regarding EmONC?

Quantitative Household survey

Frequencies; Cross-tabulations

2. Does the knowledge and awareness of women, husbands and community members improve women’s involvement in decision-making and their mobility to access health facilities?

Quantitative Household survey Birth Audit Qualitative survey

Frequencies; Cross-tabulations Thematic analysis

3. Does the presence of trained community resource persons contribute to timelier referral of complicated deliveries, or at least increase deliveries in facilities?

Quantitative Household survey Birth Audit

Frequencies; Cross-tabulations Multivariate Regression Analysis

4. Does a community support mechanism in the form of a Village Health Committee (VHC) increase access to EmONC services/facilities?

Quantitative Household survey Birth Audit Qualitative survey

Frequencies; Cross-tabulations Thematic analysis

5. How effective are community based financing mechanisms (such as community saving schemes to cover cost of transport) in improving access to facilities for complicated deliveries?

Quantitative Household survey Birth Audit Qualitative survey

Frequencies; Cross-tabulations Thematic analysis

6. Do community resource persons help improve neonatal care practices?

Quantitative Household survey Qualitative survey

Frequencies; Cross-tabulations Thematic analysis

3.2.8

End Line Evaluation

Similar to the base line survey, a detailed quantitative survey was conducted to assess the change in key variables of interest across the intervention and non-intervention areas. The end line survey similar to the base line carried the same sample size and the same quantitative questionnaire and sampling methodology.

3.2.9

Analysis of Qualitative Data

Qualitative data was analysed using qualitative content analysis. The data was transcribed from field notes by interviewers as well as from verbatim transcripts (translated from Sindhi to Urdu by professional translators) and then analysed for significant themes that were identified with particular reference to each of the groups and keeping in mind the overall study objective of identifying information about reproductive health practices in the community. Both ‘manifest content’ (visible, obvious components) and ‘latent content’ (underlying meaning) of the text were analysed. The transcripts were read several times to understand in depth the respondents’ life experiences, their views on their preparation for and knowledge about RH, MNCH, family planning and child bearing activities. ‘Meaning units’ that mirror statements, were then identified as per topic guides, by highlighting phrases in the transcripts which were ‘condensed’ and thereafter ‘codes’ were identified from the ‘condensed meaning units’ without losing the context.

Addressing Delays for Access to EmONC 16 in Non-LHW Areas of Pakistan

Finally, the research team reviewed the codes independently and grouped similar codes into sub-categories and categories. From the categories theme and sub-themes were identified after systematically analysing the commonalities, variations and disagreements of the researchers. The data was further analysed with a focus on the description and interpretation of message meaning and concepts30 for a richer perspective of how individuals receive and process information and use it at individual and group level. 3.2.10

Analysis of Quantitative Data

The data analysis for the quantitative component included descriptive and inferential analyses. In descriptive analysis frequencies, proportions and means with standard deviations were derived to understand and describe the survey participants and their characteristics. The second stage of analysis included deriving inferential statistics involved multivariate regression modelling to derive the predictors for main outcome of interest (i.e. skilled birth attendance/institutional deliveries) for key variables in relation to plausibility and objectives of the study.

17 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

4. RESULTS AND FINDINGS The quantitative survey was based on two samples. The primary sample included women and their husbands who had a child in the past three years to record their knowledge, attitudes and practices. The birth audit sample was based on women who had given birth in the past one year to explore the most recent behaviours and birthing practices after the intervention in Khudabad and the comparative performance in Kamal Khan (control UC). Only women who had delivered in the past one year were surveyed to minimise recall bias. The sample size for the birth audit was around 150 women. The end line survey similar to the baseline targeted to interview women and their husbands at end line.

4.1

Demographic and Household Characteristics

4.1.1

Quantitative Household Survey

The base line and end line quantitative surveys included women who gave birth to a child in past 3 years and their husbands. Most respondents were in their early thirties, with mean age difference of 1 year observed between the husband and wife. The overall prevalence of formal schooling was low and commonly up to primary education level among husbands, while it was much lower among women. Table 4: Mean Age of the respondents Base line

End line

Khudabad

Kamal Khan

Total

Khudabad

Kamal Khan

Total

Husband

33.9

35.7

34.8

33.5

32.5

33.0

Wife

28.7

30.4

29.6

31.4

33.0

32.3

Table 5 shows the key household characteristics of both the intervention (Khudabad) and non-intervention (Kamal Khan) UCs when the base line and end line surveys were conducted. The mean monthly income of the respondents in the end line study was PKR 8, 873 and PKR 8,096 in Khudabad and Kamal Khan respectively. Most of the houses in end line study in Khudabad (74%) and Kamal Khan (82%) were made of bricks (un-plastered). The proportion of households with a latrine facility increased from base line in both the intervention and control arm of the study. More than one third of the households in both Khudabad (36%) and Kamal Khan (35%) practiced open defecation. When compared with the base line, the practice of open defecation decreased in both the intervention and control arms of the study.

Addressing Delays for Access to EmONC 18 in Non-LHW Areas of Pakistan

Table 5: Household Characteristics across the intervention and control arm at baseline and end line Base line

End line

Khudabad (N=1018)%

Kamal Khan (N=1132)%

Khudabad (N=1013)%

Kamal Khan (N=1090)%

8,147

6,324

8,873

8,096

Houses with Mud Walls

Houses with Thatch Walls

Houses Made of Wood

Brick/Un-plastered Houses

Brick and Cement

Household ownership

Flush/Pit latrine

Open Defecation

Have a Radio

Have a Television

Own Livestock

Mean Monthly Income (PKR)

The distance from the health facility at end line decreased in Khudabad compared to base line; a higher proportion of households (58%) reported to be residing within 5 kms of a health facility. A similar pattern was observed for distances to TBA with majority of the respondents (88%) reported to have TBA within a vicinity of 5 kms. In the control UC (Kamal Khan), the distance from the health facility increased compared to base line with 61% of the households reported to have health facility at a distance more than 5 kms. However, the availability of the TBA within 5 km of the household increased from base line. Table 6: Distance to Health Care- across the intervention and control arm at base line and end line Base line Khudabad (N=1018) Health Facility

TBAs

4.1.2

End line

Kamal Khan (N=1132)

Khudabad (N=1013)

Kamal Khan (1090)

<5km

>5km

<5km

>5km

Demographic and Reproductive History of Programme Women

The mean age of the women enrolled in the intervention program was 28 years ± 5 years. The mothers included in the program had a mean number of 2.5 children and a maximum of 12 children. The mean number of pregnancies was found to be 3.12±2.71. The mean number of abortions was found to be 0.63±1.18.

19 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 7: Age and Reproductive History of Programme Women (N=846) VARIABLE

STATISTIC Minimum

Maximum

Mean (Std. Dev, Confidence Interval (CI)

27.79 (5.367, CI 27.44 to 28.13)

Age (in Years)

Minimum

Maximum

Mean (Std. Dev, Confidence Interval (CI)

2.50 (2.287, CI 2.34 to 2.65)

Minimum

Maximum

Mean (Std. Dev, Confidence Interval (CI)

3.12 (2.719, CI 2.94 to 3.31)

Minimum

No. of Live Children

No. of previous pregnancies

No .of Abortions

Maximum

Mean (Std. Dev, Confidence Interval (CI)

0.63 (1.185, CI 0.54 to 0.70)

With regards to poor pregnancy outcome (abortion, still birth, neonatal death, physical & mental abnormalities) in the past, it was found that almost one-fifth (19.8%) of the programme women had a poor outcome. Table 8: Poor outcome of last pregnancy (Abortion, still birth, neonatal death, physical & mental abnormalities etc) #

567

65.6

Yes

171

19.8

DNK

126

14.6

Total

864

100.0

4.1.3

Birth Audit

The birth audit was specifically conducted among women who had given birth in the past 12 months. The mean age of women included in the birth audit was around 29.6 years; while the mean age of their husbands was 35 years. Most of these women had been married for 10 years on average. The average household incomes were low, and commonly reported to be hardly enough to cover basic household expenses. Table 9: Mean Age and Income of recent mothers Khudabad (N=150) Mean

Std. Dev

Khudabad (N=150)

Median

Mean

Std. Dev

Median

Woman's Age

29.6

6.2

29.7

6.5

Husband's Age

34.4

7.2

34.2

7.6

Duration of Marriage Household Income

9.7

6.2

9.9

6.3

6,722

4,974

6,000

6,125

6,525

5,000

Addressing Delays for Access to EmONC 20 in Non-LHW Areas of Pakistan

Focus on girlsâ&#x20AC;&#x2122; education was poor in both UCs. With limited financial resources in the family and the prevailing culture, less than 20% of the women had ever gone to school in both Khudabad and Kamal Khan. More men had attended regular school. The women in the sub-sample were all housewives; while men generally were labourers, farmers or land owners indicating that the population primarily relied on agricultural income. Agricultural income is by nature unstable and periodic, leading to low average monthly incomes. Table 10: Education Level and Employment Status Khudabad (N=150) %

Kamal Khan (N=157) %

19%

14%

59%

44%

Regular Schooling - Women Regular Schooling â&#x20AC;&#x201C; Men

Employment Status - Men Unemployed

Land Owner

13%

17%

Farmer

26%

30%

Office Worker

Government Servant

Small Business Owner

Labourer

37%

Other

The women in the sub-sample were all housewives; while men generally were labourers, farmers or land owners indicating that the population primarily relied on agricultural income. Agricultural income is by nature unstable and periodic, leading to low average monthly incomes. The birth audit revealed that the women on average had been pregnant at least 3-4 times and had experienced at least one stillbirth in the past. The majority of women in the birth audit indicated full term (i.e. around 37 weeks of gestation) for their last pregnancy and the labour durations were normal (i.e. when considered to be less than 12 hours). ANC visits had declined from 5 to 4 at end line. Table 11: Reproductive History of Women (Birth Audit) Number of Khudabad Base line (N=130)

Number of pregnancies

Khudabad End line (N=150)

Kamal Khan Base line (N=128)

Kamal Khan End line (N=156)

Mean(+ St. Dev)

Mean(+ St. Dev)/ Median

Mean(+ St. Dev)

Mean(+ St. Dev)/ Median

3.4 (+ 2.5)

3.4 (+ 2.9)/ 3

3.6 (+ 2.7)

3.4 (+ 2.7)/3

Number of stillbirths

1.3 (+ 0.5)

1.4 (+ 0.5)/1

1.6 (+ 0.7)

1.4 (+ 0.8)/1

Number of antenatal/ during pregnancy visits

5.2 (+ 2.9)

4.4 (+ 2.2)/4

5.1 (+ 2.4)

4.1 (+ 2.6)/3

21 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

4.2

OBJECTIVE 1: Community Resource Persons - Awareness about Health-seeking and EmONC

4.2.1

Knowledge about Antenatal Care

When inquired about the number of antenatal care visits pregnant women should make, it was found that majority of women and their husbands in both intervention and control UCs suggested that pregnant women should go for at least 3-4 visits. As compared to men, more women suggested more than 4 antenatal visits. Table 12: Number of ANC Visits a Pregnant Woman Should Make - Wife and Husband â&#x20AC;&#x201C; End line Khudabad Husband (N=500) (N=513)

Kamal Khan

Wife (N=521) (N=569)

Husband

Wife

At least two

At least three

139

118

172

170

At least four

297

339

291

334

Other

No Answer

Do not know

At least One

When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). The control UC (Kamal Khan) also showed slight improvement in this regard, with proportion of women who suggested to having more than 4 antenatal visit increasing from 23% at base line to 25% at end line. Table 13: Number of Antenatal Care Visits a Pregnant Woman Should Make (Reported by wives) Khudabad Base line (N=517)

Kamal Khan

End line (N=513)

Base line (N=581)

End line (N=569)

At least One

At least two

104

At least three

140

118

166

170

At least four

198

339

251

334

Other

No Answer

Do not know

The base line and end line comparison for Khudabad showed a marked increase in the proportion of women who reported CRPs as a source of information regarding antenatal care (1% at base line and 41% at end line). There was a decrease in proportion of women who had no source of information at end line (4%) compared to base line (19%). The proportion of women who got information from a trained health care provider also

Addressing Delays for Access to EmONC 22 in Non-LHW Areas of Pakistan

increased from 6% at base line to 11% at end line. The data for control UC (Kamal Khan) revealed that only 1% of the women got information from CRPs at end line while the family members were the main source of information regarding antenatal care (68%). Table 14: Sources of Information Regarding Antenatal Care â&#x20AC;&#x201C; Wives Khudabad Base line (N=517)

No one

Kamal Khan

End line (N=513)

Base line (N=581)

End line (N=569)

Friend

Family elders

370

218

414

389

Trained health care provider

123

LHW

CRPs

209

Radio TV

Newspaper

Other

No Answer

When husbands were inquired, a similar pattern was observed as for women regarding sources of information for antenatal care in both the intervention and control UCs. There was a decrease in proportion of men who had no source of information at end line (6%) compared to base line (27%) in the intervention areas. The proportion of men who got information from CRPs showed a dramatic increase from 1% at base line to 35% at end line. Table 15: Sources of Information Regarding Antenatal Care - Husbands Khudabad

Kamal Khan

Base line (N=501)

End line (N=500)

Base line (N=551)

End line (N=521)

No one

136

102

Friend

Family elders

222

217

276

384

Trained health care

153

LHW

CRPs

177

Radio TV

Other

No Answer

23 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Regarding the components of antenatal care, husbands in Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed. Table 16: Important Components of ANC – Husbands’ and Wives’ Opinion Khudabad

Kamal Khan Husband

Base line (N=501)

End line (N=500)

Base line (N=551)

End line (N=521)

Checking for Anaemia

142

235

180

316

Measure Blood Pressure

200

308

231

316

Weighing

103

100

104

Immunisation

139

123

Counselling

119

206

144

Urine test

102

Check the foetus position

114

Don’t Know

157

Wife Base line (N=517)

End line (N=513)

Base line (N=581)

End line (N=569)

Checking for Anaemia

203

254

233

291

Measure Blood Pressure

262

356

288

327

Weighing

160

115

Immunisation

112

186

130

155

Counselling

139

189

Urine test

Check the foetus position

103

116

Don’t Know

100

*= It is important to note that responses were not shared with respondents and were recorded as mentioned. **=The percentage will be more than 100% if added, due to multiple responses

ANC Visits – Regarding the number of antenatal care visits, the base line and end line data comparisons revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The control UC (Kamal Khan) had a higher proportion of women with one or more antenatal care visits at base line (95%) compared with Khudabad and slightly improved at end line (97%).

Addressing Delays for Access to EmONC 24 in Non-LHW Areas of Pakistan

Table 17: Antenatal Care Visits (Reported by Women, Quantitative survey) Baseline Khudabad (N=517)

None

End line

Kamal Khan (N=581)

Khudabad (N=513)

Kamal Khan (N=569)

One or more antenatal visits

462

551

494

553

Not Applicable

When the program data was analysed, it was found that 92% of the program women had her first antenatal check-up, however the proportion of women going for antenatal visits progressively decreased in the second, third, forth and more than 4 antenatal visits, with only one quarter (28%) women having more than 4 antenatal visits. Table 18: Antenatal Care Visits (Reported by Programme Women) 1st Antenatal Check up (N=864)

2nd Antenatal Check up (N=864)

3rd Antenatal Check up (N=864)

4th Antenatal Check up (N=864)

More than 4 Antenatal Check ups (N=864)

120

238

374

619

Yes

794

744

626

490

245

Type of Provider â&#x20AC;&#x201C; Regarding the type of provider for antenatal care, a higher proportion of women in Khudabad availed antenatal care from a public sector LHV/doctor at end line (20%) compared to base line (7%). The utilisation of the private sector LHV/doctor for antenatal care in Khudabad slightly decreased at end line (65%) compared to base line (65%). The antenatal care seeking from TBA/Dai in Khudabad decreased at end line (7%) compared with base line (21%). Table 19: Type of Provider for Antenatal Care (Reported by Wives) Base line

End line

Khudabad (N=471)

Kamal Khan (N=560)

Khudabad (N=497)

Kamal Khan (N=555)

None

TBA/Dai

LHW

CMW

Private sector LHV/Doctor

314

434

322

431

Public Sector LHV/ Doctor

Other

25 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Practice for Birth Preparedness â&#x20AC;&#x201C; Regarding the practices for birth preparedness, both the intervention and control UCs showed a decline in the all the measures at end line compared to base line. Table 20: Practice for Birth Preparedness (Reported by Wives) Khudabad

We never had information regarding checkups during pregnancy, but once the project team gave us the information, we started taking care of women during their pregnancy A FATHER IN-LAW

Kamal Khan

Base line (517)

End line (513)

Base line (581)

End line (569)

None

Saved funds

Had ANC visits with CMW, TBA

Visited delivery facility

Arranged transport

Identify blood donor

Identified skilled provider

Identified place of delivery

Procure clean delivery kit

4.2.2

Qualitative findings

4.2.2.1

Awareness about ANC and EmONC

The first step to mitigating the first delay in seeking care is to recognise danger signs during pregnancy. The research findings clearly show higher knowledge levels regarding EmONC in the intervention area at the end line as compared to that at baseline; as well as the recognition of danger signs during pregnancy, at time of birth and after delivery, while little has changed in the non-intervention area. The concept of maternal health during pregnancy was well understood in Khudabad but less so in Kamal Khan. Knowledge about EmONC and pregnancy in Kamal Khan was superficial at best. Awareness about ANC and the ability to realise signs of danger during pregnancy were higher in Khudabad. Women in Khudabad understood the importance of nutrition for pregnant women and were able to identify signs of danger during pregnancy and childbirth. Clearly this was an improvement over the base line when they had known many of the complications related to nutrition but now came to link them with specific nutrition problems and their solutions. They also acknowledged the importance of breastfeeding in strengthening the babyâ&#x20AC;&#x2122;s immune system. In Kamal Khan, women had little knowledge of complications; but they understood the need for rest and a healthy diet during pregnancy. Information on neonatal and postnatal care was not demonstrated in Kamal Khan. Awareness levels among men in Khudabad were decent. They understood womenâ&#x20AC;&#x2122;s need for nutrition and rest and were even able to recognise certain danger signs during pregnancy and early signs of labour. Men in Khudabad claimed to take pregnant women in their households for regular ANC visits and for immunisation, and were aware that if a danger sign appeared they should take the mother and/or the newborn to the hospital immediately. This signals a departure from their prior practices when there was considerable suspicion for institutional care. On the other hand, men in Kamal Khan exhibited no knowledge of EmONC. The other change from the base line is the presence of community based mechanisms for transport of women either for ANC or for EmONC. In the base line assessment, the lack of these means had been highlighted as a major impediment facility based care for women in Khudabad.

Addressing Delays for Access to EmONC 26 in Non-LHW Areas of Pakistan

TBAs in Khudabad exhibited clear awareness of childbirth and recognition of complications; and demonstrated sound knowledge of safe birthing practices. They stated that regular check-ups and a healthy diet are important for pregnant women and were able to identify specific steps in the care of a newborn as opposed to only guesses that were recorded at the base line. TBAs in Kamal Khan were unable to provide any details on the handling of deliveries, care necessary during pregnancy and the importance of ANC and PNC visits. They were only able to provide some basic information on how to handle newborn babies. Fathers-in-law indicated some basic knowledge about neonates and pregnant women, which is an improvement over the base line. However, as for all other respondents they made no mention of PNC visits or their importance. They had some vague knowledge about childbirth; however their information was weak. Mothers-in-law in Khudabad exhibited sound knowledge of EmONC. In Khudabad the community understood the need for 2-3 medical check-ups during pregnancy; but was unable to demonstrate an understanding of postnatal care visits. The VHCs were well aware of precautions necessary during pregnancy, required ANC visits and neonatal health. VHCs who received training from the project team were better able to take care of pregnant women; guiding them for regularly spaced ultrasound tests to ascertain the foetusâ&#x20AC;&#x2122;s health, to ensure that there is no excessive amniotic fluid in the womb, and whether the foetus is correctly positioned. VHC exhibited sound knowledge of nutrition requirements for pregnant women and their immunisation. They advised pregnant women to work less after 3-4 months of pregnancy; to avoid lifting heavy objects and ensure that they are vaccinated. They however were unable to demonstrate knowledge about postnatal care.

4.2.2.2

Recognising Danger Signs for Complicated Pregnancies and Neonatal Health

Overall, women were able to recognise complications during pregnancy and childbirth. They were also convinced of the benefits of colostrum for neonatal health and were keen on BCG vaccines for newborns. Women in the intervention area were aware of signs of neonatal complications including â&#x20AC;&#x2DC;blue babyâ&#x20AC;&#x2122;, jaundice, breathing asphyxia, and tetanus and knew of common health problems that arise during pregnancy such as weakness, vomiting, swelling, fever, and blood pressure. Men in Khudabad did have knowledge of danger signs during pregnancy, delivery and post-delivery and were prepared to take women and newborns to the hospital if any of the danger signs appeared. They were aware of complications such as unstable blood pressure after 5-6 months of pregnancy, lower abdominal pain, lethargy, seizures, heavy bleeding, and incomplete discharge of placenta. Their knowledge was slightly higher than at the base line. They also understood the need to take the woman to hospital if the baby is breaching and a C-section is required. In this regard there was a higher level of acceptance of facility births than at the base line. Regarding neonatal care, men in Khudabad demonstrated less information and only showed understanding of breathing asphyxia. While influential persons did have some knowledge about pregnancy; they could not describe complicated pregnancies. Normal symptoms such as anaemia, lack of Vitamin C, weakness, laziness, backaches, and vomiting were incorrectly suggested as problems related to pregnancy. Most participants depended on women to tell them when they were not feeling well. They exhibited some knowledge of newborn care such as delays in immunisation due to transport issues, and understood that it was a concern if the child did not breast feed, or suffered from seizures. Most TBAs in Khudabad had adequate knowledge and were able to identify complicated cases and refer women to the hospital in time. The TBAs in Kamal Khan were unable to express their knowledge or experience. A few suggested they were experienced in discerning the difficulty level of the delivery. Most said they could not handle complicated pregnancies.

The health centre has no services, no beds, no personnel, no water or gas, and no bathroom. The doctor only visits for an hour and is never there when he is needed. They cannot solve our health problems; they only have basic medicine A COMMUNITY MEMBER

Usually, there is no bed, electricity or other necessary facilities but water is available in most health centres A MOTHER IN-LAW

27 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

In Kamal Khan, knowledge about pregnancy or complications was poor and TBAs were unable to distinguish between normal and complicated pregnancies. The women in the intervention district had sound knowledge of ‘good’ practices for neonatal health. Men in Kamal Khan had very little and inappropriate knowledge of danger signs. They mentioned conditions such as swollen feet and face and chronic disease to be complications of pregnancy.

4.2.2.3

Social Restraints on the Movement of Women When Seeking Healthcare

While neither women nor men describe from either Kamal Khan or Khudabad feel that women are restrained from seeking health care, however there is a strong feeling that they need to be accompanied by a man or an elderly woman. In the absence of a male household member, women can go with another woman or even a young child. They feel that if a woman were to go to the hospital by herself to give birth, she cannot do anything on her own. She cannot buy medicines or find transportation in that situation. While these restrictions are based on perceived needs – absence of support staff at facilities and the fact that in Pakistan families are often called upon to buy even the most routine of supplies - they can sometimes cause delays in seeking care, particularly during emergencies since a woman must wait for someone to accompany her to the hospital. In some villages of Kamal Khan, women face restrictions on their movement. They cannot go anywhere without their husband’s permission nor can they travel alone. In cases where the husband is not available, a child or an elderly woman goes with the woman. The head of the household decides about place of childbirth and the woman does not seek health care without his permission. The woman consults the head of the household for place of delivery and the TBA also gives her suggestions when asked.

4.2.3

Summary of Findings – OBJECTIVE 1

CRPs were effective in raising the knowledge of communities regarding Antenatal care. When the end line data was compared with the base line, it was found that the proportion of women who suggested to have more than 4 antenatal visits increased from 19% to 27% in the intervention UC (Khudabad). Regarding the components of antenatal care, husbands in the Khudabad showed improved knowledge regarding all components of antenatal care at end line. A similar pattern was observed for women in Khudabad at end line where an improvement in all the components of antenatal care was observed. Regarding the number of antenatal care visits, the base line and end line data comparison revealed that there was a considerable improvement in the proportion of women who had one or more antenatal visits in Khudabad (89% at base line and 96% at end line). The programme data revealed that 92% of the programme women had their first antenatal check-up; 86%, 73% and 57% had a second, third and fourth antenatal visit. The CRPs visited nearly 91% of the households and were cited as the main source of information in intervention UC at the end line for antenatal care by 41% of the women and 35% of the husbands. The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to base line. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The CRPs helped to increase awareness regarding complications during pregnancy among husbands from 36% to 79% (an increase of 43%) and from 83% to 94% among women. With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications

Addressing Delays for Access to EmONC 28 in Non-LHW Areas of Pakistan

such as severe bleeding, convulsions, high fever, loss of consciousness, labour period of longer than 12 hours and un-delivered placenta when compared to base line. When the women were inquired about the source of information for complications during delivery it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by trained health care provider (11%).

4.3

OBJECTIVE 2: Knowledge and Involvement in Decision Making and Access to Health Facilities

4.3.1

Knowledge about Birth Preparedness

Birth preparation and planning is an important process for any family that is about to have a child. Childbirth involves a number of risks to maternal and child health; as well as financial implications that require planning and resource management. At base line, women from Khudabad largely depended on family elders for information (91%); however, at end line majority of women (64%) did not mention any source of information for knowledge about birth preparedness. It is possible that they learn through observations or experiences. However, these characteristics were not explored in this research study and therefore the evidence is non-conclusive. An increased proportion of women at end line in Khudabad reported to get information from a trained health care provider (6%) and CRPs (9%) compared to base line (trained health care provider = 3%, CRPs= 1%). Table 21: Source of Knowledge of Respondents Regarding Birth Preparedness â&#x20AC;&#x201C; Wives Khudabad Base line (N=360)

Kamal Khan

End line (N=490)

Base line (N=468)

End line (N=539)

No one

315

301

Friend

Family elders

326

401

170

Trained health care provider

LHW

CRPs

The knowledge regarding birth preparedness in Khudabad showed slight improvement for identifying birth place (7%) and procuring clean delivery kits (4%) compared to baseline. However, there was a decline in proportion of women who had the knowledge to save money (57%), arrange transport (32%) and identify a skilled provider (2%). The knowledge of birth preparedness for women in control UC (Kamal Khan) showed a decline in all the preparatory measures except identification of delivery place which increased from 2% at base line to 7% at end line.

29 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 22: Knowledge of Birth Preparedness (Reported by Wives) Khudabad Base line (N=517) #

Kamal Khan

End line (N=513)

Base line (N=581)

End line (N=569)

Arrange transport

237

166

182

156

Save money

459

293

529

259

Identify blood donor

Identify skilled provider

Identify the place

Procure clean kits

4.3.2

Preferred Place for Giving Birth

Regarding the preferred place for giving birth, the base line and end line comparison revealed that home persisted to be most preferred place for giving birth in both the intervention and control UCs. A decline in the preference for public facility was also observed at end line in both intervention and control UCs. Table 23: Preferred Place for Giving Birth (Reported by Wives) Khudabad Base line (N=300) #

Kamal Khan

End line (N=427) #

Base line (N=372) #

End line (N=516) #

Home

149

242

177

244

Private facility

108

164

124

255

Public facility

CMW house

Other

Discussion Regarding Place of Next Delivery â&#x20AC;&#x201C; Couples demonstrated maturity in handling pregnancy situations and discussed where to have their next child. A higher proportion of women discussed regarding the place for next delivery in both the intervention and control UCs (Khudabad and Kamal Khan) at end line (83% & 91%, respectively) compared to base line (58% & 64%).

Addressing Delays for Access to EmONC 30 in Non-LHW Areas of Pakistan

Figure 1: Inter-spousal Communication for place of Delivery (Reported by Women) 100 90

70 60

40 30 20 10 0 Baseline N=517

Endline N=513

Baseline N=581

Khudabad

4.3.3

Endline N=569

Kamal Khan

Knowledge of Pregnancy Related Complications

When the women were inquired about the pregnancy related complications, it was found that a higher proportion of women (94%) in Khudabad knew of at least one complication compared to base line (83%). The mean number of pregnancy related complications also showed improvement from base line (2.7) to end line (3.5) in Khudabad. A similar pattern was observed for husbands in Khudabad. The proportion of husbands who knew of at least one pregnancy related complication increased from 36% at base line to 95% at end line. The mean number of complications known increased from 1.2 to 3.0 at end line. The proportion of women in the control UC (Kamal Khan) with knowledge of at least one pregnancy related complication showed slight improvement at end line (93%) compared to base line (92%), however, the mean number of complications decreased from 3.4 to 2.9. Table 24: Number of Pregnancy Related Complications Known Base line

End line

Khudabad (N=517)

Kamal Khan (N=581)

Khudabad (N=513)

Kamal Khan (N=569)

Knew of at least one complication

83%

92%

94%

93%

Number of complications known (Mean)

2.7

3.4

3.5

2.9

(N= 583)

(N=536)

(N=555)

(N=552)

Knew of at least one complication

36%

79%

93%

95%

Number of complications known (Mean)

1.2

2.1

3.0

Wife

Husband

31 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Regarding the knowledge about pregnancy related complications, women in Khudabad showed improvement for the complications such as bleeding, severe abdominal pain, convulsions, accelerated/ reduced foetal movements, swollen hands/feet and loss of consciousness when compared to base line. This could be attributed to an increased focus by CRPs on creating awareness about complications, which require frequent referrals to health facilities. Bleeding, severe abdominal pain and convulsions are known to be some of the worst complications which require immediate care. The intervention seems to have worked to raise awareness for knowledge about pregnancy related complications. In the control UC Kamal Khan, knowledge of women about some of the complications (convulsions, loss of consciousness, accelerated/reduced foetal movements) showed improvement, while the knowledge of women about other complications declined. Table 25: What Pregnancy Related Complications Wives Know About Khudabad

Kamal Khan

Base line (N=430)

End line (N=481)

Base line (N=533)

End line (N=528)

None

Bleeding

Severe headache

Blurred vision

Convulsions

Swollen Hands/face

High fever

Loss of conscious

Difficulty in breathing

Severe weakness

Severe abdominal pain

Accelerated /reduced foetal movement

Water breaks

Regarding the respondentâ&#x20AC;&#x2122;s opinion whether a woman can die from complications during pregnancy, the findings revealed that at the end line a lower proportion of both women and their husbands in Khudabad and Kamal Khan believed that a woman can die from complications during pregnancy. Source of Information about Complications during Pregnancy â&#x20AC;&#x201C; With regards to source of information about complications during pregnancy, CRPs were found to be the most common source for women in Khudabad at end line with almost half of them receiving information from the CRPs. There seems to be a shift from family members as source of information to CRPs. For the control UC Kamal Khan, family members were found to be main source of information both at base line and end line.

Addressing Delays for Access to EmONC 32 in Non-LHW Areas of Pakistan

Table 25: Source of Information about Complications During Pregnancy (Reported by Wives) Khudabad Base line (N=371) #

Kamal Khan

End line (N=319)

Base line (N=493)

End line (N=304) #

No one

Friend

Family elders

303

127

375

226

Trained health care

LHW

CRPs

151

Radio TV

Newspaper

Other

When the women were inquired about the source of information for complications during pregnancy it was found that in Khudabad family members and CRPs were the main source of information at end line (46% & 38%, respectively) followed by a trained health care provider (11%). For the control UC Kamal Khan, family members were found to be the main source of information (72%) followed by a trained health care provider (20%). Table 26: Source of Information for Complications during Delivery (Reported by Women) Khudabad Base line (N=438)

Kamal Khan

End line (N=493)

Base line (N=552) #

End line (N=549) #

No one

Friend

Family elders

354

227

399

396

Trained health care provider

110

LHW

CRPs

189

Radio TV

Newspaper

Other

33 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Knowledge Regarding Complications during Delivery- The knowledge regarding complications during delivery for both women and their husbands in Khudabad improved for complications such as severe bleeding, convulsions, high fever, loss of consciousness, labour period of longer than 12 hours and undelivered placenta when compared to base line. The ability of respondents to recognise the three significant complications during delivery, which are severe bleeding, prolonged labour and retention of placenta improved at the end line in Khudabad. Table 27: Knowledge of Complications that Can Occur During Delivery Khudabad

Kamal Khan

Base line

End line

Base line

End line

Husband (N=501)

Wife (N=517)

Husband (N=500)

Wife (N=513)

Husband (N=551)

Wife (N=581)

Husband (N=521)

Wife (N=569)

None

Severe Bleeding

Severe Headache

Convulsions

High fever

Loss of conscious

Labour more than 12 hrs

Placenta not delivered

4.3.4

Recognition of Danger Signs for Post-partum Period

Addressing Delays for Access to EmONC 34 in Non-LHW Areas of Pakistan

Table 28: Recognition of danger signs for post-partum period – Wives Base line

End line

Khudabad (N-517)

Kamal Khan (N=581)

Khudabad (N=513)

Kamal Khan (N=569)

None

Bleeding

Severe headache

Blurred vision

Convulsions

High fever

Loss of conscious

Difficulty in breathing

Severe weakness

Severe abdominal pain

Don’t know

*= It is important to note that responses were not shared with respondents and were recorded as mentioned. **=The percentage will be more than 100% if added, due to multiple responses

Perceived Impact of Post-partum Danger Signs on a Woman’s Life – The perceived impact of post-partum danger signs on women’s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad. Figure 2: Perceived Impact of Post-partum Danger Signs on a Woman’s Life (Reported by Wives) 100 95

Endline N=499

Baseline N=558

90 85 80 75

70 0 Baseline N=454

Khudabad

Endline N=548

Kamal Khan

Sources of Information about Danger Signs during the Post-partum Period – The most common sources of information in Khudabad was family elders at base line, however, CRPs emerged as an important source of information regarding danger signs during the post-partum period at the end line. For the control UC Kamal Khan, the family elders remained as the main source of information at end line.

35 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 29: Sources of Information about Danger Signs during the Post-partum Period (Reported by Wives) Khudabad Base line (N=443) #

Kamal Khan

End line (N=492) #

Base line (N=556)

End line (N=541) #

No one

Friend

Family elders

306

136

401

221

Trained health care

142

LHW

CRPs

147

Radio TV

Newspaper

Perceived Risks to the Life of a Newborn - The perceived risk to the life of newborn increased from 76% at base line to 94% at end line. Figure 3: Perceived Risks to the Life of a Newborn (Reported by Wives) 100 95 94

85 80 75 70

65 60 55 50 0 Baseline N=438

Endline N=513

Khudabad

Baseline N=515

Endline N=569

Kamal Khan

Most Important Things to do with a Newborn â&#x20AC;&#x201C; The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination, avoid feeding complimentary foods for the first 6 months, early initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth.

Addressing Delays for Access to EmONC 36 in Non-LHW Areas of Pakistan

Table 30: Most Important Things to do with a Newborn – Wives Khudabad Base line (N=517)

Immediate Bathing

Kamal Khan

End line (N=513)

Base line (N=581)

End line (569)

196

171

300

251

Covering in blanket

323

361

366

344

Cleaning

325

367

386

390

Showing to family

107

116

Feeding complimentary foods

169

Vaccination

147

125

Early initiation of breastfeeding

144

181

150

223

Don’t know

Danger Signs for a Neonate – The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessively crying were correctly identified as signs of danger. Table 31: Danger Signs for a Neonate (Reported by Women) Khudabad Base line (N=517) #

Kamal Khan

End line (N=513) #

Base line (N=581) #

End line (569) #

None

Turning red

140

141

207

Turning blue

135

177

190

133

Not breathing

257

222

284

179

Not feeding

190

256

234

243

Excessive crying

187

259

249

244

Not moving

106

Understanding of Exclusive Breastfeeding – The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% suggesting at end line that child should only be breastfed for first six months of life.

37 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 32: Understanding of Exclusive breastfeeding (Reported by Women) Khudabad Base line (N=517)

Kamal Khan End line (N=404)

Base line (N=581)

End line (N=451)

Breastfeeding with other milk when mother’s milk is short

355

428

Breastfeeding with other foods when mother’s milk is short

Breastfeeding with water

Only breastfeeding for a period of six months

186

187

Other

No Answer

126

199

Source of Information about Newborns – As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. At base line, the primary source of information was family elders which shifted to CRPs at end line. Table 33: Source of Information about New-borns (Reported by Wives) Khudabad Base line (N=517)

No one

Kamal Khan

End line (N=513)

Base line (N=581)

End line (569)

100

Friend

Family elders

367

161

417

239

Trained health care provider

109

LHW

CRPs

205

Radio TV

Decision Makers to Seek Treatment – With regards to decision maker to seek treatment, there was a considerable increase in proportion of women in Khudabad who were engaged in decision making at end line (10% at base line to 39% end line).

Addressing Delays for Access to EmONC 38 in Non-LHW Areas of Pakistan

Table 34: Decision-makers to Seek Treatment (Reported by Women) Khudabad Base line (N=462) #

Kamal Khan

End line (N=460) #

Base line (N=570)

End line (N=546)

Myself

178

248

Husband

374

254

490

277

Father

Mother

Father-in-law

Mother-in-law

Brother

Sister

Brother in law

Sister in law

Other

Don't know

Did Not Seek Treatment â&#x20AC;&#x201C; Women who experienced complications sought treatment at a health facility. Key reasons for not seeking treatment, included failure to recognise the complication, and thinking that the complication would heal on its own. The number of women who failed to recognise the complications was higher at the end line. Table 35: Did not Seek Treatment (Reported by Women) Khudabad Base line (N=10)

Kamal Khan

End line (11)

Base line (N=15)

End line (N=3)

Did not think the ailment was serious

Thought they will get better on own

Discussed with elder or community elder who suggested staying home

Other

No Answer

DNK

Time Taken to Seek Healthcare â&#x20AC;&#x201C; The time taken to seek health care showed improvement for women in Khudabad with almost three fifth seeking health care immediately (59%) at end line compared with 50% at base line.

39 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 36: Time Taken to Seek Healthcare (Reported by Wives) Khudabad

Kamal Khan

Base line (N=417)

End line (N=449)

Base line (N=528)

End line (N=543)

Immediately

210

266

257

290

After 1-6 hours

137

177

130

After 7-12 hours

13-24 hours

Between 1-2 days

>2 days

Don't know

Reasons for Delay – When the reasons for delay in seeking health care were explored, it was found that generating funds was the main reason for women in Khudabad both at base line and end line. However, there was a slight improvement in terms of a lower proportion of women who didn’t know where to go, had no transport or had to discuss with the family. Table 37: Reasons for Delay (Reported by Women) Khudabad Khudabad (n=85)

Kamal Khan

Kamal Khan (n=178)

Khudabad (n=83)

Kamal Khan (n=94)

Had to discuss with family

Husband wasn’t home

Had to generate funds

122

No transport

Didn’t know where to go

Elders/others prohibited

Other

Total

100

178

100

Where was Treatment Sought – The utilisation of the public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/clinic stayed as the most sought health providers both at base line and end line.

Addressing Delays for Access to EmONC 40 in Non-LHW Areas of Pakistan

Table 38: Where was Treatment Sought (Reported by Women) Khudabad

Kamal Khan

Base line (N=462)

End line (N=460)

Base line (N=570)

End line (N=546)

Lady Health Worker

TBA

Dispensary

Local Govt. hospital

District Govt. hospital

Tehsil Hospital

Private Clinic

Private Doctor

270

249

416

306

Pharmacist

What Prompted Them to Seek Healthcare â&#x20AC;&#x201C; Vomiting, shortness of breath and severe headaches were common reasons for seeking health care in Khudabad both at base line and end line. High blood pressure, heavy menstrual bleeding and severe lower pain prompted a higher proportion of women at end line to seek health care. Table 39: What Prompted to Seek Healthcare? (Reported by Wives) Khudabad

Kamal Khan

Base line (N=462)

End line (N=460)

Base line (N=570)

End line (N=546)

Vomiting

260

227

348

290

Shortness of breath

189

217

292

217

Severe headache

247

206

351

238

Swelling of face

127

Severe lower pain

159

171

286

231

Heavy menstrual bleeding

High blood pressure

137

136

176

Fits or convulsions

Anaemia

Jaundice

41 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

4.3.5

Summary of Findings â&#x20AC;&#x201C; OBJECTIVE 2

Wives in Khudabad demonstrated an increase in their ability to recognise danger signs such as bleeding, blurred vision, convulsions, difficulty in breathing, severe weakness, severe abdominal pain and difficulty in breathing during the post-partum period. The perceived impact of post-partum danger signs on a womanâ&#x20AC;&#x2122;s life increased in Khudabad. Counselling and information sessions with CRPs seem to have improved risk awareness and health consciousness among the households in Khudabad. The most common sources of information regarding danger signs during the post-partum period in Khudabad was family elders at base line, however, CRPs emerged as an important source of information at the end line. The perceived risk to the life of newborn increased from 76% at base line to 94% at end line among women in Khudabad. The knowledge of the women in Khudabad improved at end line regarding keeping newborns warm, ensuring their vaccination; avoid feeding food, initiation of breastfeeding and to avoid bathing newborns until 48 hours after birth. The knowledge of women in Khudabad regarding danger signs for a neonate improved at end line. The child turning blue, not feeding and excessive crying were correctly identified as signs of danger. The knowledge of women in Khudabad increased considerably regarding exclusive breastfeeding from 4% at base line to 46% suggesting at end line that child should only be breastfed for first six months of life. As for other components of maternal and child health, CRPs were found to be the main source of information about newborn care in Khudabad. With regards to decision maker to seek treatment, there was considerable increase in proportion of women in Khudabad who were engaged in decision making at end line (10% at base line to 39% end line).

OBJECTIVE 3: Community Resource Persons and Timely Referral (Increased Timely Referral for Complicated Deliveries and Facility Births) Place of Delivery for Last Pregnancy â&#x20AC;&#x201C; The last place of delivery for women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at public sector health facility. Comparing with program women data, a higher proportion of women (24%) gave birth at public sector health facility while 28% delivered at home. The program women data revealed that for around 66% women delivery was conducted by skilled health provider. Figure 4: Comparison of place of delivery at baseline with program women (Khudabad) Place of Delivery at Base Line Wives in % (N=517)

Place of Delivery-Programme Women in % (N=864)

Addressing Delays for Access to EmONC 42 in Non-LHW Areas of Pakistan

Figure 5: Who Conducted Delivery (Reported by Programme women) (N=864)

A higher proportion of women in base line study had live birth (91%) compared to programme women (85%). Almost 9% of the programme women had miscarriage/abortion while 5% had still birth. Figure 6: Comparison of Outcome of Delivery for Women in Base Line Study with Programme Women Outcome of Delivery at Base Line Reported by Wives in % (N=517)

Outcome of Delivery in % (reported by Programme Women) (N=864)Â

Live Birth Abortion Miscarriage Still Birth Missing

Live Birth Congenital Abnormality Dont Know Still Birth Other

Reason for Delivery at Selected Place â&#x20AC;&#x201C; For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed distantly by advice from family, confidence in provider, costs and advice from provider. The pattern was similar for Khudabad and Kamal Khan.

43 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 40: Reason for Delivery at Selected Place (Reported by Women) Khudabad

Kamal Khan

Khudabad

Kamal Khan

Convenience

236

193

362

356

Cost

Confidence

Advice from provider

Advice from family

107

Other

No Answer

180

245

Visits by CRPs â&#x20AC;&#x201C; The CRPs had set targets that involved visiting all households with in the catchment population once a month and visiting pregnant women twice a month. Women indicated a good presence of CRPs in the area. Almost 91% of the women claimed that a CRP had visited them and 87% said they had received IEC material. Thus the CRPs had actively visited households to carry out their duties. Figure 7: CRP Visited

Figure 8: Received IEC Material

(Reported by Women - Birth Audit)

100

87 01

0 Khudabad N=150

Kamal Khan N=157

Khudabad N=150

Kamal Khan N=157

Information Gained from IEC Material â&#x20AC;&#x201C; More than two-thirds of women reported receiving information on ANC, birth preparedness and PNC. Thus the project was well executed in terms of providing materials to community women. Figure 9: Information Gained from IEC Material (Reported by Women - Birth Audit) 80 60

70%

75%

Antenatal Care

Birth preparedness and safe delivery

61%

40 20 0

Postnatal care of mother & neonatal

Addressing Delays for Access to EmONC 44 in Non-LHW Areas of Pakistan

4.3.6

Qualitative Findings

Preferred Place for Childbirth In the intervention community (Khudabad), there have been significant changes in mind sets. Health facilities were considered the safest place for delivery as they are equipped with the necessary equipment and trained staff to deal with all kinds of complications. Despite realising that facility based births were safer, women continued to deliver at home. Quantitative analysis suggests that costs and convenience are the basic factors affecting the decision regarding place of birth. Regarding birth in health facilities, women in Kamal Khan said they had heard bad experiences as well, and that they could not afford it. Men in Kamal Khan (non-intervention community) considered home-based births to be safer. In Khudabad, TBAs are no longer preferred due to their attitude. They were said to be rude and misbehaved with household members. Hospitals were considered safer for giving birth since they were better equipped to deal with emergencies. Private hospitals were preferred over public hospitals due to better service quality, paramedical staff and flexible timings in most instances. In contrast, public hospitals were said to be quite ill-equipped as compared to private health facilities. The community complained about poor service quality and high absenteeism in public hospitals. On the other hand, private hospitals were unaffordable and therefore not an option for the poor. Home-based deliveries were still considered convenient in Kamal Khan. Facility births are safer as they have facilities and skilled staff; however travelling was a problem in most villages as transport was not easily available. Although hospitals were considered safer; other financial and transport constraints caused most households to make choices based on convenience rather than quality. The health facilities in Dadu were not functional round the clock, thus impeding the delivery of institutional EmONC services. The BHU in both the intervention and control UC were only open till 2pm. The MCH centre of Khudabad was initially open till 2pm, and was later converted into a 24/7 facility towards the end of the project. Apart from the MCH centre the civil hospital of Dadu is also open 24 hours a day but is distant and hard to reach for the people of Khudabad and Kamal Khan. People reported that at the UC level, the BHUs and MCH centre were poorly equipped and did not have medicines. In addition, the quality of service is poor and absenteeism is high. Public facilities are visited mostly for ANC and in case of complications, as they are more affordable to the community than private facilities. Many women felt that the public hospital staff members run private clinics in the evening, where they sell off the medicine provided by the government to medical stores. In emergencies, healthcare providers tell the family to take the patient to a private hospital â&#x20AC;&#x201C; often ones that they themselves operate. Health providers in the non-intervention UC (Kamal Khan) were said to be well trained but seldom available. Furthermore, in days when available, their timings were restricted to 2pm. People had to travel to Johi for even a simple injection. In some health centres the doctors were well-mannered and skilled; however cultural restrictions did not allow pregnant women to seek health care from male doctors. Some TBAs suggested the doctors were barely available during the entire working day. Also the doctors were unable to deal with complicated cases. Absenteeism was common and limited hours further restricted the use of facilities in Kamal Khan. It is clear from the above discussion that the three delays can be reduced if public centres are staffed with trained personnel, have medicines available, can handle complicated pregnancies and births, effectively take care of neonates, operate on a 24/7 basis to provide EmONC, have electricity, water, beds, and other basic equipment. While many of these facilities were provided at the MCH and BHU levels in Khudabad through the project, the outcome of health care services was beyond the control of the project. The project intervention had no power over staff absenteeism, behaviour and practices.

There is no guarantee anywhere, even in hospitals women die. A COMMUNITY MEMBER

The doctor at the health centre in another village appears for a day and then disappears for the next 10 days. A TBA

45 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

With the help of Project Team a village health committee was formed which helped us solve all kinds of problems related to health. A FATHER-IN-LAW.

Project Team formed a mechanism for financial and EmONC support, they gave us PKR 300-500 for transport in case of emergency, which is quite a benefit for us, being poor community. Such a mechanism should be formed in other areas as well. A MOTHER-IN-LAW

Knowledge and Practices of TBAs A vast difference was noted in the knowledge, sophistication and skill levels of TBAs in Khudabad and Kamal Khan. At the base line, we had found that the TBAs were generally fixed in their own ways and reluctant to change. They were also suspicious of referrals which they had felt would reduce their “business”. They were educated in timely referrals and some basic good practices during this intervention. At the end line, TBAs in Khudabad were well aware of EmONC. They had adequate knowledge on regular check-ups and nutrition, were able to recognise signs of complications during pregnancy as well as complicated pregnancy cases early on, and seem to have referred women to the hospital in time. TBAs in Kamal Khan were unable to provide any details on handling pregnancies, care necessary during pregnancy and the importance of ANC and PNC visits; and could only provide some basic details on how to handle newborn babies. A few suggested they were experienced in recognising whether the delivery will be easy or difficult. TBAs in the intervention area, who had received training from the project team, were better able to take care of pregnant women; guiding them for regularly spaced ultrasound tests. Previously they had attempted to take care of all situations, even when they were clearly unable to. However they were able to identify which situations they could manage and when they should refer and also appreciated the links that the intervention had created for them to refer to. The project team trained TBAs appeared technically competent; they have a delivery kit, wear gloves and wash their hands with soap. They were well aware of precautions during pregnancy, ANC visits and neonatal health. They however were unable to demonstrate knowledge about postnatal care.

Normal Practice Regarding Births There was mixed evidence for normal practices regarding childbirth. High absenteeism in public health facilities severely affected the availability of services for pregnant women, particularly for cases of childbirth. As a result, in some villages of Khudabad births were conducted at home under the supervision of a TBA. In other villages, families were in favour of facility based births and among those who could afford, most births were conducted in private hospitals. Many people suggested getting an initial check-up and information from a TBA, and then going to see a doctor and deliver at civil hospital Dadu. Families in Kamal Khan mostly preferred childbirth at home by Traditional Birth Attendants. As seen in the quantitative section, a number of men and women understood that facility births were safer but could not afford to have their deliveries at facilities. There were a few instances where the research team reported that families had gone to facilities at the onset of labour. However the men became upset 6-7 hours into the process because they were used to calling the TBA for home deliveries when birth was imminent. It was discovered that for many of the families, the understanding of labour was the time of crowning to birth – a mere few minutes – rather than the 6-8 hours that start from the first onset of labour pains and end at birth. When they went to the facility at the onset of labour pains as instructed by intervention personnel, they were irate when the labour stretched for longer than they had to been accustomed to. Some even expressed suspicions that they had been prematurely summoned in order to extract money from them and in one instance a husband even called the local parliamentarian to intervene and have the doctor deliver the child more quickly. In general women favoured going to private health facilities for ANC; however they preferred to deliver at home. In Kamal Khan, women preferred to deliver at home assisted by a TBA and only went to health facilities in case of complications. Men worried about inadequately trained TBAs who had no formal training or knowledge on how to use medical instruments. However, they felt that there was little privacy in health facilities for the women to

Addressing Delays for Access to EmONC 46 in Non-LHW Areas of Pakistan

deliver and therefore preferred having their wives deliver at home. Those in favour of facility based births said they took women to the MCH Centre in case of a normal delivery and only went to the DHQ if there was a complication or they were referred there. The “Thardeep Project” was frequently referred to and praised for raising the standard of health facilities nearby. These views were echoed by the TBAs in Khudabad who said that they were the first ones to be called for delivery at home. If they were unable to handle the case, they would ask the family to take the woman to the hospital. The pervasive poverty in Khudabad also drives many towards home deliveries with facilities sought only for complications. Among these, public facilities were preferred because they were cheaper. Most such women went to Khudabad District Hospital, which had been equipped by the project.

4.3.7

COMMUNITY INFLUENCER

Summary of Findings – OBJECTIVE 3

The time taken to seek health care showed improvement for women in Khudabad with almost threefifths seeking health care immediately (59%) at end line compared with 50% at base line. The utilisation of the public sector health facilities (local govt. hospital, district hospital and tehsil hospital) in Khudabad increased from 17% at base line to 22% at end line. However, the private doctors/clinic remained as the most sought health providers both at base line and end line. The place of delivery for last pregnancy among women in Khudabad at base line was home (46%) followed by private health facility (42%) while around 11% of women gave birth at a public sector health facility. Comparing with programme data, a higher proportion of women (24%) gave birth at public sector health facility while 28% delivered at home. The programme women data revealed that for around 66% women delivery was conducted by a skilled health provider. For most women in Khudabad, the place of delivery was chosen mainly for convenience, followed by advice from family, confidence in provider, costs and advice from provider. Around one-fifths of the women (22%) and husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line.

4.4 OBJECTIVE 4 & 5: Village Health Committees – VHC, Community based financing and Access to EmONC Services and Facilities Mechanisms to Provide Financial Support – Around one-fifths of the women (22%) and one-fifths of the husbands (25%) in Khudabad were aware of the mechanism that provided financial relief in EmONC. In the control UC Kamal Khan, only 1% of the women and 3% of the husbands were aware of such measures. Figure 10: Mechanism to Provide Financial Support (End line) 30 25 20

25 22

15 10 5 0 Baseline N=500

Endline N=513

Khudabad

There is a trained nurse who takes good care of pregnant women who have come for childbirth. Her behaviour is very polite

03 Baseline N=521

01 Endline N=569

Kamal Khan

You need to have money or a reference to get good treatment in public hospitals A COMMUNITY MEMBER

We took a pregnant woman from our family to a hospital. The doctor asked the family to wait as the delivery will take time. Our woman was in severe pain and we didn’t have money to go to another doctor. We brought the woman back home and called the midwife, but the child died in the womb. A COMMUNITY MEMBER

47 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Source of Information for Financial Support Mechanisms â&#x20AC;&#x201C; CRPs were the main source of information regarding financial support mechanisms for both women and their husbands in Khudabad at end line. CRPs were actively involved in creating awareness about the mechanism and became the primary source of information in Khudabad. Table 41: Source of Information for Financial Support Mechanisms (End line) Khudabad Husband (N=124)

Kamal Khan

Wife (N=114)

Husband (N=15)

Wife (N=7)

Friend or relative

CRPs

TBA/Dai

Doctor/Nurse/LHV

LHW

Husband

Village Health Committee member

Other

Presence of a Community Mechanism to Provide Support for Transport â&#x20AC;&#x201C; A considerably higher proportion women and their husbands (43% & 47% respectively) had knowledge of community mechanism to provide transport support in Khudabad at end line compared to base line. Figure 11: Knowledge of Community Mechanism to Provide Transport Support 50 45

35 30 25 20 15 10

07 05

04 Husband N=501

Wife N=517

Husband N=500

Khudabad

Wife N=513

Husband N=551

Wife N=581

Husband N=521

Kamal Khan

Wife N=569

Addressing Delays for Access to EmONC 48 in Non-LHW Areas of Pakistan

Receive Community Support for EmONC Services – A higher proportion of women and their husbands (23% & 33% respectively) in Khudabad received community support for EmONC services when compared with base line. A 10% increase for husbands and 4% increase for women is a considerable accomplishment within a span of 12 months of intervention. Figure 12: Receive Community Support for EmONC Services 35

Husband • Khudabad

30 25 20 15 10

33 23

5 0 Endline N=500

Baseline N=501

Types of Support from Community for EmONC services – Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%). Table 42: Type of Support from Community for EmONC Services (Reported by women, End line) Khudabad (N=117)

Fund for transport

Kamal Khan (N=15)

Transport

Fund for treatment

Referral advise

Don't know

Source of Funds – Few households had their own savings. Around one-fifths of the women (21%) in Khudabad at end line had own funds available for delivery while more than three-fifths had to take a loan (64%).

49 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 43: Source of Funds – Wives Khudabad

Kamal Khan

Baseline (N=462)

End line (N=460)

Baseline (N=570)

End line (N=546)

Own funds

101

Savings from the family

Village committee

Loan

279

294

449

408

Selling household items

Other

No Answer

Use of VHC Fund – Around a quarter (24%) of the women who delivered at a place other than home, availed the VHC fund. This is a considerably low utilisation of available funds which needs to be addressed by improving access and reducing the hassle in availing funds. Figure 13: Avail VHC fund – Birth Audit (Reported by Women) 40

% 24 05

0 Khudabad N=75

Kamal Khan N=21

Mode of Transport – The mode of transport was mostly rented transport; although around 11% also said they used the VHC transport.

Addressing Delays for Access to EmONC 50 in Non-LHW Areas of Pakistan

Figure 14: Mode of Transport â&#x20AC;&#x201C; Birth Audit (Reported by Women) 100 95%

88%

95%

80 2%

% 40

20 2% 4%

Khudabad Baseline N=56 Own Transport

Khudabad Endline N=74 VHC Transport

Rented

4.4.1

Postnatal and Postpartum Care

4.4.1.1

Postpartum Care

0% Kamal Khan Baseline N=66

2% 3%

Kamal Khan Endline N=60

Friends or Relatives transport

Women who went to a Health Facility for Postpartum Check-up â&#x20AC;&#x201C; Around 28% of the women at base line in Khudabad went to a health facility for postnatal check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high end line. Figure 15: Did you go to a Health Facility for a Post-partum Check-up (Reported by Wives) 40 35

30 30

25 20

15 10 05 0 Baseline N=517

Endline N=513

Khudabad

Baseline N=581

Endline N=569

Kamal Khan

51 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Who Examined the Woman Immediately after Birth – The overall trend remained same for Khudabad at base line and end line with most of the women being examined by lady doctors and TBAs. However, there was an improvement in proportion of women examined by trained TBAs from 0% at base line to 6% at end line. Table 44: Who Examined the Woman Immediately after Birth (Reported by Wives) Base line Khudabad (N=229) #

End line

Kamal Khan (N=298)

Khudabad (N=361) #

Kamal Khan (N=486) #

Lady Health Worker

Trained TBA

TBA

144

219

Nurse

Lady Doctor

116

157

156

225

Gynaecologist

Other (Specify)

Don't know

Postnatal Care Physical Examination within 24 Hours of Delivery – There was considerable improvement in the proportion of women who had a physical examination within 24 hours of delivery. Around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line. Training health staff and improving the couple’s knowledge had a joint effect on accessing postpartum care. Figure 16: Physical Examination within 24 Hours of Delivery (Reported by Women) 90 80

70 70 60 50 40

30 20 10 0 Baseline N=500

Endline N=513

Khudabad

Baseline N=521

Endline N=569

Kamal Khan

Addressing Delays for Access to EmONC 52 in Non-LHW Areas of Pakistan

Physical Examination within the First Week of Delivery â&#x20AC;&#x201C; Women in Khudabad reported as much as a 19% increase in post-partum care within first week of delivery at end line. The overall trend remained same for Khudabad at base line and end line with most of the women being examined by lady doctors and TBAs. However, there was an improvement in proportion of women examined by trained TBAs from 2% at base line to 15% at end line. Figure 17: Women Who Were Examined Within the First Week (Reported by Women) 50 40 30

36 %

20 19

Baseline N=581

Endline N=569

10 0

Baseline N=517

Endline N=513

Khudabad

Kamal Khan

Table 45: Who Were They Examined By (Reported by Women) Baseline Khudabad (N=89) #

End line

Kamal Khan (N=112) #

Khudabad (N=186) #

Kamal Khan (N=258) #

Lady Health Worker

Trained TBA

TBA

130

221

Nurse

Lady Doctor

Gynaecologist

Other (Specify)

Don't know

Mechanisms for Providing Referrals and Financial Support for EmONC Services Women were aware of the mechanism run by the project team for helping poor women who need EmONC. They were also aware of the sessions that the project team had conducted on maternal and child health and claimed to participate in the monthly meetings. The VHC arranges vehicle and also provides money for fuel. There were no support mechanisms in Khudabad. Only one group mentioned a community committee where everyone contributed PKR 20 to help pregnant women in case of emergency. The committee was developed by another NGO working in the area. In Khudabad, men showed awareness about a mechanism to provide financial support but they did not have complete information. Most suggested selling livestock or borrowing money at the time of an emergency.

The Thardeep programme provided rickshaws and motorcycles for rent; we would only pay for petrol at the time of childbirth. It was good but an ambulance would be much better COMMUNITY INFLUENCER

53 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Most men said that families usually start saving money from the beginning of the pregnancy. In Kamal Khan however, there was no mechanism for support during emergencies. Men claimed to borrow money from neighbours, relatives or feudal lords or sell livestock to arrange funds for EmONC. The community suggests developing a committee for providing finance in birthing emergencies. However, low level of trust within the community inhibits this development. The participants requested third party assistance to develop and manage a committee that can help families during childbirth. No one in the community had been able to run such a committee alone, because there is no trust in the community. The Thardeep VHC fund was considered very helpful by the villagers; although they suggested the need for an ambulance. There was no mechanism in Kamal Khan to provide financial support in emergency situations. People borrow or mortgage crops for money. Sometimes villagers contribute to transport costs and at other times people beg for money and/or borrow. The land lord also sometimes helps with money or transport. One village had a committee but the manager appropriated the funds for his personal use instead of giving them to families in cases of emergency. The committee was a local fund that is generated by village members contributing to a common goal. Transport is a problem especially in childbirth related emergencies. A committee was setup in one of the villages of Kamal Khan; however it was never implemented or heard of. In the absence of any committee, the villagers (who are all mostly relatives) help each other out. Financial help solves part of the problem and helps reduce delays in childbirth. However, the lack of transport within the village still needs to be addressed. Having money but no transport also causes unnecessary delays in seeking EmONC, putting both mother and child at risk. Efforts to provide transport services or an ambulance need to be considered as next steps in helping these communities.

4.4.2

Summary of Findings â&#x20AC;&#x201C; OBJECTIVE 4 AND 5

A considerably higher proportion of women and their husbands (43% & 47% respectively) had knowledge of community mechanism to provide transport support in Khudabad at end line compared to base line (4% & 9%, respectively). A higher proportion of husbands (33%) in Khudabad received community support for EmONC services when compared with base line (23%). Developing a community mechanism to provide funds for transport was a key intervention. The fund for transport was received by 36% of the women in Khudabad at end line. The other forms of support that women received were transport (25%), fund for treatment (33%) and referral advice (3%). Around 28% of the women at base line in Khudabad went to a health facility for post-partum check-ups which slightly increased to 30% at end line. The results were consistent at base line and end line possibly since distances to facilities were high during end line assessment. The overall trend remained the same for Khudabad at base line and end line with most of the women being examined immediately after birth by lady doctors and TBAs. However, there was an improvement in the proportion of women examined by trained TBAs from 0% at base line to 6% at end line. Regarding post natal care, around 44% of women in Khudabad at base line had a physical examination within 24 hours of delivery which increased to 70% at end line.

4.5

OBJECTIVE 6: Readiness of Staff and Supplies and Uptake of Services

Time Taken to be Seen at a Health Facilityâ&#x20AC;&#x201C; The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times.

Addressing Delays for Access to EmONC 54 in Non-LHW Areas of Pakistan

Table 46: Time Taken to be Seen at a Health Facility (Reported by Women) Base line Khudabad

End line

Kamal Khan

Khudabad

Kamal Khan

<30 min

217

239

346

410

30min - 1 Hour

169

261

104

120

2-4 Hours

>4 Hours

No Answer

4.6

Health Facility Audit

The health facility audit was carried out both at the time of conduct of base line and end line surveys. The audit included observation and staff response for key information related to management, staffing, availability of medicines and equipment at the BHUs and MCH centres in Khudabad and Kamal Khan. The interventions were directed towards reducing third delay in receiving Emergency Obstetric and Neonatal care at a health facility.

4.6.1

Summary of Findings

Overall, basic health services were being provided in all health facilities. Health promotion activities included health sessions which are conducted mostly in the community through community resource persons. Outreach activities were mostly limited to routine immunisation services and supervision of LHWs. During the programmatic interventions, a functional referral system was established and patients were being referred for antenatal, postnatal care, delivery and neonatal care as well as FP services from primary care level (i.e. MCH Centre Khudabad and BHU Aminani) to the secondary level. There was no referral system in place in the non-intervention area of BHU Kamal Khan. Use of referral system was found to be effective as understood by the vehicle through VHC used at the time of delivery for transport to health facility though the programmatic data. The availability of transport at the time of emergency obstetric situations is a testament that the project through its interventions (and contributions of VHCs and CRPs) was successful in reducing the second delay in seeking EmONC services (result reflected in section 4.7 for predictors of facility based deliveries).

55 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Table 47: Summary Table for Health Facility Audit UC Khudabad

UC Kamal Khan

Management Protocols

No written protocols Weak monitoring and evaluation mechanism

Staff Position

Frequent employee turnover MCH centre was well-staffed Some positions in DHQ remained vacant

Frequent employee turnover Key positions in UC Kamal Khan remained vacant

Medicines and Supplies

Some medicines to treat routine health problems were available; however key drugs and supplies such as gauze for dressing were not available in any facility.

Some medicines were available while many medicines and supplies remained unavailable at the facilities.

Equipment and Instruments

Project implementers provided equipment to public health facilities

Most basic medical equipment was unavailable No laboratory equipment

Child Delivery Facilities

Only available at MCH centre MCH centre converted into 24 hours service provider Labour room in DHQ could not be built

MCH centre had limited timings. No labour room in BHU Aminani

Medicines and supplies were generally available but some important medicines were not in stock such as emergency drugs, anti-hypertensive medicines, water for injection and plasma expanders. A delay of fifteen days was reported in the supply of medicine (from 21st May to 11th June 2013) in the BHU Aminani. Medical equipment was not fully available and some basic medical equipment was not available in BHU Aminani and Kamal Khan. As supported through the project interventions, the MCH Centre Khudabad was well equipped and backed up with an ambulance, oxygen cylinder, ultrasound machine and suction machine. There was no labour room in BHU Aminani or a separate bathroom for the female patients. The presence of such provisions in the MCH centre, reflect that through support in provision of materials and equipment, the said facilities could be enhanced at primary care level (Table 47). The results from MCH also highlight the importance of having adequate availability of materials, medicines and equipment to enhance service utilisation at the primary care level. There was little monitoring and supervision support from the district level managers. Supervision and monitoring mechanism was based on a short and single monthly visit of the District Support Manager (DSM) of the PPHI to all facilities. Since these DSMs are commonly non-medical personnel, the effectiveness of such single monthly visits is also further understood to be compromised, in adding value to the quality and range of services. The majority of support staff positions were filled in all facilities. Some positions such as medical technician/assistant and Dais were vacant. WMO of MCH Centre Khudabad highlighted the need of the training and refresher courses of the staff e.g. LHVs, Vaccinator and TBAs.

4.6.2

Availability of Specific Health Services

Most basic health facilities were being provided by all the facilities including general curative, antenatal, natal, postnatal, EPI and family planning services. However, child delivery services were only provided at the MCH centre. Nutritional rehabilitation services were not available in BHU Kamal Khan and MCH

Addressing Delays for Access to EmONC 56 in Non-LHW Areas of Pakistan

Centre Khudabad; BHU Kamal Khan also did not provide growth monitoring services for newborns and infants. Outreach activities are an integral part of a first level healthcare facility (FLCF). These services usually include outreach for routine immunisation, family planning, midwifery, health education, antenatal and postnatal services and surveillance for certain diseases. In the visited facilities primary outreach activities included EPI and supervision of LHWs in BHU Kamal Khan; health education, family planning, antenatal, natal and postnatal care and EPI activities in BHU Aminani; and a whole range of above mentioned services including health education were being offered in MCH centre Khudabad. As the FLCFs are primary level care facilities, many of the higher level services required by the patients were not be available at the centre. As ascertained through such cases these patients were being referred to secondary and/or tertiary care hospitals. The referrals observed during the end line activity. In the visited facilities patients were being referred for antenatal services, natal and postnatal services as well as child care from BHU Aminani and MCH centre Khudabad while BHU Kamal Khan was not referring any patients. The findings suggest that in the project intervention areas, where interventions focused to enhance the referral of patients and effectively linked the FLCFs with higher tiers of service provision in the health system, the project was successful in increasing the referrals. This thus improved the service delivery as per the patient needs through ensuring the mandated range of services at the FLCF, while also augmenting the referral system.

4.6.3

Health Facility Management

Management Protocols The clinical protocols for acute conditions such as diarrhoeal diseases, EPI, ARI, Malaria, Tuberculosis and FP were available in some forms. Application and action on these protocols was unclear due to a lack of standardised written protocols and a well-organised monitoring and evaluation system to ensure the quality of services.

Figure 18: Display of Management and Clinical Protocols at BHU Aminani

57 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Staff Position The FLCFs are mandated to have certain a number of support staff members for efficient functioning and facilitation in the provision of the services from the facility. The majority of technical positions were filled in all three facilities including medical officer, women medical officer, dispenser and medical technician. However some support staff was not posted in in BHU Kamal Khan especially the midwife. The woman medical officers were attending the facilities on alternate days in BHU Aminani and Kamal Khan. No medical assistant, Dai/midwife or laboratory technician was available in BHU Aminani. Only the MCH centre Khudabad was providing services with well trained, committed and sufficient staff members. As noted earlier, the programmatic efforts to support the MCH centre, as ascertained through the end-line assessment of the MCH centre reflect positive results for the intervention areas. The interventions need to be expanded to include the BHUs in a more robust manner to hence improve service delivery at the FLCF level.

Medicines and Supplies The FLCFs are required to provide basic/primary health care and preventive facilities for which there is proscribed essential list of medicines/supplies and vaccines. The list includes dressing materials, disinfectants, analgesics, antibiotics, emergency drugs, anticonvulsants, IV fluids, Oxytocin, antihypertensive, anaesthetics, contraceptive and some miscellaneous such as water for injection, ORS, anti-helminthic drugs, anti-malarial drugs, iron tablets and vaccines. During the end line survey, some key drugs and supplies were not available in any facility. These materials included gauze for dressing, any emergency drugs (except cortisone), anti-convulsants, anaesthetics, plasma expanders, anti-hypertensive drugs. In addition, water for injection (distal water) was available in BHU Kamal Khan only. Family Planning materials, including Condoms and IUCDs were not available in BHU Aminani. Iron-folate tablets were only available in BHU Kamal Khan. Contraceptive pills and injections were not available even in MCH Centre Khudabad. Only 100 packets of ORS were being supplied per month to the BHU Aminani. As elicited through the findings of the end line survey, the project was partially successful in ensuring the requisite medicines and their disbursement during the implementation period. It is hence concluded that through higher emphasis on ensuing the availability of supplies and medicines, the quantity and quality of service can be enhanced at the FLCF level.

Figure 19: Medicine supply and their storage in BHU Kamal Khan and Aminani respectively

Addressing Delays for Access to EmONC 58 in Non-LHW Areas of Pakistan

Equipment and Instruments In addition to medicines and supplies some important equipment should also be available at primary care facilities for provision of the mandated range of services. These include some basic medical equipment such as stethoscope, blood pressure apparatus, thermometer, weighing scales (adult and infant), foetoscope, tape measure and examination couch. Preventive services such as routine immunisation require a functional refrigerator, thermometer and vaccine carriers for adequate storage of vaccines and maintenance of cold chain. As per the government criteria for service provision, some basic laboratory equipment to conduct basic laboratory investigations (e.g. haemoglobin status, Urine and Stool Routine examinations etc.) should also be available such as microscope, centrifuge, test tubes and glass slides. It was found during the end line survey that generally this equipment was available in both the surveyed FLCFs i.e. BHU Aminani and MCH Centre Khudabad in the intervention areas. Health education material was available in BHU Aminani only. Wheel chairs, stretchers, adult weighing scales and rubber sheeting/ mackintosh were available in MCH Centre Khudabad but there was no otoscope, torch or tongue depressor at this centre. An ambulance, oxygen cylinder, ultrasound machine and suction machine were also there and in good conditions. All basic medical equipment except for a wheel chair, stretcher, rubber sheeting, suture set and nebuliser were available in BHU Aminani.

Figure 20: Infant Weighing Scale at BHU Kamal Khan

Figure 21: Medical equipment at MCH Centre Khudabad

Most of the basic medical equipment was not available in BHU Kamal Khan, and no laboratory equipment was found at this BHU. There was a significant difference in availability of equipment and instruments following the intervention period. However, there was lack of laboratory testing at the intervention area facilities. From these findings of the end line survey, it may hence be deduced that the project was successful in ensuring the availability of most of the services at the FLCF level; however, ensuring basic laboratory investigations were identified to be the weaker areas of project implementation.

4.6.4

District Health Information Systems

Health Management Information System (HMIS) is considered to be the pillar of the district health system. This pillar is essential to facilitate the monitoring and review of functioning of a health facility and its services. The primary care facility prepares a DHIS report and sends to its supervising authority on a monthly basis. It was found during the end line survey, that in each health facility at least one staff member was trained on DHIS reporting, which was usually the

Figure 22: Record of supervisory visit by District Manager PPHI at BHU Aminani

59 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Paramedical staff only comes when the doctor is there. The health centre is not equipped for emergencies. A FATHER-IN-LAW.

The medicines prescribed are not available in local stores. There is water and electricity but beds and equipment are in poor condition AN INFLUENTIAL PERSON

dispenser. All facilities were sending their monthly reports on a regular basis. Feedback on the DHIS report from the supervisory level was however reported by BHU Aminani only. There were no supervisory visits from the district level to hold a meeting with staff to review the DHIS record at the facility.

4.6.5 Supervision The general supervision of all facilities was found to be carried out regularly by the PPHI staff. The District Support Manager, PPHI visited these facilities on a monthly or bi-monthly basis. Mostly the supervision was documented by signatures of DSM on some registers/documents. However, there was no documentation for feedback, suggestions and appreciation given. No staff meeting was held during these supervisory meetings.

4.6.6 Inspection Inspection of Facility through Observation Overall there was sufficient space available in each facility for provision of services; at least 7 to 10 rooms were present in each facility including stores for medicines and supplies. Waiting areas were available for male and female patients; however the latrines were not separate and were quite unclean, and not in useable condition.

Cleanliness and Overall Condition of the Building

Staff in public hospitals colluded with private ultrasound, x-ray and blood tests labs. They earn commission on diverting patients to the private clinics. AN INFLUENTIAL PERSON

Generally the cleanliness was found to be sub-optimal. The health facilities were littered and unclean. The furniture was unkempt and poor maintenance of the health facility made it look shabby. The best maintained facility in terms of cleanliness and maintenance was the MCH centre of Khudabad. Such improved cleanliness, reflected the success of interventions at this level, however, the BHU level is suggested to adopt similar efforts to maintain cleanliness, and hence ensure better environment for service provision.

Overall status of health facilities in the area The BHU in Aminani was found to be well equipped with beds, water, electricity, and necessary equipment; however, the BHU was not capacitated to deal with delivery related complications and the service hours were limited to 8:30 am to 2 pm. The MCH centre in Khudabad was also fully equipped to deal with complications and was open till late at night, on the other hand DHQ Dadu had no birthing facilities and that is why most people continued to prefer private health facilities. The staff at private health facilities was reported to be cooperative and highly competent. There was no other health centre in the area except for the Khudabad MCH centre which was open 24 hours a day. TBAs were reported to take complicated cases to this centre because of its service hours and enhanced capacity to provide Basic EmONC services. This was reported to save families a distant trip to Dadu city at night. The TBAs indicated that equipment provided by the project team to the health centre in Khudabad was useful, and as a result it was well equipped to deal with childbirth and pregnancy related complications. The TBAs gave mixed reviews on the effectiveness of health facilities. It is believed that these mixed responses were based on different experiences â&#x20AC;&#x201C; some had positive and some had negative experiences. The general belief was that hospitals were now better equipped to deal with complicated maternal cases.

Addressing Delays for Access to EmONC 60 in Non-LHW Areas of Pakistan

The facility in Khudabad had beds, water, and electricity and was in decent condition. In case of electricity failure, there was a back-up generator available. VHCs suggested the presence of an ambulance but the patients had to pay for the fuel costs themselves. It was shared by the VHC members that Project Team also gave PKR 300-400 for transport in case of emergency. Doctors and staff were available at the Khudabad health facility from 9 am to 2 pm. Medicine supplies, however, were reported to be not available at the facility and had to be purchased elsewhere. After new providers were appointed, the environment was considered to have improved. In Kamal Khan, there was no hospital nearby. The staff in public hospitals also operates private clinics, where they apparently sell the medicine that is given to them by the government to medical stores. In an emergency, the healthcare providers at the public hospital tell the family to take the patient to a private hospital. Medical staff at public hospitals is frequently absent, or positions are vacant altogether. The only exception is the BHU in Aminani where personnel were reported to adhere to facility timings. There were no skilled doctors in the Johi hospital, which was the nearest hospital for the villages of Kamal Khan. In Kamal Khan, men claimed the health facilities were poorly equipped and patients werenâ&#x20AC;&#x2122;t treated properly unless they had a reference from an influential community member. Beds were made available to the poor only on the basis of a strong reference (i.e. by local influential people) or by the patient giving financial incentives to the staff. Doctors in Kamal Khan were not punctual and absenteeism was high. The TBAs claimed that the hospitals were distant and poorly equipped. Even basic facilities such as water and electricity were missing. Pregnant women were mostly taken to private hospitals since public hospitals faced shortage of beds, medical equipment and poor staff presence. The private hospitals were well equipped to deal with complications but were expensive. Other issues such as community rivalries sometimes restrict access to health care in which cases villagers go to health centres in Johi. The hospital in Johi was found to be equipped with beds, electricity and water; however hospital staff often asks for non-monetary gifts such as bundle of cotton stems. Furthermore, the health centre in Johi was reported to frequently suffer from power outages which impeded the provision of EmONC services.

Availability of Skilled Paramedical Staff Reviews for availability of skilled paramedical staff were mixed. Some members of the community were satisfied. Staff in selected health facilities was trained as part of the intervention and respondents seemed satisfied with the service quality. Community claimed the staff was well behaved in Khudabad; no complaints of scolding or mistreating patients were recorded. However, they were not trained or equipped to deal with all the complications and referred the difficult cases to bigger hospitals. In Kamal Khan, the paramedical staff at the nearest health facilities was poorly trained, rude and unwilling to help. Most qualitative component respondents suggested they were only treated well if they knew someone in the staff. Women in Kamal Khan claimed the paramedical staff was poorly trained and rude. Some also complained that doctors in public health facilities in Kamal Khan mistreated patients and frequently scolded them. Others were not very satisfied and said they were mistreated at public facilities. Paramedical staff in the Khudabad MCH centre was said to be well-trained, and cooperative; however they did not deal with emergency cases. According to these community respondents trained paramedical staff from public hospitals had their own private practices and was usually available in private hospitals. Other healthcare providers in the hospital had been appointed based on personal contacts and did not provide healthcare. Nurses were said to have very little training or experience. Most people believed that nurses were hired based on personal references. The medical staff was believed to give preference to patients who appeared to be affluent and gave them a much better quality of service. Many women who gave birth in the Khudabad

There was an organisation where we would collect money for a needy hour. But the villagers have stopped giving money. Population wise the village is quite big and there are many such cases every month. The money collected was not enough for all the cases. A COMMUNITY MEMBER

61 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

The doctors give up treatment at the slightest sign of complication AN INFLUENTIAL PERSON

We took a pregnant woman from our family to a hospital. The doctor asked the family to wait as the delivery will take time. Our woman was in severe pain and we didnâ&#x20AC;&#x2122;t have money to go to another doctor. We brought the woman back home and called the midwife, but the child died in the womb A COMMUNITY MEMBER

Government doctors say, come to their private clinic for delivery, in spite of poverty, in emergency we go to their private clinic. A MOTHER IN-LAW.

In public hospital doctors take care of rich people and give them all kinds of facilities. A FATHER IN-LAW

MCH centre, reported that there were no special services. The hospital was ill equipped to deal with emergencies. There were no beds, paramedical staff, medicines, water or electricity. According to some, private hospitals were far better equipped.

Suggestions to Improve/Change Overall Health Service Delivery and Particularly EmONC The community wanted to arrange transport for emergency cases, train the health centre personnel, and keep the centre open for 24 hours. Villagers also wanted to enrol in short courses on maternal and child health so they know about the complications and the need for health care and become self-reliant. Villagers reported to not have transport and it was difficult to take a woman to the hospital especially at night and therefore wanted to be trained in childbirth. They also suggested the need for funds for medical help. Respondents suggested that a focal person from the Thardeep project be provided to help the community upgrade and maintain services and ensure availability of medicines at health centres. Monitoring of health facilities would help improve service quality in health centres. Poor people demanded free medicine and most households suggested the need for an ultrasound machine within the village to avoid travel to city and also to save money. It was opined that more villages required committees similar to those developed by the project. In some villages, the committee was developed; however the people were extremely poor and could not even afford to contribute PKR 10. In such cases, it was perceived that alternative mechanisms such as charity need to be developed and sustained. Funds from the committee or charity were suggested to be used to buy an emergency transport vehicle to facilitate the villagers. Community members in Kamal Khan said they wanted a health facility that offered round the clock EmONC service with ensuring electricity and water supply, availability of beds, and oxygen cylinders so that families would be able to avoid transport costs to distant hospitals. The Focus group respondents were interested in organising a committee where they put in a fixed amount of money every month to help those in need. Such an organisation was initiated before but did not survive long because people were not educated and were unable to realise the benefits of the system.

4.6.7

Summary of Findings

A third component of the intervention attempted to reduce the delays at health facilities and provided some basic medical equipment to public sector health facilities as well as training paramedical staff and TBAs. The operational hours of the MCH centre were extended from 2 pm to 8 pm. The time taken to be seen at health facility in Khudabad reduced considerably with almost 75% of the women seen within half an hour at end line compared to 47% at base line. Interventions such as provision of medical equipment and training could have improved service delivery thus resulting in lower waiting times. However, the qualitative findings repeatedly revealed high absenteeism, vacancies of key paramedical staff and unpleasant staff attitudes, especially towards the poor, as a major deterrent to institutional births. Community members frequently complained of poor treatment, being yelled at or scolded or being asked for a reference before they were treated adequately. The project however had little control over these problems. Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. It was found that use of vehicle arranged through VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery.

Addressing Delays for Access to EmONC 62 in Non-LHW Areas of Pakistan

4.7

Predictors of Facility Based Deliveries

Binary logistic regression analysis was conducted to ascertain the predictors of having the delivery conducted at a health facility. The multivariate logistic regression modelling was simultaneously tested for goodness of fit (i.e. robustness of the developed multivariate model) to ascertain the best statistical model for identifying predictors of having a facility based delivery during the current pregnancy (Table 48). It was found that use of vehicle arranged through VHC for transport to a health facility at the time of delivery, having history of adverse pregnancy outcome of an abortion/stillbirth in the last pregnancy, and current pregnancy being screened and identified as a high risk pregnancy predicted the occurrence of a facility based delivery. These predictors were statistically significant when adjusted for 1. Use of folic acid during the current pregnancy (indicator for better health practices during pregnancy and as a result of antenatal care use), 2. Received TT vaccine (indicator for use of ANC from health facility), 3. Number of living children (indicator for reproductive health burden of a respondent) 4. Last delivery through Caesarean Section (indicator for high risk during current pregnancy) Table 48: Predictors of Having Facility Based Deliveries – Program Data Sig.

Adj OR*

95% C.I. for EXP(B) Lower

Upper

Vehicle Used for Delivery at facility - Yes

0.00

41.34

9.27

184.35

Used Folic Acid during current Pregnancy – Yes

0.22

1.85

0.69

4.96

Received TT vaccine current pregnancy – Yes

0.85

0.90

0.32

2.54

Abortion/Stillbirth in last pregnancy - Yes

0.01

0.22

0.65

.729

Number of living children

0.46

.92

.74

1.14

Last delivery through C Section - Yes

0.48

.36

.02

5.9

Current Pregnancy High Risk – Yes

0.03

3.54

1.10

11.34

* Adj OR = Adjusted Odds Ratio

The follow-up data hence reflects that those who had used a vehicle arranged by VHC for transport to a health facility at the time of delivery were 41 times more likely to have delivered on a facility as compared to those who did not utilise such a transport service. Furthermore, those who had history of abortion/stillbirth during the past pregnancy were almost five times (Adjusted OR=0.22) less likely to deliver at a health facility for the current pregnancy. In this regard, those who were identified to have a higher risk of adverse pregnancy related complications were 3.54 times more likely to deliver at a health facility. The developed multivariate regression model was tested for goodness of fit. This fitness test reflected a very good fit (χ2 goodness of fit p-value <0.97), thus endorsing the robustness of prediction model. These predictors help us understand that the use of vehicle arranged by VHC at the time of delivery reflects the effectiveness of this intervention in enhancing institutional deliveries. The finding can thus support the conclusion that the transport availability through VHCs is proven to be an effective intervention and successfully enhances the facility based birthing (and concomitantly through skilled birth attendants) becoming more prevalent in the intervention areas. The high value of Odds Ratio of 41 and a wide 95% Confidence Interval (9.3 – 184.4), needs to be understood in the context of relatively smaller number of

63 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

cases using vehicular transport from VHC during the follow-up period. Hence given the broad confidence interval with simultaneous statistically significant result for adjusted odds ratio, also portray that despite small numbers of VHC vehicle service users, the intervention has a profound effect on improving institutional births in served populations. Those who were screened through antenatal care and identified to be at high risk of pregnancy and/or delivery related complications were found to be 3.54 times more likely to have an institutional delivery. The result supports the notion, that through the programmatic interventions antenatal screening was effective in identifying high risk pregnancies, and those once identified to be at high risk of complication, were more likely to have institutional deliveries and through skilled care providers. It is important to highlight here, that non-LHW covered areas where community based screening is not conducted through community based arm of the health system, the project needs to be commended for enhancing antenatal care at the facility level. This hence resulted in skilled care use at the time of delivery. Concomitantly the covariate of adverse pregnancy outcome during the last pregnancy (i.e. abortion or stillbirth) leading to less predisposition to have a facility based pregnancy (Adj OR = 0.22) seems to be a biologically non-plausible finding. However, it should be understood that despite having adverse perinatal outcomes in the past there is still possibility that women do not seek institutional deliveries in the served communities. This finding needs to be viewed from a health systems perspective, where history of adverse pregnancy outcome needs to be used for classifying women at high risk of pregnancy/delivery complication. Such cases need to be focused more through programs to enhance skilled birth attendance and institutional deliveries.

Addressing Delays for Access to EmONC 64 in Non-LHW Areas of Pakistan

65 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

5. Summary, Discussion and Conclusions The reducing delays in seeking EmONC services was a multi-dimensional intervention project that adopted a diverse set of methods to understand, improve and demonstrate the effect of various interventions at the community and FLCF levels to reduce the three delays in seeking Emergency Obstetric and neonatal care in rural settings of Sindh province. The project introduced interventions of 1. Community Resource Persons (CRPs) in both men and women segments of the population. 2. Community organization at the village level to formulate Village Health Committees, that played a role to improve the maternal and neonatal health outcomes 3. Establishment and regulation of a community based emergency transport mechanism to reduce the second delay in accessing EmONC care 4. Use of financial support mechanisms to reduce both second and third delay in seeking EmONC care 5. Employing diverse approaches to enhance awareness and knowledge among men and women on various aspects of MNCH through the use but not limited to IEC materials, counselling and group meeting sessions 6. Supporting the staff and facilities through provision of materials and capacity building at the facility level 7. Supplementing referral mechanisms for reducing second and third delays for seeking EmONC services

5.1 KEY FINDINGS The project was able to demonstrate the effect of various interventions to successfully reduce the 3 delays of seeking and utilising EmONC care at the community and facility level through involvement of CRPs and establishing effective referral systems supported through financial and transport means and executed with the support of Village Health committees.

5.1.1

Birth Outcomes

Birth outcomes improved during the course of the project as assessed through birth audit, end-line survey and programmatic per-post intervention data. It was found that the incidence of adverse pregnancy outcomes reduced in the intervention areas. This was correlated with an enhancement in institutional deliveries and conducted by higher proportion of skilled birth attendants (Trained TBAs, Doctors and LHVs) as compared to the baseline. As narrated by the qualitative participants, support through VHCs (financial and transport) facilitated them to seek timely care through timely referrals and availability of services at the nearest health facility. Similar improvements have been documented in Pakistan through intervention projects that focused to improve referral systems through better community based linkages and by increasing awareness and knowledge among married women of reproductive ages, and supplementing the skills of TBAs through capacity building44

5.1.2

Facility Based Births

Promoting institutional deliveries is empirically known to reduce maternal and neonatal mortality in developing country settings across the globe and in South Asia including Pakistan45, 46. To produce an impact on the maternal and neonatal mortality in this manner, the demonstrated behaviour change model of knowledge attitudes and practices was adopted in this intervention project. Through improving knowledge

Addressing Delays for Access to EmONC 66 in Non-LHW Areas of Pakistan

among women and their husbands, by employing community resource persons (trusted local residents who could easily access potential beneficiaries easily) to change attitudes through positive deviance methods (promoting birth preparedness and ability to identify complications) and using simple but effective approaches of timely referral and provision of financial and transport support; the project was successfully able to enhance institutional births attended by skilled birth attendants. The findings as demonstrated through multivariate regression revealed that transportation at the time of delivery (once complication is identified) significantly enhances facility based deliveries. This is thus anticipated to reduce maternal and perinatal disease burden and mortality in the project areas.

5.1.3

Antenatal Care

Antenatal care is empirically known to improve the maternal health indicators among women in Pakistan. It is also known to reduce adverse pregnancy outcomes and result in higher proportion of normal weight births with lesser impact on the health of women47 through counselling, iron-folate supplementation and on-going/regular screening for danger signs of complications.48 ,49 Through the project interventions of male and female CRPs and their roles in enhancing knowledge and awareness at the community level, reflected to be the major contributors for enhancing antenatal care among pregnant women in the intervention areas. The project was able to demonstrate enhancement in knowledge levels among both men and men, enhanced capacity to identify pregnancy related complications at the household level, improved referrals for antenatal care, increase uptake of ANC through skilled providers and financial support were the key variables in improving the antenatal care adoption in intervention areas of Dadu. These results as achieved through the innovative techniques of having separate CRPs (male and females) were able to demonstrate that if men (who are decision makers for healthcare seeking and utilisation at the household level and often neglected in intervention projects) have better knowledge about maternal health aspects can result in improved uptake of antenatal care in rural and resource constrained settings of the Sindh province.

5.1.4

Postnatal and Neonatal Care

Similar to the pattern observed for natal and prenatal care, the project was able to demonstrate improvements in awareness about postnatal care, capacity to identify postpartum complications (e.g. PPH) and having immediate support at the community level through community based VHCs can effectively enhance the uptake of postnatal care in rural settings. Given the low prevalence of formal schooling in the targeted communities (especially among females), the project was able to demonstrate the importance of context specific and culturally acceptable interventions of CRPs, with males educating and facilitating male counterparts and females supported through women CRPs. It is understood, that if such pilots are replicated at scale, they may greatly contribute towards increasing the uptake of postnatal and neonatal care (especially during emergency situations) and hence contribute in reducing the maternal and perinatal disease burden. Such successful interventions if taken to scale through implementation research initiatives and development of scale-up plans to help the country to achieve its Millennium Development Goals 4 & 5.

5.1.5

Role of Community Resource Persons and VHCs in Reducing the Three Delays

Use of CRPs and Village Health Committees, especially the gender-sensitive approach adopted in this project, clearly demonstrates the positive effect on knowledge, attitudes, behaviours and practices related to MNCH in the intervention areas of the project. Employing such local resources has been demonstrated

67 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

to be highly effective in improving maternal and child health outcomes in the country and specially Sindh (e.g. MARVI workers project by HANDS). This is all the more important in areas where there is a dearth of community based service providers such as LHWs and Community Midwives. Community Resource Persons and Village Health Committees have been employed in the past for various post-disaster relief activities and WASH programmes in the country in recent times. Their involvement at the community level for improving MNCH services utilisation, especially for the poor and marginalised segments of the populations reflects an excellent and implementable model for improving key maternal and child health indicators through reducing the three delays in seeking EmONC care in rural settings of the country.

5.2 LIMITATIONS It is understood that despite several strengths the project also had some limitations. These pertained to the following aspects 1. Lack of programmatic data (enrolment and follow-up of pregnant women) in non-intervention areas may have limited the capacity to ascertain the natural reduction in the 3 delays and how much was actually possibly attributable to the programmatic interventions. This is however, understood to have less impact, given that base line and end line surveys in both intervention and non-intervention areas somewhat reduced the inability of the project to relate the effect of interventions in Khudabad as compared to Kamal khan areas. 2. The unavailability of the duration of gestation at the time of enrolment during pregnancy (i.e. duration of exposure to interventions) may possibly have resulted in lack of adequate adjustment in regression analysis and inability to use Cox regression methods to acquire adjusted measures of association to gauge the true effect of project interventions. This however, is understood to have led to nondifferential misclassification of information given that a pre-post intervention design (in the absence of time duration of exposure) may still be used to accurately assess the predictors of favourable health practices (i.e. outcome of interest of institutional births/skilled attendant) through odds ratios. 3. Loss to follow-up was small for the programmatic data, with birth outcomes elicited for 91.3% of the enrolled and followed women and their respective neonates. This loss to follow-up is however assumed to result in lesser impact on the assessment of outcomes, given that there was no systematic loss to follow-up. Such lack of systematic loss to follow up is hence understood to have less impact on the project results through information bias, given that follow-up studies of relatively small durations (e.g. 12 months) may at times have more than one third (33%) loss to follow-up; while the present study only had 8.7% loss to follow-up. 4. Finding educated female CRPs. In order to include the most marginalised groups, all populations in the UC were targeted. In areas where literacy levels are low, finding literate CRP selection was a challenge and sometimes the eligibility criteria of education was intentionally lowered to facilitate the most marginalised clusters. 5. Creating the VHC fund was one of the most difficult tasks. The project team worked hard to open an account in local bank branches; however the banks were strongly hesitant to open an account for the community. The process was tedious and frustrating at best. The programme was finally able to find a solution â&#x20AC;&#x201C; accounts were opened in the local post office rather than a bank - and the VHC fund was operational in the sixth month of the programme; effectively reducing its functional period from 12 months to 6. 6. Availing VHC funds was sometimes difficult due to unavailability of cash on hand. If cash was not available at the time of need, the money had to be retrieved from the account after an emergency for

Addressing Delays for Access to EmONC 68 in Non-LHW Areas of Pakistan

childbirth was proclaimed. The process was time-consuming and often inconvenient. Although this was partially overcome by reimbursing expenses after the fact, it still meant that families had to seek funds in the face of an emergency and often had to rely on loans as they had done so prior to this intervention. 7. The last intervention involved ensuring that hospitals where women were referred are equipped with staff and medical equipment. While the project successfully trained TBAs and provided some basic equipment to public health facilities the outcome variables such as provision of health care by public facilities were still beyond the projectâ&#x20AC;&#x2122;s control. 8. In retrospect, UC Kamal Khan was a poor control for comparison. Although demographic characteristics for the two UCs (Khudabad and Kamal Khan) were similar; however, floods in Kamal Khan in 2010 had brought considerable relief work and interventions to the UC and these interventions were continuing while our intervention was underway, thus changing indicators in Kamal Khan on a regular basis and making it a poor control. 9. The MCH centre had the highest clientele. These were converted into 24/7 facilities. Frequent turnover of staff at the MCH centre affected referrals negatively. This meant the new staff had to be recruited and trained â&#x20AC;&#x201C; an exercise repeated several times during the intervention. FMOs were also not available for several months. 10. The main sample at base line to draw attitudes and practices included women who have given birth in the past 3 years. Women who had given birth in the past 1 year were only a small secondary part of the sample. To maintain consistency at end line, a similar approach was adopted. However, for the purpose of end line evaluation changes in practices can only be measured for women who had given birth in the past one year (when the interventions were implemented). Therefore the primary sample for the purpose of evaluation should have been women who had given birth in the past year.

5.3 LESSONS LEARNED Several lessons have been learned during the course of this research regarding the projectâ&#x20AC;&#x2122;s implementation, working with the community and challenges in making such interventions more effective. The interventions to create and raise awareness were commendable. Surveys show the active role of CRPs in the community and high rates of coverage. IEC materials were helpful in emphasising critical health seeking situations. The intervention was tailored to the target communities and focused on both men and women to improve information sets. In addition, some further lessons are listed below: 1. The utilisation of VHC funds needs to be addressed through improved access and reducing difficulty in availing the funds. Currently the process of retrieving funds was difficult. It required prior consent of the project staff (done to build accountability of VHC members). This was done in reaction to an incident that happened in one community; where the VHC member retrieved and kept all funds from the account. To discourage this practice and potential misuse of funds; the project team decided to restrict open access to funds by VHC members. Effectively this limited the availability of funds during off hours and emergencies. Households bore the costs first and then claimed reimbursements; which meant that they still had to seek funds and incurred delays. 2. The project worked closely with government partners, however little progress seems to have been made in terms of accountability mechanisms in public hospitals and reduced waiting times. High rates of turnover in public health sector (including 5 new EDOs health, and 3 changes in woman medical officers in 12 months) impeded the effectiveness of the intervention to reduce third delay. Providing training and medical equipment alone will not ensure quality of services in public health facilities.

69 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

3. The project was successful in increasing knowledge and in bringing behavioural changes that did not involve significant cost implications, such as ANC visits, maternal and child immunisation, and exclusive breastfeeding. However other behaviours such as preferring facility based births, and going for PNC visits may need more time and positive reinforcement as they have both cost and social implications. 4. At least among some households, social norms favour many children while a lower premium is placed on the health and lives of the mothers and these children. This not only promotes large families but less attention is also paid to each individual family memberâ&#x20AC;&#x2122;s health and wellbeing. It may be useful to understand who among the communities would be less amenable to messages; reach the more amenable ones with conventional interventions but also seek to understand what may be done to reach others. 5. The project duration was too short to bring significant changes in behaviour, particularly since a significant amount of project time was spent in organising and establishing the interventions which left little time for project operations. While creating awareness requires less time; changing behaviours is a tedious and long term process. In order to change behaviours, the community must be able to realise the tangible and intangible gains of new practices and behaviours. Furthermore, positive reinforcements are required for sustained change of behaviours. Economic improvements also play a significant role in this process. Behavioural changes that have financial and economic implications are even harder to achieve in low income communities such as in UC Khudabad. 6. Economic conditions of the selected UC were poor, and hence facility births were not affordable for most. Given these economics realities, most people prefer home based births; even when they realise facility based births are safer. This poor purchasing power in the community also has profound effects on the availability and quality of services and effectiveness of interventions, resulting in little change in birth places across UC Khudabad. Currently, as a result of the interventions, the shift in birthing place from home to public facilities was due to interventions that trained staff, provided equipment and operationalised these facilities to work in 2 rather than one shift (from 8 am to 8 pm, rather than only until 2 pm).

5.4 RECOMMENDATIONS On the basis of research project findings, the following set of policy recommendations are put forward: 1. As more than 42% of Pakistanâ&#x20AC;&#x2122;s rural population is not covered by the LHW programme; the CRP model can be considered a potential solution for providing healthcare in non-covered areas, if it is scaled up. Currently the federal and provincial governments are facing technical, human and financial resource constraints for investing in the LHW program and expanding it further into non-covered areas. In this context, the federal and provincial governments; as well as donors can adopt the CRP model as a low cost alternate to the LHWs in the un-covered areas till the government is able to deploy LHWs in these areas. CRPs can be trained to be an effective, community based solution for providing information and referrals to rural, non-covered areas. 2. The CRP programme to work in non-covered areas should have community mobilisation as an integral component. This may take the form of the VHCs, support groups or Community Organisations. The evidence from this research project has demonstrated that active community institutions are essential to ensure community ownership and support mechanism for CRPs to address social and cultural barriers at the local level. Moreover, these community institutions should engage with district health management to initiate the process of local accountability for improving health results. 3. Identification of high risk pregnancy was a predictor for facility based deliveries. This finding endorses the importance of antenatal care in promoting facility based deliveries. This result also helps us to

Addressing Delays for Access to EmONC 70 in Non-LHW Areas of Pakistan

recommend that whatever the mechanism may be (i.e. risk identification during pregnancy and through LHWs/CRPs/TBAs or other approaches), the public sector possibly in partnership with the private sector should work to provide universal coverage for screening of women during pregnancy. 4. The role of VHC as a predictor of facility based delivery provides evidence for the value of the community based support systems and health financing mechanism for emergency transport services. To gain better results, the community should have an effective role in designing and implementing financing schemes with a focus on poorest of the poor, as well as on local resource mobilisation. 5. TBAs play an important role in referring complicated cases to health facilities and promoting institutional deliveries. Being key local stakeholders, TBAs should be formally included in the health programmes, trained and provided regular supportive supervision to ensure positive results. 6. Properly equipped and functional health facilities play instrumental role in meeting the demand for quality services. Keeping in view the nature of MNCH issues, difficulties in access and rural poverty, the health facilities located in rural areas should be made functional round the clock. 7. The evidence from the research project indicates that frequent transfers of the healthcare providers leads to sub-optimal results. A policy framework should be devised to minimise transfers.

71 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

6. References 1

National Institute of Population Studies P, Measure DHS. Pakistan Demographic and Health Survey 2006-7. 2008.

Ref Type: Report 2. National Institute of Population Studies P, Measure DHS. Pakistan Demographic and Health Survey 2006-7. 2008.

Ref Type: Report

3. Alam AY, Nishtar S, Amjad S, Bile KM. Impact of wealth status on health outcomes in Pakistan. East Mediterr Health J 2010;16 Suppl:S152-S158. 4. Lawn JE, Zupan J, Begkoyian G, Knippenberg R. Newborn Survival. 2006. 5. Banerjee AV, Duflo E. The Economic Lives of the Poor. J Econ Perspect 2007;21:141-167. 6. Banerjee A, Deaton A, Duflo E. HEALTH, HEALTH CARE, AND ECONOMIC DEVELOPMENT: Wealth, Health, and Health Services in Rural Rajasthan. Am Econ Rev 2004;94:326-330. 7. De B, V, Tonglet R, Van LW. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West? Trop Med Int Health 1998;3:771-782. 8. Nour NM. An introduction to maternal mortality. Rev Obstet Gynecol 2008;1:77-81. 9. Nour NM. An Introduction to Global Womenâ&#x20AC;&#x2122;s Health. Rev Obstet Gynecol 2008;1:33-37. 10. Khan S. Briefing Paper: Gender Inequality, Social Exclusion and Maternal and Newborn Health. 2010. The Research and Advocacy Fund. Ref Type: Report 11. Bhutta ZA, Chopra M, Axelson H et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 2010;375:2032-2044. 12. Noor NM. An Introduction to Maternal Mortality. Rev Obstet Gynecol 2008;1:77-81. 13. Turab A, Ariff S, Habib MA et al. Improved accessibility of emergency obstetrics and newborn care (EmONC) services for maternal and newborn health: a community based project. BMC Pregnancy Childbirth 2013;13:136. 14 Morelli R, Missoni E. Training TBAs in Nicaragua. World Health Forum 1986;7:144-149. (15) Alisjahbana A, Peeters R, Meheus A. TBAs can identify mothers and infants at risk. World Health Forum 1986;7:240-242. (16) Namboze JM. Maternal Health Services. In: Sofoluwe GO, Bennett FJ, eds. Principles and practice of community health in Africa. Ibadan: University Press; 1985;323-333. 17 Wilson A, Hillman S, Rosato M et al. A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries. Int J Gynaecol Obstet 2013;122:192-201. 18 Hussein J, Kanguru L, Astin M, Munjanja S. What kinds of policy and programmeme interventions contribute to reductions in maternal mortality? The effectiveness of primary level referral systems for emergency maternity care in developing countries. A systematic review. 2011. EPPI Centre. Ref Type: Report 19 Greenwood BM, Bradley AK, Byass P et al. Evaluation of a primary health care programmeme in The

Addressing Delays for Access to EmONC 72 in Non-LHW Areas of Pakistan

Gambia. II. Its impact on mortality and morbidity in young children. J Trop Med Hyg 1990;93:87-97. 20. Greenwood AM, Bradley AK, Byass P et al. Evaluation of a primary health care programmeme in The Gambia. I. The impact of trained traditional birth attendants on the outcome of pregnancy. J Trop Med Hyg 1990;93:58-66. 21. Rosenfield A, Maine D, Freedman L. Meeting MDG-5: an impossible dream? Lancet 2006;368:11331135. 22. Maine D, Rosenfield A. The Safe Motherhood Initiative: why has it stalled? Am J Public Health 1999;89:480-482. 23. Maine D, Rosenfield A, McCarthy J, Kamara A, Kucas AO. Safe Motherhood Programmes: Options and Issues. New York, NY, USA.: Columbia University Press, 1991. 24. Fauveau V, Chakraborty J. Women’s health and maternity care in Matlab. In Matlab, women, children and health. In: Fauveau V, ed. Dhaka: ICDDR’B; 1994;109-138. 25. Filippi V, Ronsmans C, Campbell OM et al. Maternal health in poor countries: the broader context and a call for action. Lancet 2006;368:1535-1541. 26. Koblinsky MA, Tinker A, Daly P. Programmeming for safe motherhood: a guide to action. Health Policy Plan 1994;9:252-266. 27. Turmen T, AbouZahr C. Safe motherhood. Int J Gynaecol Obstet 1994;46:145-153. 28. Rutstein SO. The DHS Wealth Index: Approaches for Rural and Urban Areas. 2008. USAID. Ref Type: Report 29. Rutstein SO, Johnson K. The DHS Wealth Index. 2004. Measure DHS. Ref Type: Report 30. Graneheim UH, Lundman B. Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Educ Today 2004;24:105-112. 31. Darmstadt G. Can Changing Behaviour Save Newborn Lives? http://www.healthynewbornnetwork. org/blog/can-changing-behavior-save-newborn-lives. 2013. Ref Type: Report 32. Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Soc Sci Med 1998;46:981-993. 33. Goldie SJ, Sweet S, Carvalho N, Natchu UC, Hu D. Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. PLoS Med 2010;7:e1000264. 34. Goldenberg RL, McClure EM. Maternal mortality. Am J Obstet Gynecol 2011;205:293-295. 35. Barros AJ, Ronsmans C, Axelson H et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012;379:12251233. 36. Goldenberg RL, McClure EM. Disparities in interventions for child and maternal mortality. Lancet 2012;379:1178-1180. 37. Knight HE, Self A, Kennedy SH. Why are women dying when they reach hospital on time? A systematic review of the ‘third delay’. PLoS ONE 2013;8:e63846.

73 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

38. Pandey P, Sehgal AR, Riboud M, Levine D, Goyal M. Informing resource-poor populations and the delivery of entitled health and social services in rural India: a cluster randomised controlled trial. JAMA 2007;298:1867-1875. 39. Chowdhury N. Safety lessons from Matlab, Bangladesh. Plan Parent Chall 1998;28-29. 40. Koenig MA, Roy NC, McElrath T, Shahidullah M, Wojtyniak B. Duration of protective immunity conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh. Am J Public Health 1998;88:903-907. 41. DeGraff DS, Phillips JF, Simmons R, Chakraborty J. Integrating health services into an MCH-FP programme in Matlab, Bangladesh: an analytical update. Stud Fam Plann 1986;17:228-234. 42. Yunus M, Sohel N, Hore SK, Rahman M. Arsenic exposure and adverse health effects: a review of recent findings from arsenic and health studies in Matlab, Bangladesh. Kaohsiung J Med Sci 2011;27:371376. 43. Ronsman C, Vanneste AM, Chakraborty J, Ginnelen JV. A Comparison of Three Verbal Autopsy Methods To Ascertain Levels and Causes of Maternal Deaths in Matlab, Bangladesh. International Journal of Epidemiology 1998;27:660-666. 44. Jokhio, A. H., H. R. Winter, et al. (2005). “An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan.” New England Journal of Medicine 352(20): 2091-2099. 45.

Janjua, N. Z., E. Delzell, et al. (2008). “Determinants of low birth weight in urban Pakistan.” Public Health Nutrition 12 (6): 789 - 798

46. Jehan, I., H. Harris, et al. (2009). “Neonatal mortality, risk factors and causes: a prospective populationbased cohort study in urban Pakistan.” Bulletin of World Health Organization 87: 130 47. Agha, S. and T. W. Carton (2011). “Determinants of Institutional delivery in rural Jhang, Pakistan.” International Journal of Equity Health 10: 31-42. 48. Khan, A. (1999). “Mobility of Women and Access to Health and Family Planning Services in Pakistan.” Reproductive Health Matters 7(14): 40-48. 49. Ashraf, T. (1996). “Maternal mortality: A four-year review.” Journal of the College of Physician and Surgeon Pakistan 6: 159-162.

Addressing Delays for Access to EmONC 74 in Non-LHW Areas of Pakistan

7. Appendices 7.1 Map of district Dadu

75 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

CONSENT FORM

7.2 WOMENâ&#x20AC;&#x2122;S QUESTIONNAIRE (QUANTITATIVE SURVEY)

Project Information Research Title: Research on Removing Three Delays for improving Access to Emergency Obstetric and Neonatal Care in Non-LHW areas of Pakistan.

Project Number:-N/A

ERC Ref No:

Grant: RAF

Principal Investigation: Mr. Bashir Anjum

Organization: Rural Support Programmes Network

Location: Islamabad

Phone:051-2822476

Invitation to Participate:

. . . . Purpose of the Study .1

: (Three Delays) . .

Procedures and Process of the Research Study .2 30 20 . . . .

Possible Risks and Discomforts .3

‫‪Addressing Delays for Access to EmONC 76‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫‪Confidentiality .a‬‬

‫رازداري‪:‬‬

‫ا ن ﺌ و ا ﺐ آ ﺌن ڏ‪ ‬ﺌت ڏ ﺌ ‪ ،‬ا ﺌن وٽ ان ي ڻ ‬ ‫ ﺌ ا ﺌ د آ ‪ ¥ .‬ال ۽ اب ﮗ ﮘ ﺌ و ا ۽ ﺐ ﺌ ا و و ڙ ﺌن وه ﺐ د و‪،‬‬ ‫ ي ﺌن ڏ‪ ‬ﺌت ¨ﺌﮡ ﺑ ‪ .‬ا و ڏ ﮙ ﺌ‪ °‬ڊ ڏ‪ ‬ﺌت ﮗ ﮘ ® ظ ي‪« ،‬ﺌ ‪ ª‬ف ۽‬ ‫‪ ª‬ف ®´ ´ ‪ ² ³‬ڏ ‪.‬‬ ‫‪Interview .b‬‬ ‫ا و ‪· /‬ﺌ ﮗﺌ¶ﺌ ‪:‬‬ ‫ا و ﺌن ﺌن ﺌ ي ´¸ﺌن و ا ‪ 20‬ﺌن ‪ 30‬۾ « ‪ ‬و‪ .‬ا و ﺌدي ﺌ»‪ º‬ر ﺌرڊ و و ۽ ﺐ ۾ ‬ ‫ ﺌت ‪ ´ ³ °‬ﺋ و ي‪.‬‬

‫ « ﺌﺊ ا‪:‬‬

‫‪Possible Benefits .4‬‬ ‫ ﺌن ®´ ‪ Ã‬۾ ‪ Â‬ﮙ ‪Á‬و ﺋ ن ﺐ ﺌﺊ و و‪ ،‬وي ﺌ ﺌ ﺌﺊ ن ۽ ن ‪À‬ﺌول ﺌرن ﺐ ﺌر ¿ﺌل ¾ ور ‬ ‫ ‪ É Ê ®ª‬ح ﮙ « ‪ Ç‬ﺌ‪ Å Æ‬ن ۽ و ام ڙڻ ۾ د ڏ ا‪.‬‬ ‫‪Financial Consideration .5‬‬ ‫ ﺌ‪ Æ‬ﺌو¾ ‪:‬‬ ‫ ®´ ´ ۾ ¸ و ﮙ ﺌن ﺐ ﺌ‪ Æ‬ﺌو¾ و‪ ،‬وي ﺌن ۽ ﺌن ‪Ì‬ﺌ ﺐ ج ‪ Æ‬‬ ‫ ﺌ‪ Å Æ‬ن ڙڻ ۾ ا ‪ ²‬دار ادا و‪.‬‬ ‫‪Treatment Alternatives .6‬‬

‫ ج ‪ ²‬ا‪Æ‬ﺑ ل ‪:‬‬

‫ ®´ ‪ Ã‬ﺌن وا ﺌ ‪.‬‬ ‫‪ Available Treatment Options for Adverse Events .7‬ﺌ ﺌ‪ Æ‬۾ د ج ن ‪ Æ‬ن ‪:‬‬ ‫ ®´ ‪ Ã‬ﺌن وا ﺌ ‪.‬‬ ‫‪Termination of this Research Study & Voluntary Participation .8‬‬

‫ ®´ ‪ Ã‬ا ﺌم ۽ ر¾ﺌ ﺌرا ‪:Ç Æ Â‬‬

‫ا ن ﺌ ﺌﮡ ﺌص ﺌرﮡ ‪ /‬ﺑﺑ ي ®´ ´ ۾ ¸ و ا آ ‪ ،‬ان ي ﺌن ﺐ ®´ ‪ Ã‬۾ ¸ و ﮙ ﺌ ‬ ‫و ﮙ آزاد آ ‪ Ï« .‬ﺌن ¸ و ﺌ ﺐ و‪ ÇÎ‬ا و ‪ ²‬ي ﺌ‪ Ï« .‬ﺌن ®´ ‪ Ã‬۾ ¸ ‪Ð‬ﺌ و ﺌ ا و ‬ ‫ﺐ و‪ ² ÇÎ‬ﺌ ان ¸ ﺌن ﺌن ‪ Ç®ª‬ﺌ ‪ ،‬ا ﺌن ۽ ادارن ﺌن د ‪ Ã‬ﺐ ا‪ Ñ‬و و‪.‬‬ ‫‪ Available Sources of Information & Questions .9‬ﺌت ۽ ·ﺌ ﮗﺌ¶ﺌ د ذر ﺌ‪:‬‬ ‫ ®´ ‪ Ã‬۽ را¾ ﺌ ﺐ ‪ É‬ر ﮙ ﺌن ‪Ï‬ي ‪ ‬ﺐ ‪ Ô‬ڏ‪ ‬ﺌﮡ نﮭ ﺌن ﺌﺐ ﺌت ﺌ‪ ª‬ي ﺌ‪.‬‬

‫ﺌ‪ : Æ‬ﺐ‪ Ö‬ا ‪ª ²‬ﺌ ﺎ‬ ‫راﺐ ‪051-2822476:‬‬

‫ ﺌ ‪ ª‬ر ®ﺌل‪:‬‬

‫‪Emergency .10‬‬ ‫ ®´ ‪ Ã‬دوران «‪ Ï‬ﺌن ﺐ ز ‪ ²‬ﺌ « ‪ Ù‬ا‪ Ø‬ﺌن ‪ Ç®ª‬ن ¾ ور ن ‪ SDAR‬ﺌ ان ﺌ زم ر ن ا‪ .‬وڌ ‪،‬‬ ‫ «‪ Ï‬ا ﺌن ا م ®´ ‪ Ã‬دوران ﺌن ۽ ﺌ ﺐ ‪«Â‬ﺌر آ ا ﺌن ا ن و ﺌرش ا ‬ ‫ « ﺌن ‪ Ü‬۾ ا ﺋ ﺌن ‪ Ç‬د ﺌ‪ ª‬ي ‪.‬‬ ‫‪Authorization (VERBAL) .11‬‬ ‫ا ﺌزت )زﺐﺌ (‪:‬‬ ‫ ن ﺌرم آ ۽ ¸ آ آﺊ ن ®´ ‪ Ã‬۾ ر¾ﺌ ﺌرا ‪ É‬ر ¸ و س‪ ،‬ان ﺌ ´¸ ‪´ É ،‬ﺌ ۽ « ن ۽ ﺌﺊ ن ﺐﺌﺐ‪ ß Ç‬‬ ‫آ ﺌ ڏ وﺊ آ ‪ .‬ن ﺌرم ´‪ ‬ﺐ ﺌ‪ ª‬ﺋ آ ۽ ﺌرم ۾ د اد ‪À ß‬ﺌڻ ﮙ آ ‪ .‬آﺊ ن ﺌن را¾ ﺌ ‬ ‫ ده و ﺌ‪ ª ، Î‬ﺐﺌﺊ ۽ ´ﺌ ‪Î‬ﺌ ﺑ ‪ ‬و‪.‬‬ ‫_____________________‬

‫_________________‬

‫را¾‪ °‬ڏ ‪ß‬ﺌر ڙ ‪Ê ®ª‬‬

‫ ن‪:‬‬

‫ «‪ Ï‬ﮗﺌ ‪ ‬ﺌﮡ ن را¾ ﺌ ‪ Ð Ê ®ª‬ي ‪ ،‬ا و و ڙ زﺐﺌ را¾ ﺌ و ﮙ ¸ ‪ Ã‬و‪.‬‬ ‫‪2‬‬

77 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Women’s Questionnaire (Quantitative Survey)

‫ﻋورﺘن ﻻ ِء ﺴواﻟﻨﺎﻤو‬

(Quantitative Survey)

To be filled for women who have had a pregnancy during the last 3 years

.‫ان ﻋورت ﺠو ﭝﺮﻴو وﻴﻨدو ﺠﻨﮭن ﮑﻲ ﮕذرﻴل ن ﺴﺎﻟن ۾ ﺤﻤل ﭥﻴو ھﺠﻲ‬ Section 1: Household and Basic Information:

: Household and Basic Information ‫ ﮕﮭﺮ ﺠﻲ ﺒﻨﻴﺎدي ﻤﻌﻠوﻤﺎت‬01:‫ﺴﻴ ﺸن‬ 1.

10.

Union council

‫ﻴوﻨﻴن ﺎﺌوﻨﺴل‬

District

‫ﻀﻠﻌو‬

Taluka

‫ﺘﻌﻠﻘو‬

Household No.

‫ﮕﮭﺮ ﺠو ﻨﻤﺒﺮ‬

Village

‫ﮙوٺ‬

Household address

‫ﮕﮭﺮ ﺠو ﭙﺘو‬

Caste

‫ذات‬

Religion:

‫ﻤذھب‬

Name of Head of Household

‫ﮕﮭﺮ ﺠﻲ ﺴﺮﺒﺮاھﻪ ﺠو ﻨﺎﻟو‬

Languages spoken in this household

‫ﮕﮭﺮ ۾ ﮙﺎﻟﮭﺎﺌﻴﻨدڙ ﭕوﻟﻴون‬

Sindhi

Balochi

‫ﺴﻨڌي‬ ‫ﺒﻠوﭽﻲ‬ ‫ا ردو‬

Urdu

Other (specify)

Interviewer visits

11.

‫ﻨدڙ ﺠﺎ دورا‬ ‫اﻨﺮوﻴو‬

Visit

‫دورو‬

(‫ﺎ ﭕﺌﻲ )ﻟﮑو‬

Name of Interviewer

‫ﻨدڙ ﺠو ﻨﺎﻟو‬ ‫اﻨﺮوﻴو‬

Date

12. Start time

‫ﺸﺮوع ﺠو‬ ‫ﺘﺎرﻴﺦ‬ ‫وﻗت‬

13.

14.

End time

Response

‫اﺨﺘﺘﺎم ﺠو‬ ‫وﻗت‬

‫ﺠواب‬

‫ﭙﮭﺮﻴون‬ ‫ﭕﻴو‬ ‫ ﻴون‬ 1. Complete interview

‫ﻤ ﻤل اﻨ ﺮوﻴو‬

3. No one was home

‫ﮕﮭﺮ ۾ وﺒﻪ ﻨﻪ ھﻴو‬

2. Incomplete interview ‫اﻨ ﺮوﻴو‬

‫ﻨﺎﻤ ﻤل‬

Codes for Question 14

‫ ﺠو وڊ‬14 ‫ﺴوال ﻨﻤﺒﺮ‬ 4. Declined interview‫اﻨ ﺎر‬

‫اﻨ ﺮوﻴو ڏﻴڻ ﮑﺎن‬ 3

Addressing Delays for Access to EmONC 78 in Non-LHW Areas of Pakistan

Name of supervisor:

15.

â&#x20AC;Ťďş´ď&#x2122;ďşŽŮ&#x2C6;Ř§ďş&#x152;ďť´ďş°Řą ďş Ů&#x2C6; ďť¨ďş&#x17D;ďť&#x;Ů&#x2C6;â&#x20AC;Ź

16.

â&#x20AC;Ť Ů&#x2C6;Ú&#x160;Řą ďş Ů&#x2C6; ďť¨ďş&#x17D;ďť&#x;Ů&#x2C6;â&#x20AC;Ź

17.

â&#x20AC;ŤÚ&#x160;ďť´ ďş&#x17D; Ř§ďť¨ ďşŽŮ&#x160; ďşŽÚť ďş Ů&#x2C6; ďť¨ďş&#x17D;ďť&#x;Ů&#x2C6;â&#x20AC;Ź

Name of coder:

Name of data enterer:

Section 2: Socio Demographics Section No. 201. How old are you?

â&#x20AC;Ťďş´ Ů&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź

Question

â&#x20AC;Ťďş Ů&#x2C6;Ř§Ř¨â&#x20AC;Ź

Response _________ years

â&#x20AC;Ťďş´ďş&#x17D;Ů&#x201E;___________ ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďş ďť˛ ďť&#x2039;ďť¤ďşŽ ďť´ďş&#x2DC;ďşŽŮ&#x160; Ř˘Úžďť˛â&#x20AC;Ź

202. Educational Level: (number of years of completed education)

_________ years

203. Distance to facility with maternity services:

<5 km

>5 km

1. 2. 3. 4. 5.

1 km 2 km 3 km 4 km 5 km

<5 km

>5 km

(â&#x20AC;Ťďş´ďş&#x17D;Ů&#x201E;___________ ďş&#x2DC;ďť&#x152;ďť ďť´ďť¤ďť˛ ďť&#x2014;ďş&#x17D;ďş&#x2019;ďť ďť´ŘŞ )ďş&#x2DC;ďť&#x152;ďť ďť´Ů&#x2026; ďş¤ďş&#x17D;ďşźŮ&#x201E; ďşŽÚť ďş ďş&#x17D; ďş´ďş&#x17D;Ů&#x201E;â&#x20AC;Ź â&#x20AC;Ťďť¤ďş&#x17D; Ů?ŘĄ Ű˝ ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďşźďş¤ŘŞ ďť¤ďşŽ ďş° ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6;â&#x20AC;Ź

(Maternity services include care of mother during pregnancy, birthing and immediately post birth)

â&#x20AC;Ť ďť¤ďş&#x17D; Ů?ŘĄ ďş ďť˛ ďş¤ďť¤Ů&#x201E; ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďş´ďş&#x17D;Řąďş´ďť¨ď?ďş&#x17D;Ů&#x201E; ď&#x2122;ďť´ŘŻŘ§ďş&#x152;Ř´ Ű˝â&#x20AC;ŹŘ&#x152; â&#x20AC;Ť)ďť¤ďş&#x17D; Ů?ŘĄ Ű˝ ď&#x2022;ďş&#x17D;Řą ďş Ů&#x2C6;Ů&#x2020; ďşźďş¤ŘŞ ďş´ďŽŮ&#x2C6;ďť&#x;ďş&#x2DC;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź (â&#x20AC;Ťď&#x2122;ďť´ŘŻŘ§ďş&#x152;Ř´ ďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6; Ů?ŘĄâ&#x20AC;Ź

204. If <5 km, describe approximate distance to facility w/ maternity services:

â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´ ďşŽ ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďŽ&#x2022;ďŽŮ˝ Ř˘Úžďť˛ ďş&#x2DC;ďťŞ ďť¤ďş&#x17D; Ů?ŘĄ Ű˝ ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďşźďş¤ŘŞ ďť¤ďşŽ ďş°â&#x20AC;Ź5 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; ďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6;â&#x20AC;Ź .â&#x20AC;Ťďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďş&#x2DC;ďť&#x2DC;ďşŽďť´ďş&#x2019;Ů&#x2020; ďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6; ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź

205. Distance of TBA who provides maternity services:

â&#x20AC;ŤŘŻŘ§ďş&#x152;ďť˛ ďş ďť´ ďş&#x17D; ďş¤ďť¤Ů&#x201E; ďş Ů&#x2C6;Ů&#x2020; ďş´ďŽŮ&#x2C6;ďť&#x;ďş&#x2DC;Ů&#x2C6;Ů&#x2020; Ú?Ů&#x160; ďĽďť˛ Ř§Ů&#x2020; ďş ďť˛ ďŽ&#x2022;ďŽďşŽ ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6;â&#x20AC;Ź

1. 2. 3. 4. 5.

206. If <5 km, describe approximate distance to TBA w/ maternity services:

â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´ ďşŽ ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďŽ&#x2022;ďŽŮ˝ Ř˘Úžďť˛ ďş&#x2DC;ďťŞ ŘŻŘ§ďş&#x152;ďť˛ ďş ďť˛ ďŽ&#x2022;ďŽďşŽ ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďş&#x2DC;ďť&#x2DC;ďşŽďť´ďş&#x2019;Ů&#x2020;â&#x20AC;Ź5 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; ďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďť¤ďť&#x201D;ďş&#x17D;ďşźďť Ů&#x2C6; ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź

207. Monthly household Income

â&#x20AC;ŤďŽ&#x2022;ďŽďşŽ ďş ďť˛ ďť¤ďş&#x17D;ÚžŮ&#x2C6;Ř§Řą Ř˘ďť¤ŘŻďť¨ďť˛â&#x20AC;Ź

Walls

â&#x20AC;Ťď?ďş&#x2DC;ďť´Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź

208.

Use observation to see what the primary construction material is used to build the house? Mark all that apply

â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´ ďşŽ ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďť´ďş&#x17D; ďŽ&#x2022;ďŽŮ˝â&#x20AC;Ź5 â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´ ďşŽ ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďť¤ďĽďť˛â&#x20AC;Ź5

1 km 2 km 3 km 4 km 5 km

_____________________ 1.

Bricks â&#x20AC;&#x201C; un-plastered

Bricks and cement

Wood

Thatch

Mud

â&#x20AC;Ťďť¤ďş¸ďş&#x17D;ÚžŘŻŮ&#x2C6; ďşŽŮ&#x160; Ú?ďş´Ů&#x2C6; ďş&#x2DC;ďťŞ ďŽ&#x2022;ďŽďşŽ ďş ďť˛ ďş&#x2DC;ďť&#x152;ďť¤ďť´ďşŽ Űž ďŽ Ů&#x2C6; ďş&#x2019;ďť¨ďť´ďş&#x17D;ŘŻŮ&#x160; ďş´ďş&#x17D;ďť¤ďş&#x17D;Ů&#x2020;â&#x20AC;Ź (â&#x20AC;ŤŘ§ďş´ďş&#x2DC;ďť&#x152;ďť¤ďş&#x17D;Ů&#x201E; ďĽďť´Ů&#x201E; Ř˘Úžďť˛ )Ř§Úžďť˛ ďş´Ú&#x20AC; ďş ďŽďťŞ ďť&#x;ďŽ&#x2018;Ů&#x2C6; ďş ďť´ Ů&#x2C6; Ř§ďş´ďş&#x2DC;ďť&#x152;ďť¤ďş&#x17D;Ů&#x201E; ďĽďť´Ů&#x201E; Ř˘Úžďť˛â&#x20AC;Ź

â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´Â&#x152;ďşŽ ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť´Ů&#x2020; ďť´ďş&#x17D; ďŽ&#x2022;ďŽŮ˝â&#x20AC;Ź5 â&#x20AC;Ť ďť Ů&#x2C6;ďť¤ďť´Â&#x152;ďşŽ ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďť¤ďĽďť˛â&#x20AC;Ź5

Other (specify)

â&#x20AC;Ť ď˝ďť´Ů&#x2C6;Ů&#x2020; ďş´ďşŽŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;Ťďş´ďť´ďť¤ďť´ďť¨Ů˝ Ű˝ ďş´ďşŽŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;Ť ďş&#x17D;Ůşâ&#x20AC;Ź â&#x20AC;Ť ďŽ&#x2018;Ů&#x2020; Ů&#x2C6;Ř§ŘąŮ&#x160; ďŽ ŘŞâ&#x20AC;Ź â&#x20AC;ŤďŽ&#x2022;ďş&#x17D;ŘąŮ&#x160; Ů&#x2C6;Ř§ŘąŮ&#x160; ďŽ ŘŞâ&#x20AC;Ź )â&#x20AC;Ť ďş&#x17D; ď&#x2022;ďť˛â&#x20AC;Ź

(â&#x20AC;Ťďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź

Roof

â&#x20AC;ŤďŽ ďş&#x2DC;ďť´Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź

Tin sheets

Roofing tiles

Concrete

Wood

Thatch

â&#x20AC;ŤÂ&#x2026;ďť´Ů&#x2020; ďş ďť˛ ďş¸ďť´Ů˝â&#x20AC;Ź â&#x20AC;ŤďŽ ŘŞ Ů&#x2C6;Ř§ŘąŮ&#x160; Â&#x2026;ďş&#x17D;ďş&#x152;ďť´Ů&#x201E;â&#x20AC;Ź ( â&#x20AC;Ťď&#x2122;ďş¨ďş&#x2DC;ďş&#x17D; )ďş´ďť´ďť¤ďť´ďť¨Ů˝ Ů&#x2C6;Ř§ŘąŮ&#x160;â&#x20AC;Ź â&#x20AC;Ť ďş&#x17D;Ůşâ&#x20AC;Ź 4

79 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Floor

ُ ‫ﭙٽ‬

How many rooms are there in the household? 209.

‫ﮕﮭﺮ ۾ ﻴﺘﺮا ﻤﺮا آھن ؟‬

(excluding toilet, kitchen, and garage)

Other (specify )

Cement

Sand/ mud

Concrete

Tiles

Wood

Other (specify)

(

‫ ک ۽ ﭙن‬ ‫ ﺎ ﭕﻲ) ﻟﮑو‬ ‫ﺴﻴﻤﻴﻨﻴٽ‬ ‫ﻤ ﻲ ۽ ﮕﺎرو‬ ‫ﭙ و‬ ‫ ﺎﺌﻴﻠﺰ‬ ‫ ﺎٺ‬ ( ‫ ﺎ ﭕﻲ )ﻟﮑو‬

______________________

(‫ ﺒورﭽﻲ ﺨﺎﻨو ۽ ﮕﻴﺮاج ﮑﺎﻨﺴوا ِء‬، ‫)ﻏﺴل ﺨﺎﻨو‬ 1.

210.

What is the ownership status of the house?

‫ﮕﮭﺮ ﺠﻲ ﻤﺎﻟ ﺎﭩﻲ ﺤﻴﺜﻴت ﮭ ي آھﻲ؟‬

‫ﭙﻨﮭﻨﺠو‬ ‫ ﺮاﺌﻲ ﺘﻲ‬ ‫ و ﭕﻴو‬

Owned

Rented

Other (specify)

1. 2.

Piped ‫ﻻﺌﻴن‬ Open/ closed well/ hand pump

Tube well/ bore

Mineral water

River/ stream/ canal/ spring

Other (specify)

Use mineral water

Boil it

Use water filter

Use chlorination/ tablets

Nothing

Other (specify)

Yes

Gas

Wood

Oil

Other (specify)

Flush latrine

Pit latrine

(‫)ﻟﮑو‬

211.

212.

213.

214.

215.

What is the main source of drinking water?

‫ﭙﻴﺌڻ ﺠﻲ ﭙﺎﭩﻲ ﺠﻲ اھم ذرﻴﻌو ﮭ و آھﻲ؟‬

What do you do to make the water safer to drink?

‫ﺘوھﺎن ﭙﺎﭩﻲ ﮑﻲ اﺴﺘﻌﻤﺎل ﻻ ِء ﺒﻨﺎﺌڻ ﻻ ِء ﮁﺎ ﻨدا آھﻴو؟‬

Does the household have electricity?

What fuel type is used for cooking?

‫ﮁﺎ ﮕﮭﺮ ۾ ﺒﺠﻠﻲ ﻤوﺠود آھﻲ؟‬

‫ﮕﮭﺮ ۾ رڌﭙﭽﺎ ُء ﻻ ِء اﺴﺘﻌﻤﺎل ﭥﻴﻨدڙ اﻴﻨڌڻ؟‬

What kind of toilet facility is available in the household?

‫ ﺴﻨداس ﺠو ﻗﺴم ﮭ و آھﻲ؟‬/ ‫ﮕﮭﺮ ۾ اﺴﺘﻌﻤﺎل ﭥﻴﻨدڙ ﻏﺴل ﺨﺎﻨو‬

‫ﭙﺎﺌﻴپ‬

‫ﻨﻠ و‬/ ‫ ﺒﻨد ﮑوھﻪ‬/‫ﮑﻠﻴل‬ ‫ ﺒورﻴﻨگ‬/ ‫ ﻴوب وﻴل‬ ‫ﻤﻨﺮل وا ﺮ‬

‫ ﻤﻴﻨﮭن ﺠو ﭙﺎﭩﻲ‬/ ‫ ﺌﻨﺎل‬/ ‫ وا ﺮ‬/ ‫ﻨدي‬ (‫ و ﭕﻴو )ﻟﮑو‬

‫ﻤﻨﺮل وا ﺮ ﺠو اﺴﺘﻌﻤﺎل‬ ‫اوﭕﺎري ﺮي‬ ‫ﻓﻠ ﺮ وا ﺮ ﺠو اﺴﺘﻌﻤﺎل‬

‫ﭙﺎﭩﻲ ﺼﺎف ﺮڻ وارﻴون ﮕورﻴون‬ ‫ ﺠﮭﻪ ﺒﻪ ﻨﻪ‬ (‫ و ﭕﻴو )ﻟﮑو‬

‫ھﺎ‬ ‫ﻨﻪ‬ ‫ﮕﻴس‬ ‫ ﺎﭡﻴون‬ ‫ﺘﻴل‬ (‫ و ﭕﻴو )ﻟﮑو‬ ‫ ﺎﻤوڊ‬ ‫ﭙٽ ﻟﻴ ﺮﻴن‬ 5

Addressing Delays for Access to EmONC 80 in Non-LHW Areas of Pakistan

3. 4.

‫ﮑﻠﻴل زﻤﻴن‬

Open field

‫ و ﭕﻴو‬

Other (specify)

(‫)ﻟﮑو‬

216.

How is the household waste disposed?

Municipal committee collects

Garbage man collects

Thrown outside in open

Buried

Other (specify)

‫ﻤﻴوﻨﺴﭙل ﺎﻤﻴ ﻲ ﮑﭩﻲ وﭹﻲ ﭥﻲ‬ ‫ﭝﻨﮕﻲ ﮑﭩﻲ وﭹﻲ ﭥو‬

‫ﭕﺎھﺮ اﮁﻼﻴو وﭹﻲ ﭥو‬ ‫ﭙورﻴو وﭹﻲ ﭥو‬

‫ﮕﮭﺮ ﺠو ﮕﻨد ﭽﺮو ﭥﻲ اﮁﻼﻴو وﭹﻲ؟‬

‫ و ﭕﻴو‬

(‫)ﻟﮑو‬ Radio

Television

Iron

Mobile phone

Land line/ phone

Refrigerator

Air conditioner

Gas stove

9. 10.

(tick all that apply)

‫ ﻴﻠﻴوﻴﺰن‬ ‫اﺴﺘﺮي‬

‫ﮁﺎ ﮕﮭﺮ ۾ ﺴﺎﻤﮭون ڏﻨل ﻤﺎن ﺠﮭﻪ ﻤوﺠود آھﻲ؟‬ (‫)ﻤوﺠود ﺸﻴن ﺠﻲ ﻨﺸﺎن ﻟﮙﺎﻴو‬

‫ﻤوﺒﺎﺌﻴل‬ ‫ﻓون‬ ‫ﻓﺮﻴﺞ‬ ‫اﻴﺌﺮ ﻨڊﻴﺸﻨﺮ‬

‫ﮕﺌس وارو ﭽﻠﮭو‬ ‫و ﻴو‬ ‫ﻤﺎﺌﻴ ﺮو‬ Microwave oven ‫اون‬ Sewing machine ‫ﺴﻼﺌﻲ ﻤﺸﻴن‬

11. Washing machine

Does the household have any of the following? 217.

‫رﻴڊﻴو‬

‫واﺸﻨگ ﻤﺸﻴن‬

14. Motorbike

‫ ﻤﭙﻴو ﺮ‬ ‫ﺴﺎﺌﻴ ل‬ ‫ﻤو ﺮﺴﺎﺌﻴ ل‬

15. Motor car

‫ﻤو ﺮ ﺎر‬

12. Computer 13. Bicycle

16. Tractor

‫ ﺮﻴ ﺮ‬

17. Donkey cart

‫ﮕڏ ھﻪ‬

‫ﮕﺎڏو‬

18. Livestock

‫ﭽوﭙﺎﻴو‬

Cow/ buffalo

Sheep/ goat

Poultry

19. Other (specify)

‫ ﻤﻴﻨﮭن‬/‫ﮙﺌون‬ ‫ ﭕ ﺮي‬/‫رڍ‬ ‫ﻴون‬

(‫ﭕﻴو ﺠﮭﻪ )ﻟﮑو‬

81 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Section 3: Birth Preparedness and Antenatal care

â&#x20AC;Ť Ů&#x2C6;ďť´Ů&#x2026; ďş ďť˛ ďş&#x2DC;ďť´ďş&#x17D;ŘąŮ&#x160; Ű˝ ŘŻŮ&#x2C6;ŘąŘ§ďť¨ďť˛ ďş¤ďť¤Ů&#x201E; ďş ďť˛ ďş´ďş&#x17D;Řąďş´ďť¨ď?ďş&#x17D;Ů&#x201E;â&#x20AC;Ź- 3: â&#x20AC;Ťďş´ďť´ ďş¸Ů&#x2020;â&#x20AC;Ź No. 301.

Question

â&#x20AC;Ťďş´Ů&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź

Do you know about any problems or complications a woman can have during pregnancy?

â&#x20AC;ŤďŽ ďş&#x17D; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďş¤ďť¤Ů&#x201E; ďş ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďĽďť´ďť¨ŘŻÚ&#x2122; ďť¤ďş´ďş&#x152;ďť Ů&#x2020; Ű˝â&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďť´ď˝ďť´ŘŻďŽ&#x2022;ďť´Ů&#x2020; ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞ ďľďş&#x17D;Úť ŘąďŽ&#x2018;Ů&#x2C6; ďĽďş&#x17D;Ř&#x;â&#x20AC;Ź

302.

What complications or problems do you know about?

â&#x20AC;Ťďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽÂ?ďť´Ů&#x2020; ď&#x2122;ďť´ď˝ďť´ŘŻďŽ&#x2022;ďť´Ů&#x2020; ďť´ďş&#x17D; ďť¤ďş´ďş&#x152;ďť Ů&#x2020; ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞ ďľďş&#x17D;ďŠŮ&#x2C6; ďĽďş&#x17D;Ř&#x;â&#x20AC;Ź

(Mark all that apply)

(â&#x20AC;Ť)Ř§ďť¨ďŽŮ&#x2020; ďş¸ďť´Ů&#x2020; ďş&#x2DC;ďť˛ ďť¨ďş¸ďş&#x17D;Ů&#x2020; ďť&#x;ďŽ&#x2122;ďş&#x17D;ďť´Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;Ťďş Ů&#x2C6;Ř§Ř¨â&#x20AC;Ź

Response 1.

â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź

Yes

â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź

Skip

â&#x20AC;ŤďŽ Ú?Ů&#x160; Ú?ďť´Ů&#x2C6;â&#x20AC;Ź

If 2 or 99 then go to 303

â&#x20AC;Ť ďť´ďş&#x17D;â&#x20AC;Ź2 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ť ď&#x2122;Ů&#x2C6; Ů?ŘĄ ďş´ďş&#x17D;Ů&#x201E; ďť¨ďť¤ďş&#x2019;ďşŽâ&#x20AC;Ź99 â&#x20AC;Ť ďş&#x2DC;ďť˛ Ů&#x2C6;ďšŮ&#x2C6;â&#x20AC;Ź303

â&#x20AC;Ťďľďş&#x17D;Úť ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99. Do Not Know 1. None

â&#x20AC;Ť ďş ďŽďťŞ ďş&#x2019;ďťŞ ďť¨ďťŞâ&#x20AC;Ź

Bleeding

Severe headache

Blurred vision

Convulsions

Swollen hands/face/feet

High fever

Loss of consciousness

Difficulty breathing

â&#x20AC;ŤŘąŘŞ Ř§ď˝Úťâ&#x20AC;Ź â&#x20AC;Ťďş¸ŘŻďť´ŘŻ ďť¤ďĽďť˛ Űž ďş´Ů&#x2C6;Řąâ&#x20AC;Ź â&#x20AC;ŤŘ§ďŽ&#x2018;ďť´Ů&#x2020; Ř§ďŽ&#x2122;ďť´ďş&#x17D;Ů&#x2020; Ř§ďť¨Ú&#x152;ďť´ďşŽŮ&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďş ďŽÂ&#x2039; ďş&#x17D;â&#x20AC;Ź

â&#x20AC;Ť ď&#x2122;ďť´ďşŽŮ&#x2020; Ű˝ ďť¤ďť¨ďŽŮ&#x2020; ďş&#x2DC;ďť˛ ďş´Ů&#x2C6;Ú&#x201E;â&#x20AC;ŹŘ&#x152;â&#x20AC;ŤÚžďĽŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ťďş&#x2DC;ďť´ďş° ďş&#x2019;ďş¨ďş&#x17D;Řąâ&#x20AC;Ź â&#x20AC;Ťďş&#x2019;ďť´ďŽŮ&#x2C6;ďş¸ďť˛â&#x20AC;Ź â&#x20AC;Ťďş´ďş&#x17D;ÚžďťŞ Űž ďş&#x2DC; ďť ďť´Ů â&#x20AC;Ź

10. Severe weakness

â&#x20AC;ŤďŽ&#x2022;ďŽďŠďť˛ ďť¤ďş°Ů&#x2C6;ŘąŮ&#x160;â&#x20AC;Ź

11. Severe abdominal pain

â&#x20AC;ŤďŽ&#x2022;ďŽďŠŮ&#x2C6; ď&#x2122;ďť´Ů˝ Űž ďş´Ů&#x2C6;Řąâ&#x20AC;Ź

12. Accelerated/ reduced fetal movement

â&#x20AC;Ť ďŽ&#x2022;ďŽÂ&#x2039;ďş&#x2DC;ďş&#x17D;ďş&#x152;ďť˛â&#x20AC;Ź/ â&#x20AC;Ťď&#x2122;ďť´Ů˝ Űž ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďş¤ďşŽ ŘŞ Űž ďş&#x2DC;ďť´ďş°Ů&#x160;â&#x20AC;Ź

13. Water breaks without labor

â&#x20AC;Ťďť&#x;ďť´ďş&#x2019;ďşŽ ďŽ&#x2018;ďş&#x17D;ďť¨ďş´Ů&#x2C6;Ř§ Ů?ŘĄ ď&#x2122;ďş&#x17D;ďŠďť˛ Ř§ď˝Úťâ&#x20AC;Ź

14. Other (specify_____________________ 99. Donâ&#x20AC;&#x2122;t know

303.

In your opinion, can a woman die from any problems or complications during pregnancy?

â&#x20AC;Ťďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďş ďť˛ ďş¨ďť´ďş&#x17D;Ů&#x201E; Űž ďť&#x2039;Ů&#x2C6;ŘąŘŞ ďş¤ďť¤Ů&#x201E; ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ď&#x2122;ďť´ď˝ŘŻďŽ&#x2022;ďť´Ů&#x2020; Ű˝â&#x20AC;Ź â&#x20AC;ŤŘ§ÚžŮ&#x2026; ďť¤ďş´ďş&#x152;ďť Ů&#x2020; ďş ďť˛ ďşŽŮ&#x160; ďť&#x201C;Ů&#x2C6;ŘŞ ďĽďş&#x152;ďť˛ ďş´ďŽ&#x2022;ďŽďť˛ ďĽďť˛Ř&#x;â&#x20AC;Ź

304.

From whom did you receive most information about complications that a woman can face during pregnancy?

â&#x20AC;ŤďŽ&#x2022;ďŽďŠŮ&#x2C6; ďşŽŮ&#x160; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďť¨ďŽŮ&#x2020; ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďş¤ďť¤Ů&#x201E; ďş ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020;â&#x20AC;Ź

1. Yes

2. No

99. Do Not Know 1. No one 2.

Friend

______________(â&#x20AC;Ť Ů&#x2C6; ď&#x2022;ďť´Ů&#x2C6; )ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź

If 99 then go to 305

99 â&#x20AC;Ť ďť´ďş&#x17D;â&#x20AC;Ź2 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;Ů&#x2C6; Ů?ŘĄ ďş´ďş&#x17D;Ů&#x201E; ďť¨ďť¤ďş&#x2019;ďşŽâ&#x20AC;Ź â&#x20AC;Ť ďş&#x2DC;ďť˛ Ů&#x2C6;ďšŮ&#x2C6;â&#x20AC;Ź305

â&#x20AC;Ťďľďş&#x17D;Úť ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź â&#x20AC;Ť ďť¨ďŽŮ&#x2020; ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďş&#x2019;ďťŞ ďť¨ďťŞâ&#x20AC;Ź 7

Addressing Delays for Access to EmONC 82 in Non-LHW Areas of Pakistan

‫اﻴﻨدڙ ﭙﻴﭽدﮕﻴن ﺒﺎﺒت ﻤﻌﻠوﻤﺎت ﺤﺎﺼل ﻨدا آھﻴو؟‬

Family/ elders

Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

5. 6. 7. 8.

305.

In your opinion how many antenatal care visits should a pregnant women make to a health facility?

‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ ﻨﮭن ﺒﻪ ﺤﺎﻤﻼ ﻋورت ﮑﻲ‬ ‫دوراﻨﻲ ﺤﻤل ﺴﺎرﺴﻨﭝﺎل ﻻ ِء ﺼﺤت ﻤﺮ ﺰ ﺠﺎ‬ ‫ ﻴﺘﺮا دورا ﺮڻ ﮕﮭﺮﺠن؟‬

306.

From whom did you receive information about antenatal care?

‫ﺘوھﺎن ﻨﮭن ﮑﺎن دوراﻨﻲ ﺤﻤل ﺠﻲ ﺴﺎرﺴﻨﭝﺎل‬ ‫ﺒﺎﺒت ﭵﺎڻ ﺤﺎﺼل ﺌﻲ آھﻲ؟‬

Community Volunteer

Radio / TV

‫ﮙوﭡﺎﭩو رﻀﺎ ﺎر‬ ‫رﻴڊﻴو ۽‬

‫ ﻴﻠﻴوﻴﺰن‬

Newspaper

‫اﺨﺒﺎر‬

At least One

________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﮕﮭٽ ۾ ﮕﮭٽ ھڪ‬

At least two

At least three

At least four

More than four

Other (Specify)_____________________

‫ﮕﮭٽ ۾ ﮕﮭٽ ﭕﻪ‬ ‫ﮕﮭٽ ۾ﮕﮭٽ ﻲ‬ ‫ﮕﮭٽ ۾ ﮕﮭٽ ﭽﺎر‬ ‫ﭽﺎر ﮑﺎن وڌﻴڪ‬

99.

__________________(‫ و ﭕﻴو )ﻟﮑو‬ Do not know ‫ﺨﺒﺮ‬ ‫ﻨﺎھﻲ‬

No one

Friend

Family/ elders

Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

7. 8.

‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ دوراﻨﻲ ﺤﻤل ﺠﻲ ﺴﺎرﺴﻨﭝﺎل ﺠﺎ‬ ‫اھم ﺠﺰا ﮭ ا آھن؟‬

‫ اﻴل اﻴﭿ‬/‫ﺘﺮﺒﻴﺘﻲ ﻴﺎﻓﺘﻪ ﺼﺤت ﺎر ن )ڊا ﺮ‬ (‫ ﻤڊواﺌﻴف‬/ ‫ ﻨﺮﺴﺮي‬/‫وي‬ LHW ‫اﻴل اﻴﭿ‬ ‫ڊﺒﻠﻴو‬

Other (Specify)__________________

In your opinion what are important components of Antenatal care?

‫ ﺒﺰرگ‬/ ‫ﮕﮭﺮ ﺠﺎ ﭝﺎﺘﻲ‬

307.

‫دوﺴت‬

‫ ﻨﮭن ﮑﺎن ﺒﻪ ﻨﻪ‬ ‫دوﺴت‬ ‫ ﺒﺰرگ‬/ ‫ﮕﮭﺮ ﺠﺎ ﭝﺎﺘﻲ‬

‫ اﻴل اﻴﭿ‬/‫ﺘﺮﺒﻴﺘﻲ ﻴﺎﻓﺘﻪ ﺼﺤت ﺎر ن )ڊا ﺮ‬ (‫ ﻤڊواﺌﻴف‬/ ‫ ﻨﺮﺴﺮي‬/‫وي‬ LHW ‫اﻴل اﻴﭿ‬ ‫ڊﺒﻠﻴو‬ Community Volunteer

Radio / TV

‫ﮙوﭡﺎﭩو رﻀﺎ ﺎر‬ ‫رﻴڊﻴو ۽‬

‫ ﻴﻠﻴوﻴﺰن‬

Newspaper

‫اﺨﺒﺎر‬

Other (Specify)__________________

Checking for Anemia

Measure Blood Pressure

________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫رت ﺠﻲ ﮑوٽ ﭽﻴڪ ﺮاﺌڻ‬ ‫ﺒﻠڊﭙﺮﻴﺸﺮ ﻤﺎﭙڻ‬ 8

83 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

(Mark all that apply)

(â&#x20AC;Ť)Ř§ďť¨ďŽŮ&#x2020; ďş¸ďť´Ů&#x2020; ďş&#x2DC;ďť˛ ďť¨ďş¸ďş&#x17D;Ů&#x2020; ďť&#x;ďŽ&#x2122;ďş&#x17D;ďť´Ů&#x2C6;â&#x20AC;Ź

Weighing

Immunization (Tetanus injection)

Counseling about food and rest requirement

Urine test

Check the position and movement of the fetus

During your last pregnancy, how many antenatal visits did you have with a healthcare provider?

â&#x20AC;ŤďŽ&#x2022;Ř°Řąďť´Ů&#x201E; ďş¤ďť¤Ů&#x201E; ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ŘŻŮ&#x2C6;ŘąŘ§ďť¨ďť˛ ďş¤ďť¤Ů&#x201E; ďş ďť˛â&#x20AC;Ź â&#x20AC;Ťďş´ďş&#x17D;Řąďş´ďť¨ď?ďş&#x17D;Ů&#x201E; ďťť Ů?ŘĄ ďşźďş¤ŘŞ ďş&#x17D;Řą Ů&#x2020; Ů&#x2C6;Ů˝ ďť´ďş&#x2DC;ďşŽŘ§ ŘŻďť&#x201C;ďť&#x152;ďş&#x17D;â&#x20AC;Ź â&#x20AC;ŤŮ&#x2C6;ďť´ďş&#x17D; Ř˘Úžďť´Ů&#x2C6;Ř&#x;â&#x20AC;Ź

309.

Whom did you see mostly for antenatal visits during previous pregnancy?

â&#x20AC;ŤďŽ&#x2022;Ř°Řąďť´Ů&#x201E; ďş¤ďť¤Ů&#x201E; ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ŘŻŮ&#x2C6;ŘąŘ§ďť¨ďť˛ ďş¤ďť¤Ů&#x201E; ďş ďť˛â&#x20AC;Ź â&#x20AC;Ťďş´ďş&#x17D;Řąďş´ďť¨ď?ďş&#x17D;Ů&#x201E; ďťť Ů?ŘĄ ďť¨ďŽŮ&#x2020; Ů&#x2C6;Ů˝ Ů&#x2C6;ďť´ďş&#x17D;Ř&#x;â&#x20AC;Ź

310.

Which of these did you receive in your last pregnancy

â&#x20AC;ŤďŽ&#x2022;Ř°Řąďť´Ů&#x201E; ďş¤ďť¤Ů&#x201E; ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽÂ&#x2018;ďť´Ů&#x2C6;Ů&#x2020; ďş¨ŘŻďť¤ďş&#x2DC;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;Ťďş¤ďş&#x17D;ďşźŮ&#x201E; ďť´Ů&#x2C6;Ů&#x2020;Ř&#x;â&#x20AC;Ź

(â&#x20AC;Ť Ů? ďş&#x17D; ďť&#x;ďŽ&#x2122;ďşŽŘ§ďş&#x152;Úť )ďş ďŽ Ů&#x2020; ďťť Ů?ŘĄâ&#x20AC;Ź

â&#x20AC;ŤďŽ&#x2018;ďş&#x17D;Ú&#x152;Ů&#x160; Ű˝ Ř˘ŘąŘ§Ů&#x2026; ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞ ďşźďťźŘ ďť¤ďş¸Ů&#x2C6;ŘąŮ&#x2C6;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďť´ďş¸ďş&#x17D;Ř¨ ďş ďť˛ ď˝ ďş&#x17D;Řłâ&#x20AC;Ź

99.

â&#x20AC;Ťď&#x2122;ďť´Ů˝ Űž ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďş ďŽ&#x2122;ďŽďťŞ Ű˝ ďş¤ďşŽ ŘŞ ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞ ďľďş&#x17D;Úťâ&#x20AC;Ź Others â&#x20AC;Ťď&#x2022;ďť´Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ť ďş ďŽďťŞâ&#x20AC;Ź Donâ&#x20AC;&#x2122;t Know â&#x20AC;Ťďş¨ ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

None

One

Two

Three

5. 6.

Four or more Not Applicable

None

TBA/ Dai

LHW

CMW

Private sector LHV

Private lady doctor

Public sector LHV

Public sector doctor

Other (Specify_______)

Checking for Anemia

Measure Blood Pressure

Weighing

Immunization (Tetanus injection)

Counseling about food and rest requirement

Urine test

Check the position and movement of the fetus

Others

308.

â&#x20AC;ŤŮ&#x2C6;Ř˛Ů&#x2020; ďşŽŘ§ďş&#x152;Úťâ&#x20AC;Ź

1 then go to â&#x20AC;Ť ÚžÚŞ ďş&#x2019;ďťŞ ďť¨ďťŞâ&#x20AC;ŹIf310 â&#x20AC;Ť ď&#x2122;Ů&#x2C6; Ů?ŘĄ ÚžÚŞâ&#x20AC;Ź1 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ť ď&#x2022;ďťŞâ&#x20AC;Ź310 â&#x20AC;Ťďş´Ů&#x2C6;Ř§Ů&#x201E; ďť¨ďť¤ďş&#x2019;ďşŽâ&#x20AC;Ź â&#x20AC;Ťďş&#x2DC;ďť˛ Ů&#x2C6;ďšŮ&#x2C6; ďťŞâ&#x20AC;Ź â&#x20AC;Ťď˝ďş&#x17D;Řą Ű˝ Ř§Ů&#x2020; ďŽ&#x2018;ďş&#x17D;Ů&#x2020; Ů&#x2C6;Ú&#x152;ďť´ÚŞâ&#x20AC;Ź Not Applicable

â&#x20AC;Ť ďť¨ďŽŮ&#x2020; Ů&#x2C6;Ů˝ ďş&#x2019;ďťŞ ďť¨ďťŞâ&#x20AC;Ź â&#x20AC;ŤŘŻŘ§ďş&#x152;ďť˛â&#x20AC;Ź â&#x20AC;ŤŘ§ďť´Ů&#x201E; Ř§ďť´ďż Ú&#x160;ďş&#x2019;ďť ďť´Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďť¤Ú&#x160;Ů&#x2C6;Ř§ďş&#x152;ďť´Ů â&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďşŽŘ§ďş&#x152;ďť´Ů&#x2C6;ďť´Ů˝ Ř§ďť´Ů&#x201E; Ř§ďť´ďż Ů&#x2C6;Ů&#x160;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďşŽŘ§ďş&#x152;ďť´Ů&#x2C6;ďť´Ů˝ Ú&#x160;Ř§ ďşŽâ&#x20AC;Ź â&#x20AC;ŤďŽ&#x2022;Ů&#x2C6;Řąďť¨ďť¤ďť´ďť¨Ů˝ Ř§ďť´Ů&#x201E; Ř§ďť´ďż Ů&#x2C6;Ů&#x160;â&#x20AC;Ź â&#x20AC;ŤďŽ&#x2022;Ů&#x2C6;Řąďť¨ďť¤ďť´ďť¨Ů˝ Ú&#x160;Ř§ ďşŽâ&#x20AC;Ź â&#x20AC;Ťď&#x2022;ďť´Ů&#x2C6; Ů&#x2C6;â&#x20AC;Ź

(â&#x20AC;Ť)ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;ŤŘąŘŞ ďş ďť˛ ďŽ&#x2018;Ů&#x2C6;Ů˝ ď˝ďť´ÚŞ ďşŽŘ§ďş&#x152;Úťâ&#x20AC;Ź â&#x20AC;Ťďş&#x2019;ďť Ú&#x160;ď&#x2122;ďşŽďť´ďş¸ďşŽ ďť¤ďş&#x17D;ď&#x2122;Úťâ&#x20AC;Ź â&#x20AC;ŤŮ&#x2C6;Ř˛Ů&#x2020; ďşŽŘ§ďş&#x152;Úťâ&#x20AC;Ź

(â&#x20AC;Ť Ů? ďş&#x17D; ďť&#x;ďŽ&#x2122;ďşŽŘ§ďş&#x152;Úť )ďş ďŽ Ů&#x2020; ďťť Ů?ŘĄâ&#x20AC;Ź

100. Donâ&#x20AC;&#x2122;t

â&#x20AC;Ťď&#x2122;ďť´Ů˝ Űž ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďş ďŽ&#x2122;ďŽďťŞ Ű˝ ďş¤ďşŽ ŘŞ ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞ ďľďş&#x17D;Úťâ&#x20AC;Ź â&#x20AC;Ťď&#x2022;ďť´Ů&#x2C6; ďş ďŽďťŞâ&#x20AC;Ź Know â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź 9

Addressing Delays for Access to EmONC 84 in Non-LHW Areas of Pakistan

311. ` Have you heard about birth preparedness?

‫ﮁﺎ ﺘوھﺎن وﻴم ﺠﻲ ﺘﻴﺎري ﺒﺎﺒت ﭕڌو آھﻲ؟‬

312.

From whom did you receive information about the birth preparedness?

‫وﻴم ﺠﻲ ﺘﻴﺎري ﺒﺎﺒت ﺘوھﺎن ﻨﮭن ﮑﺎن ﭵﺎڻ‬ ‫ﺤﺎﺼل ﺌﻲ؟‬

Yes

If 2 then go to 313

‫ھﺎ‬ ‫ﻨﻪ‬

1. No one

‫ﺠﻴ ڏھن ﭕﻪ ﭙو ِء‬ 313 ‫ﺴوال ﻨﻤﺒﺮ‬ ‫ﺘﻲ وﭹو‬

‫ ﻨﮭن ﮑﺎن ﺒﻪ ﻨﻪ‬

2. Friend

‫دوﺴت‬

3. Family/ elders

‫ ﺒﺰرگ‬/ ‫ﮕﮭﺮ ﺠﺎ ﭝﺎﺘﻲ‬

4. Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

‫ اﻴل اﻴﭿ‬/‫ﺘﺮﺒﻴﺘﻲ ﻴﺎﻓﺘﻪ ﺼﺤت ﺎر ن )ڊا ﺮ‬ (‫ ﻤڊواﺌﻴف‬/ ‫ ﻨﺮﺴﺮي‬/‫وي‬ ‫اﻴل اﻴﭿ ڊﺒﻠﻴو‬ 5. LHW

6. Community Volunteer 7. 8.

313.

‫اﺨﺒﺎر‬

Arrange transport

Save money

Identify blood donor

Identify skilled provider

Identify the place for delivery

Procure clean delivery kits

Other (Specify) ______________________

During your last pregnancy, did your family discuss where you would go to deliver?

Yes

If yes, then where?

Home (Including home of relative/TBA etc)

Private facility

Public facility

CMW house

Other (specify)___________________

None

Save funds

Had antenatal visits with CMW, TBA or other provider

In your opinion, what are some things a woman can do to prepare for birth?

(‫)اﻨﮭن ﺸﻴن ﺘﻲ ﻨﺸﺎن ﻟﮙﺎﻴو‬

‫ﮁﺎ ﮕذرﻴل ﺤﻤل دوران ﺘوھﺎن ﺠﻲ ﮕﮭﺮوارن وﻴم‬ ‫ﺠﻲ ﺠﮙﮭﻪ ﺒﺎﺒت ﮙﺎﻟﮭﻪ ﭕوﻟﮭﻪ ﺌﻲ ؟‬

316.

Newspaper Other (Specify)__________________

(Mark all that apply)

315.

‫ ﻴﻠﻴوﻴﺰن‬

‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ ﺠﮭﻪ اھ ﻴون ﮭ ﻴون‬ ‫ﺸﻴون آھن ﺠﻴ ﻲ ﻋورت وﻴم ﺠﻲ ﺘﻴﺎري ﻻ ِء‬ ‫ ﺮي ﺴﮕﮭﻲ ﭥﻲ؟‬

314.

‫ﮙوﭡﺎﭩو رﻀﺎ ﺎر‬ ‫رﻴڊﻴو ۽‬

Radio / TV

‫ﺠﻴ ڏھن ھﺎ ﺘﻪ ﭥﻲ؟‬

What preparations did you make for your most recent delivery?

‫ﺘوھﺎن ﭙﻨﮭﻨﺠﻲ آﺨﺮي ﺤﻤل دوران ﮭ ﻴون‬ ‫ﺘﻴﺎرﻴون ﻴون؟‬

(Mark all that apply)

________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﮕﺎڏي ﺠو اﻨﺘظﺎم‬ ‫ﭙﺌﺴن ﺠو اﻨﺘظﺎم‬

‫رت ڏﻴڻ واري ﺠﻲ ﻨﺸﺎﻨدھﻲ‬

‫ﺘﺮﺒﻴﺘﻲ ﻴﺎﻓﺘﻪ ﺼﺤت ﺎر ن ﺠﻲ ﻨﺸﺎﻨدھﻲ‬ ‫ﭙﻴداﺌش ﺠﻲ ﺠﮙﮭﻪ ﺠﻲ ﻨﺸﺎﻨدھﻲ‬

‫ﺼﺎف ڊﻴﻠوري ٽ ﺨﺮﻴد ﺮڻ‬

2. No

__________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ھﺎ‬ ‫ﻨﻪ‬

If 2 then go to 316

‫ﺠﻴ ڏھن ﭕﻪ ﺘﻪ‬ ‫ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو‬316

(‫ داﺌﻲ وﻏﻴﺮه‬/‫ﮕﮭﺮ )ﻤﺎﺌٽ ﺠو ﮕﮭﺮ‬ ‫ﺨﺎﻨﮕﻲ ﺼﺤت ﻤﺮ ﺰ‬ ‫ﮕورﻨﻤﻴﻨٽ ﺼﺤت ﻤﺮ ﺰ‬ ‫ﻤڊ واﺌﻴف ﺠو ﮕﮭﺮ‬

_________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ ﺎﺒﻪ ﻨﻪ‬ ‫ﭙﺌﺴن ﺠﻲ ﺒﭽت‬ 10

85 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

(тАл)я║┤я║Оя╗дяон┘И┘Ж ┌Пя╗и┘Д я║Шя╗▓ я╗ия║╕я║О┘Ж я╗ЯяоЩя║Оя╗┤┘ИтАм

тАл ╪п╪зя║Мя╗▓ я╗┤я║О янХя║Мя╗▓ я║╝я║д╪к я║О╪▒ ┘ЖтАм╪МтАля║┤ я╗▓ ╪зя╗┤┘Е ┌Кя║Тя╗ая╗┤┘ИтАм тАля║┤я║О┘Ж яоХ┌П ╪п┘И╪▒╪зя╗ия╗▓ я║дя╗д┘Д я║ая╗▓ я║┤я║О╪▒я║┤я╗иянЭя║О┘Д я║ая║О ╪п┘И╪▒╪зтАм

Visited intended delivery facility

Arrange transport

Identify blood donor

Identify skilled provider

Identify the place for delivery

Procure clean delivery kits

тАл╪▒янея╗┤┘Д ┘Ия╗┤┘Е я╗дя║о я║░ я║а┘И ╪п┘И╪▒┘ИтАм тАляоХя║О┌П┘К я║а┘И ╪зя╗ия║Ш╪╕я║О┘ЕтАм

тАл╪▒╪к ┌Пя╗┤┌╗ ┘И╪з╪▒┘К я║ая╗▓ я╗ия║╕я║Оя╗и╪п┌╛я╗▓тАм

тАля║╝я║д╪к я║О╪▒ ┘Ж я║ая╗▓ я╗ия║╕я║Оя╗и╪п┌╛я╗▓тАм тАл┘Ия╗┤┘Е я║ая╗▓ я║аяоЩяоня╗к я║ая╗▓ я╗ия║╕я║Оя╗и╪п┌╛я╗▓тАм тАл┘Ия╗┤┘Е я║ая╗▓ ┘╜ я║а┘И ╪зя╗ия║Ш╪╕я║О┘ЕтАм

10. Others (Specify)______________

________________(тАл ┘И янХя╗┤┘И )я╗ЯяоС┘ИтАм

Section 4: Skilled Care at Child Birth:

:тАлянХя║О╪▒ я║ая╗▓ янЩя╗┤╪п╪зя║М╪┤ ╪п┘И╪▒╪з┘Ж я╗дя║О┌╛я║о╪зя╗ия╗▓ я║┤я║О╪▒я║┤я╗иянЭя║О┘ДтАм No. 401.

Question

тАля║┤┘И╪з┘ДтАм

In your opinion, what are some serious health problems that can occur during labor and childbirth that can put the life of a woman in danger?

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я║ия╗┤я║О┘Д █╛ ╪з┌╛ ╪з яон ╪з ╪з┌╛┘Е я║╝я║д╪к я║ая║ОтАм тАля╗дя║┤я║Мя╗╝ я║ая╗┤ я╗▓ ┘Ия╗┤┘Е █╜ ┘Ия╗┤┘Е ╪п┘И╪▒╪з┘Ж ╪зян╜я╗▓ я║┤яоХяон┘Ж янея║ОтАм тАля║ая╗┤ я╗▓ я╗Л┘И╪▒╪к я║ая╗▓ ╪▓я╗и╪пяоХя╗▓ яоСя╗▓ я║и╪╖я║о┘К █╛ ┘Ия║аяоня╗▓тАм тАля║┤яоХяон┘Ж янея║О╪ЯтАм

None

Severe bleeding

Severe headache

Convulsions

High fever

Loss of consciousness

Labor lasting >12 hours

Placenta not delivered 30 minutes after baby

Other (specify)________________

In your opinion, could a woman die from any problems or complications during labor?

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я║ия╗┤я║О┘Д █╛ я║Оя║Тя╗к я╗Л┘И╪▒╪к ┘Ия╗┤┘Е я║ая╗▓ ╪п┘И╪▒╪з┘ЖтАм тАлянЩя╗┤ян╜я╗┤╪пяоХя╗┤┘Ж █╜ я╗дя║┤я║Мя╗а┘Ж я║ая╗▓ я║о┘К я╗У┘И╪к янея║Мя╗▓ я║┤яоХяоня╗▓тАм тАлянея╗▓╪ЯтАм

403.

From whom did you receive most information about danger signs that a women can face during delivery?

тАля║Ш┘И┌╛я║О┘Ж я╗ияон┘Ж яоСя║О┘Ж ┘Ия╗┤┘Е я║ая╗▓ ╪п┘И╪▒╪з┘Ж ╪зя╗┤я╗и╪п┌Щ я║и╪╖я║оя╗ия║О┌ктАм тАля╗ия║╕я║Оя╗ия╗┤┘Ж я║Тя║Оя║Т╪к я╗дя╗Мя╗а┘Ия╗дя║О╪к я║дя║Оя║╝┘Д я║Мя╗▓ ╪в┌╛я╗▓╪ЯтАм

тАл ┘И я║Тя╗к я╗ия╗ктАм тАля║╕╪пя╗┤╪п ╪▒╪к ╪зян╜┌╗тАм тАляоХяонянй┘И я╗дянея╗▓ █╛ я║┤┘И╪▒тАм

Skip

тАляоБ┌П┘К ┌Пя╗┤┘ИтАм

If 1 or 99 then go to 404

тАля║ая╗┤ ┌П┌╛┘Ж ┌╛┌к я╗┤я║ОтАм тАл я║Шя╗к янЩ┘И ┘Р╪б я║┤┘И╪з┘ДтАм99 тАл я║Шя╗▓тАм404 тАля╗ия╗дя║Тя║отАм тАл┘Иян╣┘ИтАм

тАля║аяон┬И я║ОтАм тАля║Шя╗┤я║░ я║Тя║ия║О╪▒тАм тАля║Тя╗┤яон┘Ия║╕я╗▓тАм

тАлянХя║О╪▒я╗ияон┘Ж я╗╝ ┘Ж яоСя║О┘Ж ┘И┌Мя╗┤┌к я╗Яя╗┤я║Тя║отАм

тАл я╗дя╗и┬И┘Ж яоСя║Оя╗иянЩ┘И ┘Р╪б я║Тя╗к янЩя╗ая╗┤я║┤я╗┤я╗и я║ОтАм30 тАлянХя║О╪▒ я║ая╗▓ янЩя╗┤╪п╪зя║М╪┤ я║ая╗▓тАм тАля║а┘И янХя║О┌╛я║о я╗ия╗к ╪зян╜┌╗тАм

99. DonтАЩt know 402.

тАля║а┘И╪з╪итАм

Response

: 4 тАля║┤я╗┤ я║╕┘ЖтАм

__________(тАл ┘И янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля║ия║Тя║отАм

тАля╗ия║О┌╛я╗▓тАм 1. Yes 2. No 99. Do not Know 1.

No one

Friend

Family/ elders

тАл┌╛я║ОтАм тАля╗ия╗ктАм тАля║и я║Тя║о я╗ия║О┌╛я╗▓тАм

If 99 then go to 404

тАл я║Шя╗ктАм99 тАля║ая╗┤ ┌П┌╛┘ЖтАм 404 тАля║┤┘И╪з┘Д я╗ия╗дя║Тя║отАм тАля║Шя╗▓ ┘Иян╣┘ИтАм

тАл я╗ияон┘Ж яоСя║О┘Ж я║Тя╗к я╗ия╗ктАм тАл╪п┘Ия║┤╪ктАм 11

Addressing Delays for Access to EmONC 86 in Non-LHW Areas of Pakistan

404.

405.

406.

Where did you deliver your last baby?

‫ﺘوھﺎن ﭙﻨﮭﻨﺠﻲ آﺨﺮي ﭕﺎر ﮑﻲ ﭥﻲ ﺠﻨم ڏﻨو؟‬

Why did you deliver there?

‫ﺘوھﺎن ﮁو اﺘﻲ ﭕﺎر ﮑﻲ ﭙﻴدا ﻴو؟‬

In case of facility delivery, who referred you to go to the facility?

‫ﺼﺤت ﻤﺮ ﺰ ﺘﻲ وﻴم ﺠﻲ ﻨﺘﻴﺠﻲ ۾ ﻨﮭن ﺘوھﺎن‬ ‫ﮑﻲ ﻤو ﻠﻴو؟‬

Instruction for enumerator: If answer of Q 404 is any type of facility ask this question.

404 ‫ ﺠﻴ ڏھن ﺴوال ﻨﻤﺒﺮ‬: ‫اﻨﻴوﻤﺮﻴ ﺮ ﻻ ِء ھداﻴت‬ ‫ﺠو ﺠواب و ﺒﻪ ﺼﺤت ﻤﺮ ﺰ آھﻲ ﺘﻪ ھﻲ‬ ‫ﺴوال ﭙﮁو‬

407.

Who helped you deliver your baby there?

‫ﺘوھﺎن ﺠﻲ وﻴم دوران اﺘﻲ ﻨﮭن ﻤدد ﺌﻲ؟‬

‫ ﺒﺰرگ‬/ ‫ﮕﮭﺮ ﺠﺎ ﭝﺎﺘﻲ‬

Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

‫اﻴل اﻴﭿ‬/‫ﺘﺮﺒﻴﺘﻲ ﻴﺎﻓﺘﻪ ﺼﺤت ﺎر ن )ڊا ﺮ‬ (‫ ﻤڊواﺌﻴف‬/‫ ﻨﺮﺴﺮي‬/‫وي‬ LHW

‫اﻴل اﻴﭿ ڊﺒﻠﻴو‬

Community Volunteer

Radio / TV

Newspaper

Other (Specify)__________________

Home

CMW/ TBA’s home

Private Health facility

BHU/ RHC

THQ/ DHQ

Other (Specify) ____________

Convenience

Cost

Confidence in the provider’s ability

Advice from provider

Advice from family

Other (Specify)___________________

LHW

CMW

Community Volunteer

Friend/ relative

TBA/ Dai

Doctor/ LHV/ Paramedic

Other (Specify)__________________

TBA/ Dai

CMW

LHV

Doctor

Other (Specify)_____________________

‫ﮙوﭡﺎﭩو رﻀﺎ ﺎر‬ ‫ ﻴﻠﻴوﻴﺰن‬/ ‫رﻴڊﻴو‬ ‫اﺨﺒﺎر‬

______________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﮕﮭﺮ‬ ‫ﻤڊواﺌﻴف ﻴﺎ داﺌﻲ ﺠو ﮕﮭﺮ‬ ‫ﭙﺮاﺌﻴوﻴٽ اﺴﭙﺘﺎل‬ ‫ آر اﻴﭿ ﻴو‬/ ‫ﺒﻲ اﻴﭿ ﻴو‬ ‫ ﻀﻠﻌﺎ اﺴﭙﺘﺎل‬/ ‫ﺘﻌﻠﻘو‬

__________________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﺴﮭوﻟت‬ ‫ﺨﺮچ‬

‫ﺼﺤت ﺎر ن ﺠﻲ ﻗﺎﺒﻠﻴت ﺘﻲ اﻋﺘﻤﺎد‬ ‫ﺼﺤت ﺎر ن ﺠﻲ ﺼﻼح‬ ‫ﮕﮭﺮ ﭝﺎﺘﻴن ﺠﻲ ﺼﻼح‬

_________________(‫ و ﺒﻪ ﭕﻴو )ﻟﮑو‬ ‫اﻴل اﻴﭿ ڊﺒﻠﻴو‬ ‫ﻤڊواﺌﻴف‬ ‫ﮙوﭡﺎﭩو رﻀﺎ ﺎر‬ ‫ ﻋﺰﻴﺰ‬/ ‫دوﺴت‬ ‫داﺌﻲ‬

‫ ﭙﺌﺮاﻤﻴڊڪ‬/ ‫ اﻴل اﻴﭿ وي‬/‫ڊا ﺮ‬ ____________(‫ و ﭕﻴو ﺒﻪ )ﻟﮑو‬

:‫ھداﻴت‬ ‫ﺠﻴ ڏھن‬ ‫ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺠو‬404 ‫ﺠواب و ﺒﻪ‬ ‫ﺼﺤت‬ ‫ﻤﺮ ﺰ آھﻲ‬ ‫ﺘﻪ ھﻲ ﺴوال‬ ‫ﭙﮁو‬

‫داﺌﻲ‬ ‫ﻤڊواﺌﻴف‬ ‫اﻴل اﻴﭿ وي‬ ‫ڊا ﺮ‬ 12

87 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

408.

What was outcome of last delivery?

‫آﺨﺮي وﻴم ﺠو ﮭ و ﻨﺘﻴﺠو ﻨ ﺘو؟‬

________________(‫ و ﭕﻴو ﺒﻪ )ﻟﮑو‬

Normal Health Child

Still birth

Child with congenital abnormality

Other (specify)_______

‫ﻤﺮده ﭕﺎر ﺠﻲ ﭙﻴداﺌش‬

What was the cost of your most recent delivery?

‫آﺨﺮي وﻴم دوران ﺘوھﺎن ﺠو ﻴﺘﺮو ﺨﺮچ آﻴو؟‬

‫ﭙﻴداﺌﺸﻲ ﻨﻘص‬

____________(‫ و ﺒﻪ ﭕﻴو)ﻟﮑو‬

99. Don’t know 409.

‫ﻤﻨﺎﺴب ﺼﺤت وارو ﭕﺎر‬

Rs._____________

Not Applicable

‫ﺨﺒﺮ ﻨﺎھﻲ‬ ____________‫ ﻴﺘﺮا ﭙﺌﺴﺎ‬

99. Don’t know 410.

In your opinion, what is the best place for child delivery?

‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ ﺴڀ ﮑﺎن ﺒﮭﺘﺮ وﻴم ﺠﻲ ﺠﮙﮭﻪ‬ ‫ ﮭ ي ھﺌﻲ؟‬

411.

Who is the best person to provide medical care during labor and delivery?

‫وﻴم ۽ وﻴم دوران ﺴڀ ﮑﺎن ﺒﮭﺘﺮ ﻋﻼج ﺠون‬ ‫ﺴﮭوﻟﺘون ﻴﺮ ﻓﺮاھم ﺮي ﭥو؟‬

‫ﺨﺒﺮ ﻨﺎھﻲ‬

Home

Friend/ neighbor/ relative home

Dai/ TBA home

CMW home

LHV facility

BHU/ RHC

THQ/ DHQ

Private facility

Other (specify)_____________

‫ﮕﮭﺮ‬

‫ ﻋﺰﻴﺰ ﺠو ﮕﮭﺮ‬/ ‫ ﭙﺎڙﻴﺴﺮي‬/‫دوﺴت‬ ‫داﺌﻲ ﺠو ﮕﮭﺮ‬ ‫ﻤڊواﺌﻴف ﺠو ﮕﮭﺮ‬ ‫اﻴل اﻴﭿ وي ﺠو ﻤﺮ ﺰ‬

‫ ﮙوﭡﺎﭩو ﺼﺤت ﻤﺮ ﺰ‬/‫ﺒﻨﻴﺎد ﺼﺤت ﻤﺮ ﺰ‬

10. TBA/ Dai

‫ ﻀﻠﻌو اﺴﭙﺘﺎل‬/ ‫ﺘﻌﻠﻘو‬ ‫ﺨﺎﻨﮕﻲ اﺴﭙﺘﺎل‬

____________(‫ﭕﻴو ﺠﮭﻪ ﺒﻪ )ﻟﮑو‬ ‫داﺌﻲ‬

11. CMW

‫ﻤڊ واﺌﻴف‬

12. LHV

‫اﻴل اﻴﭿ وي‬

13. Doctor 14. Other (Specify)_______________

‫ڊا ﺮ‬

______________(‫ﭕﻴو ﺠﮭﻪ ﺒﻪ )ﻟﮑو‬

Addressing Delays for Access to EmONC 88 in Non-LHW Areas of Pakistan

â&#x20AC;Ť Ř˛ď˝ďŽ&#x2022;ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďş¨ŘˇďşŽďť¨ďş&#x17D;ÚŞ ďş¤ďş&#x17D;ďť&#x;ŘŞ Űž ďť¤ďş&#x17D;ÚžďşŽŘ§ďť¨ďťŞ ďş´ďş&#x17D;Řąďş´ďť¨ď?ďş&#x17D;Ů&#x201E;â&#x20AC;Ź:5 â&#x20AC;Ťďş´ ďť´ďş¸Ů&#x2020;â&#x20AC;Ź Skip Response â&#x20AC;Ťďş Ů&#x2C6;Ř§Ř¨â&#x20AC;Ź â&#x20AC;ŤďŽ Ú?Ů&#x160; Ú?ďť´Ů&#x2C6;â&#x20AC;Ź Do you know of any medical problems you had 1. Yes â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź before you became pregnant? 2. No â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź â&#x20AC;ŤďŽ ďş&#x17D; ďş¤ďş&#x17D;ďť¤ďťź ďĽďť´Úť ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ď&#x2122;ďŽďşŽďť´Ů&#x2020; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽ&#x2018;ďť˛ Ů&#x2C6; Řˇďş&#x2019;ďť˛â&#x20AC;Ź â&#x20AC;Ť ďť¤ďş´ďş&#x152;ďť Ů&#x2C6; Úžďť´Ů&#x2C6;Ř&#x;â&#x20AC;Ź99. Donâ&#x20AC;&#x2122;t know â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

Section 5: Skilled Care for Obstetric Emergencies No. Question â&#x20AC;Ťďş´Ů&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź 501.

502. Have you ever had any complications during your pregnancy?

â&#x20AC;ŤďŽ ďş&#x17D; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽ&#x2018;ďť˛ ďş¤ďť¤Ů&#x201E; ďş ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ďť˛ ď&#x2122;ďť´ď˝ďť´ŘŻďŽ&#x2022;ďť´Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;ŤÚžďť´Ů&#x2C6;Ů&#x2020;Ř&#x;â&#x20AC;Ź

Yes

If 2 or 99 then go to 601

â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99. Donâ&#x20AC;&#x2122;t know

â&#x20AC;Ť ďť´ďş&#x17D;â&#x20AC;Ź2 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;Ů&#x2C6;ŘĄ ďş´Ů&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź Ů? â&#x20AC;Ť ďş&#x2DC;ďťŞâ&#x20AC;Ź99 â&#x20AC;Ť ďş&#x2DC;ďť˛â&#x20AC;Ź601 â&#x20AC;Ťďť¨ďť¤ďş&#x2019;ďşŽâ&#x20AC;Ź â&#x20AC;ŤŮ&#x2C6;ďšŮ&#x2C6;â&#x20AC;Ź

Complications during pregnancy

(read responses to the interviewee)

During childbirth

(Allow multiple responses)

During the first 40 days after delivery

503. If yes when were they?

â&#x20AC;Ť Ř§Úžďť˛ Ú?ÚžŮ&#x2020; ďĽďť´ďş&#x17D;Ř&#x;â&#x20AC;ŹŘ&#x152; â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; Úžďş&#x17D;â&#x20AC;Ź

(â&#x20AC;Ť)Ř§ďť¨Â&#x2020;ďşŽŮ&#x2C6;ďť´Ů&#x2C6; Ú?ďť´Úť Ů&#x2C6;Ř§ŘąŘ§Ů&#x160; ďş ďş&#x17D; ďş Ů&#x2C6;Ř§Ř¨ ď&#x2122;Â&#x201A;ÚžŮ&#x2C6;â&#x20AC;Ź (â&#x20AC;Ť)ďŽ&#x2022;ďŽďŠďş&#x17D; ďş Ů&#x2C6;Ř§ďş&#x2019;Ů&#x2020; ďş ďť˛ Ř§ďş ďş&#x17D;Ř˛ŘŞ Ř˘Úžďť˛â&#x20AC;Ź

504. Was treatment sought for complications?

â&#x20AC;ŤďŽ ďş&#x17D; ď&#x2122;ďť´ď˝ŘŻďŽ&#x2022;ďť´Ů&#x2020; ďş Ů&#x2C6; ďť&#x2039;ďťźŘŹ ďť´Ů&#x2C6; Ů&#x2C6;ďť´Ů&#x2C6;Ř&#x;â&#x20AC;Ź

505. If no, why not?

â&#x20AC;Ť ďş&#x2DC;ďťŞ ď&#x2122;Ů&#x2C6; Ů?ŘĄ ďŽ ďş&#x17D; ďťť Ů?ŘĄŘ&#x;â&#x20AC;ŹŘ&#x152; â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; ďť¨ďťŞâ&#x20AC;Ź

â&#x20AC;Ťďş¤ďş&#x17D;ďť¤Ů&#x201E; ďş ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020; ď&#x2122;ďť´ď˝ďť´ŘŻďŽ&#x2022;ďť´Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďť´ŘŻŘ§ďş&#x152;Ř´ ďş ďť˛ ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020;â&#x20AC;Ź

â&#x20AC;Ť Ú?ďť´ďť¨ďŽŮ&#x2020; ďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6; Ů?ŘĄâ&#x20AC;Ź40 â&#x20AC;Ťď&#x2122;ďť´ŘŻŘ§ďş&#x152;Ř´ ďş ďť˛â&#x20AC;Ź

2. No

Did not think the ailment was serious

Thought that will get better on own

Discussed with elder or community elder who suggested staying home

â&#x20AC;Ťďş&#x2019;ďť´ďť¤ďş&#x17D;ŘąŮ&#x160; ďŽ&#x2018;ďť˛ ďş´ďť¨ďş ďť´ŘŻďŽ&#x2022;ďť˛ ďş´ďş&#x17D;Ů&#x2020; ďť¨ďťŞ Ů&#x2C6;Řąďş&#x2DC;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;Ťďş´Ů&#x2C6;ď˝ďť´Ů&#x2C6; ďş&#x2DC;ďťŞ ďş¨Ů&#x2C6;ŘŻ ďş&#x2019;ďş¨Ů&#x2C6;ŘŻ ďĄďť´ÚŞ ďĽďť˛ Ů&#x2C6;ďť´ďť¨ŘŻŮ&#x2C6;â&#x20AC;Ź

â&#x20AC;ŤŮ&#x2C6;Ú?Ů&#x2020; ďş´ďş&#x17D;Ů&#x2020; ďşźďťźŘ ďť¤ďş¸Ů&#x2C6;ŘąŮ&#x2C6; ďşŽÚť ďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6; Ů?ŘĄ ďŽ&#x2022;ďŽďşŽ Űžâ&#x20AC;Ź â&#x20AC;ŤŘąÚžŮ&#x2C6;â&#x20AC;Ź

Other (Specify)______________

_____________(â&#x20AC;Ť Ů&#x2C6; ď&#x2022;ďť´Ů&#x2C6; )ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99. Donâ&#x20AC;&#x2122;t know

â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; Úžďş&#x17D; ďş&#x2DC;ďťŞ ď&#x2122;Ů&#x2C6; Ů?ŘĄ ďť&#x2039;ďťźŘŹ ďşŽÚť ďş ďť˛ ďť&#x201C;ďť´ďşźďť ďť˛ Ů&#x2C6;ďĄÚťâ&#x20AC;Ź â&#x20AC;ŤŰž ďť´ďş&#x2DC;ďşŽŮ&#x2C6; Â&#x2021;ďş&#x17D;ďş&#x152;ďť´Ů&#x2026; ďť&#x;ďŽ&#x2122;Ů&#x2C6;Ř&#x;â&#x20AC;Ź

507. Who was involved in making the initial decision that you (woman) should go for treatment?

â&#x20AC;Ťďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽ&#x2018;ďť˛ ďť&#x2039;ďťźŘŹ ďťť Ů?ŘĄ Ů&#x2C6;ďšÚť ďŽ&#x2022;ďŽďşŽďş ďť˛ ďş Ů&#x2C6; ďş¸ďşŽŮ&#x2C6;ďť&#x2039;ďş&#x17D;ďş&#x2DC;ďť˛â&#x20AC;Ź â&#x20AC;Ťďť&#x201C;ďť´ďşźďť Ů&#x2C6; ďť¨ďŽŮ&#x2020; Ů&#x2C6;Řąďş&#x2DC;Ů&#x2C6; Ř&#x;â&#x20AC;Ź

(mark all that apply)

(â&#x20AC;Ť)Ú?ďť¨Ů&#x201E; ďş Ů&#x2C6;Ř§ďş&#x2019;Ů&#x2020; ďş&#x2DC;ďť˛ ďť¨ďş¸ďş&#x17D;ďť¨Ů&#x2C6; ďť&#x;ďŽ&#x2122;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;Ť ďş&#x2DC;ďťŞâ&#x20AC;Ź1 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;Ťď&#x2122;Ů&#x2C6; Ů?ŘĄ ďş´Ů&#x2C6;Ř§Ů&#x201E; ďť¨ďť¤ďş&#x2019;ďşŽâ&#x20AC;Ź â&#x20AC;Ť ďş&#x2DC;ďť˛ Ů&#x2C6;ďšŮ&#x2C6;â&#x20AC;Ź506

506. If yes, how much time was taken to take decision for the treatment?

If 1 then go to 506

â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź

1. Yes

Immediately

After 1-6 hours

After 7-12 hours

13-24 hours

Between 1 and 2 days

More than 2 days

â&#x20AC;Ťďş ďť ŘŻâ&#x20AC;Ź â&#x20AC;Ť ďťź Ů&#x2020; ďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6; Ů?ŘĄâ&#x20AC;Ź6 â&#x20AC;ŤÚžÚŞ ďŽ&#x2018;ďş&#x17D;Ů&#x2020;â&#x20AC;Ź â&#x20AC;ŤďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6;ŘĄâ&#x20AC;Ź â&#x20AC;Ť ďťź Ů&#x2020;â&#x20AC;Ź12 â&#x20AC;Ť ďŽ&#x2018;ďş&#x17D;Ů&#x2020;â&#x20AC;Ź7 Ů? â&#x20AC;ŤďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6;ŘĄâ&#x20AC;Ź â&#x20AC;Ť ďťź Ů&#x2020;â&#x20AC;Ź24 â&#x20AC;Ť ďŽ&#x2018;ďş&#x17D;Ů&#x2020;â&#x20AC;Ź13 Ů?

â&#x20AC;ŤÚžÚŞ ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ď&#x2022;ďť¨ďŽďť˛ Ú?ďť´ďť¨ďŽŮ&#x2020; ďş ďť˛ Ů&#x2C6;Ú&#x2020; Űžâ&#x20AC;Ź

99. Don't know 1. Myself 2.

Husband

Father

â&#x20AC;Ťď&#x2022;Ů&#x2020; Ú?ďť´ďť¨ďŽŮ&#x2020; ďŽ&#x2018;ďş&#x17D;ďť¨ď&#x2122;Ů&#x2C6; Ů?ŘĄâ&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź â&#x20AC;Ťďş¨Ů&#x2C6;ŘŻâ&#x20AC;Ź â&#x20AC;Ťďť¤Â&#x2122;Řłâ&#x20AC;Ź â&#x20AC;Ťď&#x2122;ďť˛ Ů?ŘĄâ&#x20AC;Ź 14

89 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Mother

Father in law

Mother in law

Brother

Sister

Brother in law

‫ﻤﺎ ُء‬ ‫ﺴﮭﺮو‬ ‫ﺴس‬ ‫ﭝﺎ ُء‬ ‫ﭝﻴڻ‬ ‫ڏﻴﺮ‬

10. Sister in law 11. Other (Specify)________________

508. Who made the final decision that you should be taken for treatment?

‫ﻋﻼج ﻻ ِء وﭡﻲ وﭹڻ ﺠو آﺨﺮي ﻓﻴﺼﻠو ﻨﮭن‬ ‫ ﻴو؟‬

______________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬

99. Don't know Myself

‫ﺨود‬

Husband

‫ﻤ س‬

Father

‫ﭙﻲ ُء‬

Mother

‫ﻤﺎ ُء‬

Father in law

‫ﺴﮭﺮو‬

Mother in law

‫ﺴس‬

Brother

‫ﭝﺎ ُء‬

Sister

‫ﭝﻴڻ‬

Brother in law

‫ڏﻴﺮ‬

Sister in law

‫ڏﻴﺮاﭩﻲ‬

Other (Specify)________________

______________(‫ و ﭕﻴو )ﻟﮑو‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬

Don't know

509. Where were you taken for treatment? Prompt: Did you go to see anyone else? (Mark all that apply)

‫ﻋﻼج ﻻ ِء ﺘوھﺎن ﻨﮭن وٽ وﻴﺎ؟‬ ‫ ﺘوھﺎن ﭕﺌﻲ ﻨﮭن وٽ ﺒﻪ وﭹڻ ﭽﺎھﻴو‬: ‫ﺠﻠدي ﭙﮁو‬ ‫ﭙﻴﺎ؟‬ (‫)ڏﻨل ﺠواﺒن ﺘﻲ ﻨﺸﺎن ﻟﮙﺎﻴو‬

‫ڏﻴﺮاﭩﻲ‬

Lady Health Worker

TBA

Dispensary

Local government hospital or clinic

District government hospital

Tehsil Hospital

Private Clinic or Hospital

Private Doctor

Pharmacist

‫ﻟﻴڊي ھﻴﻠٿ ور ﺮ‬ ‫داﺌﻲ‬ ‫ڊﺴﭙﻴﻨﺴﺮي‬

‫ﻟو ل ﮕورﻨﻤﻴﻨٽ اﺴﭙﺘﺎل ﻴﺎ دوا ﺨﺎﻨو‬ ‫ﻀﻠﻌﺎ ﺤ وﻤت اﺴﭙﺘﺎل‬ ‫ﺘﻌﻠﻘﺎ اﺴﭙﺘﺎل‬

‫ﺨﺎﻨﮕﻲ دوا ﺨﺎﻨو ﻴﺎ اﺴﭙﺘﺎل‬ ‫ﭙﺮاﺌﻴوﻴٽ ڊا ﺮ‬ ‫ﻤﻴڊﻴ ل اﺴ ور‬ 15

Addressing Delays for Access to EmONC 90 in Non-LHW Areas of Pakistan

10. Pir/ Faqir 11. Traditional healer (including Hakim & homeopath)

‫ ﻓﻘﻴﺮ‬/ ‫ﭙﻴﺮ‬

( ‫رواﻴﺘﻲ ﻋﻼج )ﺤ ﻴم ۽ ھوﻤﭙﻴﭥڪ‬

12. Other (Specify)_____________

______________(‫ و ﭕﻴو )ﻟﮑو‬

99. Don't know 510. If necessary would you go to the same person again?

‫ﺠﻴ ڏھن ﻀﺮوري آھﻲ ﺘﻪ ﺘوھﺎن ﺴﺎﮙﻲ ﻤﺎﭩﮭو‬ ‫وٽ ﭕﻴﮭﺮ وﻴﻨدا؟‬

511. If yes, then why?

1. 2.

‫ﺨﺒﺮ ﻨﺎھﻲ‬ ‫ھﺎ‬

Yes

If 2 then go to 512

‫ ﺘﻪ‬2 ‫ﺠﻴ ڏھن‬ ‫ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو‬512

‫ﻨﻪ‬

‫ ﺘﻪ ﮁو؟‬،‫ﺠﻴ ڏھن ھﺎ‬

512. If no, then why not?

‫ ﺘﻪ ﮁﺎ ﻻ ِء؟‬،‫ﺠﻴ ڏھن ﻨﻪ‬

513. If necessary would you go to the same facility again?

‫ھﺎ‬

Yes

Vomiting

Shortness of breath

(‫)ﻤﺜﺎل طور ﮭ ﻴون ﻨﺸﺎﻴون‬

Severe headache

‫ڏﻨل ﺠواﺒن ﺘﻲ ﻨﺸﺎن ﻟﮙﺎﻴو‬

Swelling of face

Severe lower abdominal pain

Heavy menstrual bleeding

High blood pressure

Fits or convulsions

Anemia/ pale color of body

‫ﺠﻴ ڏھن ﻀﺮوري آھﻲ ﺘﻪ ﺘوھﺎن ﺴﺎﮙﻲ ﺼﺤت‬ ‫ﻤﺮ ﺰ وﻴﻨدا؟‬

514. If yes, then why? 515. If no, then why not?

‫ ﺘﻪ‬2 ‫ﺠﻴ ڏھن‬ ‫ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو‬515

‫ ﺘﻪ ﮁو؟‬،‫ﺠﻴ ڏھن ھﺎ‬ ‫ ﺘﻪ ﮁﺎ ﻻ ِء؟‬،‫ﺠﻴ ڏھن ﻨﻪ‬

516. What prompted you (woman) to seek treatment?

‫ﻻء ﻤﺠﺒور‬ ِ ‫ﺘوھﺎن ﮑﻲ ﮭ ي ﺸﻲ ِء ﻋﻼج ﺮڻ‬ ‫ ﻴو؟‬

(e.g. what symptoms) (mark all that apply)

‫ﻨﻪ‬

If 2 then go to 515

‫اُﻟ ﻴون‬ ‫ﺴﺎھﻪ ۾ ﺘ ﻠﻴف‬ ‫ﮕﮭﭩو ﻤﭥﻲ ۾ ﺴور‬ ‫ﭽﮭﺮي ﺘﻲ ﺴوج‬

‫ﭙﻴٽ ﺠﻲ ھﻴٺ ﺤﺼﻲ ۾ ﺘ ﻠﻴف‬ ‫ﮕﮭﭩﻲ ﻤﺎھواري اﭽڻ‬ ‫ﮕﮭﭩو ﺒﻠڊﭙﺮﻴﺸﺮ‬ ‫ﺠﮭ ﺎ‬

‫ ﺠﺴم ﺠو ِﭙﻴﻠو ﭥﻴڻ‬، ‫رت ﺠﻲ ﮕﮭ ﺘﺎﺌﻲ‬

10. Jaundice/ yellow color of body or eyes

‫ ﺠﺴم ﻴﺎ اﮑﻴن ﺠو ِﭙﻴﻠو ﭥﻴڻ‬/‫ﺴﺎﺌﻲ‬

11. Other (Specify)____________________ 99. Don’t Know 517. Once the decision was made to take you for treatment, when did you go?

‫ھڪ دﻓﻌو ﻋﻼج ﻻ ِء ﻓﻴﺼﻠو ﭥﻲ وﻴو ﺘﻪ اوھﺎن‬ ‫ ڏھن وﻴﺎ؟‬

(i.e.; immediately, e.g. within 1 hour or was there

Immediately

After 1-6 hours

After 6-12 hours

____________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬ ‫ان وﻗت‬ ‫ ﻼ ن ﺠﻲ اﻨدر‬6 ‫ ﮑﺎن‬1

If 1 or 2 then go to 519

2 ‫ ﻴﺎ‬1 ‫ﺠﻴ ڏھن‬ ‫ﺘﻪ ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو‬519 16

91 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

a delay)

‫ ھڪ ﻼڪ ﺠﻲ اﻨدر ﻴﺎ‬، ‫)ﻤﺜﺎل طور ان وﻗت‬ (‫ان ۾ دﻴﺮ ﻟﮙﻲ‬

‫ ﻼ ن ﺠﻲ اﻨدر‬12 ‫ ﮑﺎن‬6

Between 1 and 2 days

More than 2 days

‫ھڪ ﮑﺎن ﭕن ڏﻴﻨﮭن ﺠﻲ وچ ۾‬ ‫ﭕن ڏﻴﻨﮭن ﮑﺎن وڌﻴڪ‬

99. Don't know 518. If there was a delay (more than 6 hours in question above) what was the reason for the delay?

‫ﺠﻴ ڏھن دﻴﺮ ﭥﻲ ﺘﻪ ان ﺠو ﮭ و ﺴﺒب ھو)ﻤﭥﻲ‬ (‫ ﻼ ن ﮑﺎن وڌﻴڪ‬6 ‫ڏﻨل ﺴوال ﻤطﺎﺒق‬

519. Was it difficult to find the funds to send you for treatment?

‫ﮁﺎ ﺘوھﺎن ﮑﻲ ﻋﻼج ﻻ ِء ﻤو ﻠڻ دوران ﭙﺌﺴﺎ‬ ‫ھٿ ﺮڻ ۾ ﻤﺸ ﻼت ﭙﻴش آﺌﻲ؟‬

520. Where did the funds come from for you to go for treatment? (i.e. who paid?)

‫ﺨﺒﺮ ﻨﺎھﻲ‬

Had to discuss with family

Husband wasn’t home

Had to generate funds

Did not have means of transport

Didn’t know where to go

Elders/ others prohibited

Other (Specify)______________

Yes

‫ﮕﮭﺮ ﭝﺎﺘﻴن ﺴﺎن ﺼﻼح ﻤﺸورو ﺮﭩو ھﻴو‬ ‫ﻤ س ﮕﮭﺮ ۾ ﻤوﺠود ﻨﻪ ھﻴو‬

‫ﭙﺌﺴن ﺠو اﻨﺘظﺎم ﺮﭩو ھﻴو‬ ‫ﮕﺎڏي ﺠو اﻨﺘظﺎم ﻨﻪ ھﻴو‬

‫ﺨﺒﺮ ﻨﻪ ھﺌﻲ ﺘﻪ ﺎڏي وﭹﭩو آھﻲ‬ ‫ ﭕﻴن اﻋﺘﺮاض ﻴو‬/ ‫ﺒﺰرﮕن‬

_____________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ھﺎ‬ ‫ﻨﻪ‬

99. Don’t Know ‫ﺨﺒﺮ ﻨﺎھﻲ‬ 1. Own funds from my own savings

‫ﺠﻤﻊ ﻴل رﻗم ﺨﺮچ ﺌﻲ‬

From savings from the family

From village committee

From loan

Selling household items/ livestock etc

Other(Specify)_____________________

521. Was it difficult to find transport to send you for treatment?

Yes

522. What was mode of transport to take you for treatment?

Own transport

Public transport

Taxi

Ambulance

Other (Specify)_________________

Rs.____________

‫ﺘوھﺎن ﮑﻲ ﻋﻼج ﺮڻ ﻻ ِء ﭙﺌﺴﺎ ﭥﺎن آﻴﺎ ) ﻨﮭن‬ ‫ڏﻨﺎ(؟‬

‫ﮁﺎ ﻋﻼج ﻻ ِء وﭹڻ دوران ﺴواري ﮙوﻟڻ ۾‬ ‫ﻤﺸ ﻼت ﭙﻴش آﺌﻲ؟‬

‫ﮁﺎ ﻋﻼج وﭹڻ ﻻ ِء ﮭ ي ﺴواري ھﺌﻲ؟‬

523. How much did the transport cost?

‫ﺴواري ﻻ ِء ﻴﺘﺮو ﺨﺮچ آﻴو؟‬

‫ﮕﮭﺮ ﭝﺎﺘﻴن ﺠﻲ ﺠﻤﻊ ﻴل رﻗم‬ ‫ﮙوﭡﺎﭩﻲ ﻤﻴ ﻲ ﮑﺎن‬ ‫ﻗﺮض ﻤﺎن‬

‫ ﭽوﭙﺎﻴو وﻏﻴﺮه‬/ ‫ﮕﮭﺮ ﺠون ﺸﻴون و ﭩﻲ ﺮي‬ _____________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ھﺎ‬ ‫ﻨﻪ‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬

99. Don’t Know

99. Don’t know

‫ﭙﻨﮭﻨﺠﻲ ﺴواري‬ ‫ﭙﺒﻠڪ ﺮاﻨﺴﭙورٽ‬ ‫ ﻴ ﺴﻲ‬ ‫اﻴﻤﺒوﻟﻨس‬

_______________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ____________‫ﭙﺌﺴﺎ ﻟﮑو‬ 17

Addressing Delays for Access to EmONC 92 in Non-LHW Areas of Pakistan

524. How long did it take to get there?

тАл╪зя║Шя╗▓ янЩяонян╜┌╗ я╗╗ ┘Р╪б я╗┤я║Шя║о┘И ┘Ия╗Ч╪к я╗ЯяоЩ┘И╪ЯтАм

525. When you got to the facility how long did you have to wait before being evaluated?

тАля║а┌П┌╛┘Ж я║Ш┘И┌╛я║О┘Ж я║╝я║д╪к я╗дя║о я║░ янЩяоня║Шя║О я║Шя╗к я╗Ля╗╝╪м я║╕я║о┘И╪╣тАм тАлянея╗┤┌╗ яоСя║О┘Ж янЩяоня║оя╗┤┘Ж я╗┤я║Шя║о┘И ╪зя╗ия║Ш╪╕я║О╪▒ я╗┤┘И╪ЯтАм

526. Who evaluated you?

тАля║Ш┘И┌╛я║О┘Ж я║а┘И я╗дя╗Мя║Оя║Мя╗и┘И я╗ияон┘Ж я╗┤┘И╪ЯтАм

тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм тАл я╗╝┌к я╗┤я║О яоХяон┘╜тАм1 тАл я╗╝┌ктАм2 тАл яоСя║О┘ЖтАм1 тАл я╗╝┌ктАм4 тАл яоСя║О┘ЖтАм2 тАл я╗╝ ┘Ж яоСя║О┘Ж ┘И┌Мя╗┤┌ктАм4

<1 Hour

1-2 hours

2-4 Hours

>4 Hours

< 30 min

30 min - 1 Hour

2-4 Hours

>4 Hours

Lady Health Worker

Trained Birth Attendant

CMW

Nurse

Lady Doctor

Gynecologist

Other (Specify)________________

тАля║Ш┘И┌╛я║О┘Ж яоСя╗▓ я╗┤я║Шя║о┘К ╪▒я╗Ч┘Е я║ия║о┌Ж я║оянйя╗▓ янЩя║Мя╗▓╪ЯтАм

тАля╗Яя╗┤┌К┘К ┌╛я╗┤я╗а┘┐ ┘И╪▒ я║отАм тАл╪п╪зя║Мя╗▓тАм тАл я╗дя╗┤┘Ия╗и┬Ая╗▓ я╗д┌К┘И╪зя║Мя╗┤┘БтАм

тАля╗ия║о╪│тАм

тАля╗Яя╗┤┌К┘К ┌К╪з ┬Ая║отАм тАл┌К╪зя║Мя╗ия║Оя╗╗я║ая║┤┬А┌ктАм

____________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм

99. Don't know 527. How much did you have to pay?

тАл╪з┌М я╗╝┌к яоСя║Оя╗иянЩ┘И ┘Р╪бтАм тАл я╗╝┌ктАм1 тАл я╗дя╗и┘╜ я╗┤я║ОтАм30 тАля║ая╗▓ ╪п┘И╪▒╪з┘ЖтАм тАл я╗╝┌ктАм3 тАл яоСя║О┘ЖтАм2 тАл я╗╝┌к яоСя║О┘Ж ┘И┌Мя╗┤┌ктАм4

Rs.____________

99. DonтАЩt know

тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм ____________тАлянЩя║Мя║┤я║О я╗ЯяоС┘ИтАм тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм

528. Did they refer you to some other facility or provider?

Yes

529. If YES: Where to?

THQ

DHQ

Private Facility

To the city (to a larger hospital)

Other (Specify)________________

тАляоБя║О ╪зя╗ияон┘Ж я║Ш┘И┌╛я║О┘Ж яоСя╗▓ я╗ияон┘Ж янХя╗▓ я║┤яон┘Ия╗Я╪к я╗дя║о я║░ я╗┤я║ОтАм тАля║╝я║д╪к я║О╪▒ ┘Ж ┌П╪зя╗ияон┘Ж я╗д┘И я╗ая╗┤┘И╪ЯтАм

530. Did you go there?

тАл я║Шя╗к я╗┤┌П╪зя╗ияон┘Ж╪ЯтАм: тАля║ая╗┤ ┌П┌╛┘Ж ┌╛я║ОтАм

тАляоБя║О я║Ш┘И┌╛я║О┘Ж ╪зя║Шя╗▓ ┘Ия╗┤я║О╪ЯтАм

531. Would you go there (to the original Facility) again if necessary?

тАл┌╛я║ОтАм тАля╗ия╗ктАм

If 2 then go to 601

2 тАл я╗┤я║ОтАм1 тАля║ая╗┤ ┌П┌╛┘ЖтАм тАля║Шя╗к янЩ┘И ┘Р╪б я║┤┘И╪з┘Д я╗ия╗дя║Тя║отАм тАл я║Шя╗▓ ┘Иян╣┘ИтАм601

тАля║Шя╗Мя╗ая╗Шя║О ╪зя║┤янЩя║Шя║О┘ДтАм тАля╗Ая╗ая╗Мя║О ╪зя║┤янЩя║Шя║О┘ДтАм тАлянЩя║о╪зя║Мя╗┤┘Ия╗┤┘╜ я║┤яон┘Ия╗Я╪ктАм

(тАля║╕яоня║о ┌П╪зя╗ияон┘Ж ) я╗ияон┘Ж ┘И┌П┘К ╪зя║┤янЩя║Шя║О┘Д █╛тАм

Yes

________________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм тАл┌╛я║ОтАм тАля╗ия╗ктАм тАл┌╛я║ОтАм

If 2 then go to 533 and if 99 then go to 601

93 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

‫ﮁﺎ ﺘوھﺎن اﺘﻲ )ﭙﮭﺮﻴن ﺴﮭوﻟت ﮕﮭﺮ ( وري وﻴﺎ؟‬

‫ﻨﻪ‬

‫ﺨﺒﺮ ﻨﺎھﻲ‬

99. Don’t Know

532. If yes, then why? 533. If no, then why not?

‫ ﺘﻪ‬2 ‫ﺠﻴ ڏھن‬ ‫ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو ۽‬533 ‫ ﺘﻪ‬99 ‫ﺠﻴ ڏھن‬ ‫ ﺘﻲ‬601 ‫ﭙو ِء‬ ‫وﭹو‬

‫ﺠﻴ ڏھن ھﺎ ﺘﻪ ﮁو ؟‬ ‫ ﺘﻪ ﮁو ﻨﻪ؟‬، ‫ﺠﻴ ڏھن ﻨﻪ‬

Section 6: Early Postpartum Care

‫ وﻴم ﮑﺎﻨﭙو ِء ﺠﻲ ﺸﺮوﻋﺎﺘﻲ ﺴﺎرﺴﻨﭝﺎل‬:6 ‫ﺴﻴ ﺸن‬ No. 601.

Question

‫ﺴوال‬

‫ﺠواب‬

Response

In your opinion what danger signs a woman can experience during postpartum period?

‫ﮑﺎﻨﭙوء‬ ‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ ﺎ ﺒﻪ ﻋورت وﻴم‬ ِ ‫ ﮭ ﻴن ﺨطﺮﻨﺎڪ ﻨﺸﺎﻨﻴن ﮑﻲ ﻤﻨﮭن ڏﺌﻲ‬ ‫ﺴﮕﮭﺠﻲ؟‬

None

Bleeding

Severe headache

Blurred vision

Convulsions

High fever

Loss of consciousness

Difficulty in breathing

Severe weakness

‫ ﺎ ﺒﻪ ﻨﻪ‬

Skip

‫ﮁڏي ڏﻴو‬

If 1 or 99 then go to 604

99 ‫ ﻴﺎ‬1 ‫ﺠﻴ ڏھن‬ ‫ﺘﻪ ﭙو ِء ﺴوال ﻨﻤﺒﺮ رت اﭽڻ‬ ‫ ﺘﻲ وﭹو‬604 ‫ﮕﮭﭩو ﻤﭥﻲ ۾ ﺴور‬ ‫ڌﻨڌﻟو ڏﺴڻ‬ ‫ﺠﮭ ﺎ‬

10. Severe abdominal pain

‫ﺘﻴﺰ ﺒﺨﺎر‬ ‫ﺒﻴﮭوﺸﻲ‬

‫ﺴﺎھﻪ ۾ ﺘ ﻠﻴف‬ ‫ﮕﮭﭩﻲ ﻤﺰوري‬ ‫ﭙﻴٽ ۾ ﮕﮭﭩﻲ ﺘ ﻠﻴف‬

11. Other (specify)_______________ 99. Don’t know 602.

In your opinion, can these danger sign risk the life of women?

‫ اھﻲ ﺨطﺮﻨﺎڪ ﻨﺸﺎﻨﻴون ﻋورت‬،‫ﺘوھﺎن ﺠﻲ ﻤطﺎﺒق‬ ‫ﺠﻲ زﻨدﮕﻲ ﻻ ِء ﺨطﺮو آھن؟‬

603.

From whom did you receive the information about danger signs during postpartum period?

‫ﺘوھﺎن وﻴم ﮑﺎﻨﭙو ِء اﻴﻨدڙ ﺨطﺮﻨﺎڪ ﻨﺸﺎﻨﻴن ﺠﻲ‬ ‫ﺒﺎري ۾ ﭵﺎڻ ﻨﮭن ﮑﺎن ﺤﺎﺼل ﺌﻲ؟‬

Yes

99. Don’t Know 1. No one 3.

Friend

Family/ elders

___________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬ ‫ھﺎ‬

If 99 then go to 604

‫ ﺘﻪ‬99 ‫ﺠﻴ ڏھن‬ ‫ﭙو ِء ﺴوال ﻨﻤﺒﺮ‬ ‫ ﺘﻲ وﭹو‬604

‫ﻨﻪ‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬ ‫ ﻨﮭن ﮑﺎن ﻨﻪ‬ ‫دوﺴت‬

Addressing Delays for Access to EmONC 94 in Non-LHW Areas of Pakistan

4. 5.

604.

Did anyone examine you in the first 24 hours after you gave birth?

тАл я╗╝ ┘Ж ╪зя╗и╪п╪▒ я║Ш┘И┌╛я║О┘Ж я║ая╗▓тАм24 тАлянЩя╗┤╪п╪зя║М╪┤ яоСя║Оя╗иянЩ┘И ┘Р╪бтАм тАл я╗ияон┘Ж я╗дя╗Мя║Оя║Мя╗и┘И я╗┤┘И╪ЯтАм 605.

If yes then who examined you?

тАл я║Шя╗к янЩ┘И ┘Р╪б я╗ияон┘Ж я╗дя╗Мя║Оя║Мя╗и┘И я╗┤┘И╪ЯтАм╪М тАля║ая╗┤ ┌П┌╛┘Ж ┌╛я║ОтАм

тАл я║Тя║░╪▒┌птАм/тАляоХяоня║о янЭя║Оя║Шя╗▓тАм

Trained health care provider ( Doctor/ LHV/ Nurse/ CMW)

тАл ╪зя╗┤┘ДтАм/ тАля║Шя║оя║Тя╗┤я║Шя╗▓ я╗┤я║Оя╗Уя║Шя╗к я║╝я║д╪к я║О╪▒ ┘Ж )┌К╪з я║отАм (тАл я╗дя╗┤┘Ия╗и я╗▓ я╗д┌К┘И╪зя║Мя╗┤┘БтАм/ тАл я╗ия║о╪│тАм/тАл╪зя╗┤ян┐ ┘И┘КтАм

LHW

тАл╪зя╗┤┘Д ╪зя╗┤ян┐ ┌Кя║Тя╗ая╗┤┘ИтАм

Community Volunteer

Radio / TV

Newspaper

Other (Specify)_______________

Where were you examined?

тАля║Ш┘И┌╛я║О┘Ж я╗дя╗Мя║Оя║Мя╗и┘И янея╗▓ я║о╪зя╗┤┘И╪ЯтАм

607.

Did anyone come to your home to examine/ evaluate you in the first week after you gave birth?

тАл я╗┤я╗ая╗┤┘Ия╗┤я║░┘ЖтАм/ тАл╪▒я╗┤┌Кя╗┤┘ИтАм

тАл┌╛я║ОтАм тАля╗ия╗ктАм

2. No

Lady Health Worker

Trained Traditional Birth Attendant

Traditional Birth Attendant

Nurse

Lady Doctor

Gynecologist

Other (Specify)_____________

тАля╗Яя╗┤┌К┘К ┌╛я╗┤я╗а┘┐ ┘И╪▒ я║отАм тАля║Шя║оя║Тя╗┤я║Шя╗▓ я╗┤я║Оя╗Уя║Шя╗к ╪п╪зя║Мя╗▓тАм тАл╪п╪зя║Мя╗▓тАм тАля╗ия║о╪│тАм тАля╗Яя╗┤┌К┘К ┌К╪з ┬Пя║отАм тАляоХя║Оя║Мя╗ия║О я║Оя╗Я┘Ия║ая║┤┘╜тАм

___________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм

Home

At the TBAтАЩs home

At CMWтАЩs home/ facility

At other private facility

At BHU/ RHC

At DHQ/ THQ

Yes

Lady Health Worker

тАляоХяоня║о █╛тАм тАл╪п╪зя║Мя╗▓ я║ая╗▓ яоХяоня║отАм

тАл я║╝я║д╪к я╗дя║о я║░тАм/тАл я╗дя╗┤┘Ия╗и┬Пя╗▓ я╗д┌К┘И╪зя║Мя╗┤┘Б я║ая╗▓ яоХяоня║отАм тАлянЩя║о╪зя║Мя╗┤┘Ия╗┤┘╜ я║┤яон┘Ия╗Я╪к я╗дя║о я║░ я║Шя╗▓тАм

тАл яоЩ┘Иянбя║Оянй┘И я║╝я║д╪к я╗дя║о я║░тАм/тАля║Тя╗ия╗┤я║О╪п┘К я║╝я║д╪к я╗дя║о я║░тАм

тАля╗дя╗Мя║Оя║Мя╗и┘И я║о┌╗ я╗╗ ┘Р╪б ╪вя╗┤┘И╪ЯтАм If yes then who?

If 2 then go to 607

тАл я║Шя╗ктАм2 тАля║ая╗┤ ┌П┌╛┘ЖтАм тАлянЩ┘И ┘Р╪б я║┤┘И╪з┘Д я╗ия╗дя║Тя║отАм тАл я║Шя╗▓ ┘Иян╣┘ИтАм607

тАл┘Ия╗┤┘Е я║ая╗▓ ┌╛┌к ┌╛я╗Фя║Шя╗▓ ╪зя╗и╪п╪▒ я║Ш┘И┌╛я║О┘Ж я║ая╗▓ яоХяоня║о ┘ИтАм 608.

тАл╪зя║ия║Тя║О╪▒тАм

____________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм

1. Yes

99. Don't know 606.

тАляоЩ┘Иянбя║Оянй┘И ╪▒я╗Ая║О я║О╪▒тАм

тАл я║Шя╗Мя╗ая╗Ш┘И ╪зя║┤янЩя║Шя║О┘ДтАм/ тАля╗Ая╗ая╗М┘ИтАм тАл┌╛я║ОтАм тАля╗ия╗ктАм

If 2 then go to 609

тАл я║Шя╗ктАм2 тАля║ая╗┤ ┌П┌╛┘ЖтАм тАлянЩ┘И ┘Р╪б я║┤┘И╪з┘Д я╗ия╗дя║Тя║отАм тАл я║Шя╗▓ ┘Иян╣┘ИтАм609 20

95 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

тАля║ая╗┤ ┌П┌╛┘Ж ┌╛я║О я║Шя╗к я╗ияон┘Ж╪ЯтАм

тАля╗Яя╗┤┌К┘К ┌╛я╗┤я╗а┘┐ ┘И╪▒ я║отАм

Trained Traditional Birth Attendant

Traditional Birth Attendant

Nurse

Lady Doctor

Gynecologist

Other (Specify)________________

Did you go to a health facility for your checkup after the delivery?

тАл┘Ия╗┤┘Е яоСя║Оя╗иянЩ┘И ┘Р╪б я║Ш┘И┌╛я║О┘Ж я╗дя╗Мя║Оя║Мя╗ия╗▓ я╗╗ ┘Р╪б я╗ияон┘Ж я║╝я║д╪ктАм тАля╗дя║о я║░ ┘Ия╗┤я║О╪ЯтАм

Yes

701.

Question

тАля╗Яя╗┤┌К┘К ┌К╪з я║отАм

____________(тАл ┘И янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм

тАл я╗ия║Мя╗┤┘Ж ян╡я║О┘И┘Д янХя║О╪▒ я║ая╗▓ я║┤я║О╪▒я║┤я╗иянЭя║О┘ДтАм:7 тАля║┤я╗┤ я║╕┘ЖтАм тАля║┤┘И╪з┘ДтАм

In your opinion what are most common danger sign that a newborn can experience during neonatal period?

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я╗д╪╖я║Оя║Т┘В ┘Ия║Тя╗к я╗ия║М┘И┘Ж ян╡я║О┘И┘Д янХя║О╪▒тАм тАля║╕я║о┘Ия╗Ля║Оя║Шя╗▓ я╗Ля║оя║╝я╗▓ ╪п┘И╪▒╪з┘Ж яон я╗┤┘И┘Ж я║и╪╖я║оя╗ия║О┌ктАм тАля╗ия║╕я║Оя╗ия╗┤┘Ж яоСя╗▓ ┌Пя║┤я╗▓ я║┤яоХяоня╗▓ яне┘И╪ЯтАм

Response

In your opinion can these danger signs risk the life of child?

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я╗д╪╖я║Оя║Т┘В ╪з┌╛я╗▓ я║и╪╖я║оя╗ия║О┌к я╗ия║╕я║Оя╗ия╗┤┘И┘Ж янХя║О╪▒ я║ая╗▓тАм тАл╪▓я╗и╪пяоХя╗▓ я╗╗ ┘Р╪б я║и╪╖я║о┘И ╪в┌╛┘Ж╪ЯтАм

In your opinion what are most important things to be done for health of newborn?

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я╗д╪╖я║Оя║Т┘В ┘Ия╗┤┘Е яоСя║Оя╗иянЩ┘И ┘Р╪б я╗У┘И╪▒┘Ж я╗ия║Мя╗┤┘Ж ян╡я║О┘И┘ДтАм тАлянХя║О╪▒ я║ая╗▓ я║╝я║д╪к я║ая╗▓ я║д┘И╪зя╗Яя╗▓ я║┤я║О┘Ж яон я╗┤┘И┘Ж ╪з┌╛┘ЕтАм

тАляоБ┌П┘К ┌Пя╗┤┘ИтАм

None

Turning Red

Turning Blue

Not Breathing

Not feeding

Excessive Crying

Not Moving

Other (specify)________________

Yes

тАл я║Оя║Тя╗к я╗ия╗ктАм

If 1 or 99 then go to 703

тАл яоСя║О┘ЖтАм1 тАля║ая╗┤ ┌П┌╛┘ЖтАм тАл я║Шя╗к янЩ┘И ┘Р╪б я║┤┘И╪з┘Д яоЩя║О┌Щ┌╛┘И янея╗▓ ┘Иян╣┌╗тАм99 тАл я║Шя╗▓тАм703 тАля╗ия╗дя║Тя║отАм тАл┘Иян╣┘И я╗ия╗┤я║о┘И янея╗┤┌╗тАм тАля║┤я║О┌╛я╗к я╗ия╗к яоСянй┌╗тАм тАлянеян╖ я╗ия╗к янЩя╗┤я║М┌╗тАм тАляоХяонянй┘И ╪▒┘Ия║М┌╗тАм тАля║дя║о ╪к я╗ия╗к я║о┌╗тАм

_________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм тАл┌╛я║ОтАм тАля╗ия╗ктАм тАля║и я║Тя║о я╗ия║О┌╛я╗▓тАм

99. DonтАЩt Know 703.

Skip

тАля║а┘И╪з╪итАм

99. DonтАЩt know. 702.

тАля╗ия║о╪│тАм

тАл┌╛я║ОтАм тАля╗ия╗ктАм

Section 7: Neonatal Care No.

тАл╪п╪зя║Мя╗▓тАм

тАляоХя║Оя║Мя╗ия║О я║Оя╗╗я║ая║┤┘╜тАм

99. Don't know 609.

тАля║Шя║оя║Тя╗┤╪к я╗┤я║Оя╗Уя║Шя╗к ╪п╪зя║Мя╗▓тАм

Bathing

Covering with blanket or chadar

тАлян╡я╗д┌╗ яоСя║Оя╗иянЩ┘И ┘Р╪б ┘И┌╛я╗ия║ая║О╪▒┌╗тАм тАлян╜я║О╪п╪▒ я╗┤я║О ┬Ю┘И╪з┘Д █╛ ┌Н ┌╗тАм 21

Addressing Delays for Access to EmONC 96 in Non-LHW Areas of Pakistan

(Mark all that apply)

‫ﺸﻴون ﺮي ﺴﮕﮭﺠن ﭥﻴون؟‬

Cleaning

(‫)ڏﻨل ﺠواب ﺘﻲ ﻨﺸﺎن ﻟﮙﺎﻴو‬

Showing to family

Feeding with food or medicine

Vaccination

Exclusive Breastfeeding

Other (Specify)_________________

How long after birth was the newborn given bath?

‫ﻨﺌﻴن ﭵﺎول ﭕﺎر ﮑﻲ ﻴﺘﺮي ﻋﺮﺼﻲ ﮑﺎﻨﭙو ِء‬ ‫وھﻨﺠﺎرڻ ﮕﮭﺮﺠﻲ؟‬

Instruction for enumerator: Immediately means bath is given between as soon as the child is born and within 1 hour of birth

‫ ﻓوري طور ﺠو ﻤطﻠب ﭕﺎر‬:‫اﻨﻴوﻤﺮﻴ ﺮ ﻻ ِء ھداﻴﺘون‬ ‫ﺠﻲ ﭙﻴداﺌش ﮑﺎﻨﭙو ِء ھڪ ﻼڪ ﺠﻲ اﻨدر ﺠﻠد‬ ‫ﮑﺎن ﺠﻠد وھﻨﺠﺎرڻ ﮕﮭﺮﺠﻲ‬

705.

In your opinion what is Exclusive Breastfeeding?

‫ﺘوھﺎن ﺠﻲ ﺨﻴﺎل ۾ ﺼﺮف ۽ ﺼﺮف ﻤﺎ ُء ﺠﻲ ﭥﭷ‬ ‫ﻤﺎن ﮁﺎ ﻤﺮاد آھﻲ؟‬

Did you feed your child with the colostrum (please explain as below)?

‫ﮁﺎ ﺘوھﺎن ﭕﺎر ﮑﻲ ﭙﻴداﺌش ﮑﺎﻨﭙو ِء ﭙﮭﺮﻴن ﭥﭷ‬ ‫ﭙﻴﺎري؟‬

707.

‫ ُ ﺎ‬

____________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ﺨﺒﺮ ﻨﺎھﻲ‬

Immediately after birth

1 to 2 hours after birth

2 to 3 hours after birth

3 to 6 hours after birth

6 hours after birth

Don’t remember

Breastfeeding with other milk when mother’s milk is short

‫ﭙﻴداﺌش ﮑﺎن ﻓورن ﺒﻌد‬

‫ ﻼ ن ﮑﺎﻨﭙو ِء‬2 ‫ ﮑﺎن‬1 ‫ﭙﻴداﺌش ﺠﻲ‬ ‫ ﻼ ن ﮑﺎﻨﭙو ِء‬3 ‫ ﮑﺎن‬2 ‫ﭙﻴداﺌش ﺠﻲ‬ ‫ ﻼ ن ﮑﺎﻨﭙو ِء‬6 ‫ ﮑﺎن‬3 ‫ﭙﻴداﺌش ﺠﻲ‬ ‫ ﻼ ن ﮑﺎﻨﭙو ِء‬6 ‫ﭙﻴداﺌش ﺠﻲ‬ ‫ﻴﺎد ﻨﺎھﻲ‬

‫ﺠﻴ ڏھن ﻤﺎ ُء ﺠﻲ ﭥﭷ ﮕﮭٽ آھﻲ ﺘﻪ ﻤﺎ ُء ﺠﻲ ﭥﭷ‬ ‫ﺴﺎن ﮕڏوﮕڏ ﭕﺎھﺮﻴون ﮑﻴﺮ ڏﻴڻ‬

Breastfeeding with other foods when mother’s milk is short

‫ﺠﻴ ڏھن ﻤﺎ ُء ﺠﻲ ﭥﭷ ﮕﮭٽ آھﻲ ﺘﻪ ﭥﭷ ﺴﺎن‬ ‫ﮕڏوﮕڏ ﭕﺌﻲ ﻏذا ڏﻴڻ‬

Breastfeeding with water

Only breastfeeding for a period of six moths

Other(Specify)________________

Yes

‫ﭥﭷ ﺴﺎن ﮕڏ ﭙﺎﭩﻲ ڏﻴڻ‬

‫ ﻤﮭﻴﻨن ﺘﺎﺌﻴن ﺼﺮف ۽ ﺼﺮف ﻤﺎ ُء ﺠو ﮑﻴﺮ ڏﻴڻ‬6 ___________(‫ ﺠﮭﻪ ﭕﻴو )ﻟﮑو‬ ‫ھﺎ‬

‫ﻨﻪ‬

(Colostrum is the thick milk that comes first after delivery)

99. Don’t know

How long after birth did you first put your child to the breast?

‫) وﻟﺴ ﺮم ﺠو ﻤطﻠب اھﺎ ﮕﮭﺎ ﻲ ﭥﭷ آھﻲ ﺠﻴ ﺎ‬ ‫ﭙﻴداﺌش ﮑﺎن ﻓورن ﺒﻌد ﭙﻴﺎري وﻴﻨدي آھﻲ‬

‫ﻏذا ﻴﺎ دوا ﭙﻴﺎراﺌڻ‬

706.

‫ﮕﮭﺮ ﭝﺎﺘﻴن ﮑﻲ ﭕﺎر ڏﻴﮑﺎرڻ‬

‫ﺼﺮف ۽ ﺼﺮف ﻤﺎ ُء ﺠﻲ ﭥﭷ ڏﻴڻ‬

99. Don’t know

704.

‫ﺼﺎف ﺮڻ‬

‫ﺨﺒﺮ ﻨﺎھﻲ‬

Immediately within minutes

‫ﺠﻠد ﺠﮭﻪ ﻤﻨٽ ﮑﺎﻨﭙو ِء‬ 22

97 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

тАлянЩя╗┤╪п╪зя║М╪┤ яоСя║Оя╗иянЩ┘И ┘Р╪б я╗┤┌П┘К я╗дяон┘Д я║Ш┘И┌╛я║О┘Ж янХя║О╪▒ яоСя╗▓ янЩя╗ияоня╗ия║ая╗▓тАм тАляоБя║Оя║Шя╗▓ я║┤я║О┘Ж я╗ЯяоЩя║Оя╗┤┘И╪ЯтАм

708.

Why Exclusive Breastfeeding is necessary for newborn? (Mark all that apply)

тАля║╝я║о┘Б █╜ я║╝я║о┘Б я╗дя║О ┘П╪б я║ая╗▓ янеян╖ я╗ия║Мя╗┤┘Ж ян╡я║О┘И┘Д янХя║О╪▒ я╗╗ ┘Р╪бтАм тАляоБ┘И я╗Ая║о┘И╪▒┘К ╪в┌╛я╗▓╪ЯтАм (тАл) ┌Пя╗и┘Д я║а┘И╪зя║Т┘Ж я║Шя╗▓ я╗ия║╕я║О┘Ж я╗ЯяоЩя║Оя╗┤┘ИтАм

709.

How many months did you exclusively breastfeed your child?

тАл я╗┤я║Шя║о╪з я╗дяоня╗┤я╗ия║О я║Ш┘И┌╛я║О┘Ж янХя║О╪▒ яоСя╗▓ я║╝я║о┘Б █╜ я║╝я║о┘Б янеян╖тАм тАл┌Пя╗и┘И╪ЯтАм

710.

From whom do/ did you receive the information about newborn care and danger signs?

тАля║Ш┘И┌╛я║О┘Ж я╗ияон┘Ж яоСя║О┘Ж я╗ия║Мя╗┤┘Ж ян╡я║О┘И┘Д янХя║О╪▒ я║ая╗▓ я║┤я║О╪▒я║┤я╗иянЭя║О┘ДтАм тАля╗дя║Шя╗Мя╗а┘В █╜ я║и╪╖я║оя╗ия║О┌к я╗ия║╕я║Оя╗ия╗┤┘Ж я║ая╗▓ я║Тя║О╪▒┘К █╛ ян╡я║О┌╗тАм тАля║дя║Оя║╝┘Д я║оя╗┤┘И╪ЯтАм

Hours ______

Days _______

Did not breast feed

Builds strong body

Good for growth

Keeps the child from getting infections

Other (Specify)_________________

None

Less than six months

Six months

Other (specify)______________

DonтАЩt remember

None

Friend

Family/ elders

Trained health care provider (Doctor/ LHV/ Nurse/ CMW)

801.

Question

__________тАл┌Пя╗┤я╗ияон┘ЖтАм тАлянеян╖ я╗ия╗к ┌Пя╗┤┌╗тАм тАля╗дя╗Ая║Т┘И╪╖ я║ая║┤┘ЕтАм тАля║┤янбя╗▓ ┘И╪з┌М ┘Ия╗┤я║аяоня╗ктАм

тАлянХя║О╪▒ яоСя╗▓ я║Тя╗┤я╗дя║О╪▒я╗┤┘Ж яоСя║О┘Ж я║Тян╜я║Оя║М┌╗тАм

__________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля║Тя╗а ┘Д я╗ия╗ктАм тАл я╗дяоня╗┤я╗ия║О яоСя║О┘Ж яоХяон┘╜тАм6 тАл я╗дяоня╗┤я╗ия║ОтАм6 тАлянЩ┘И╪▒╪зтАм

___________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм тАля╗┤я║О╪п я╗ия║О┌╛я╗▓тАм тАл я╗ияон┘Ж яоСя║О┘Ж я║Тя╗к я╗ия╗ктАм тАл╪п┘Ия║┤╪ктАм тАл я║Тя║░╪▒┌птАм/ тАляоХяоня║о я║ая║О янЭя║Оя║Шя╗▓тАм

тАля║Шя║оя║Тя╗┤╪к я╗┤я║Оя╗Уя║Шя╗к я║╝я║д╪к я║О╪▒ ┘Ж ) ┌К╪з ┬Тя║о ╪зя╗┤┘Д ╪зя╗┤ян┐тАм (тАл я╗дя╗┤┘Ия╗и┬Тя╗▓ я╗д┌К┘И╪зя║Мя╗┤┘БтАм/тАл я╗ия║о╪│тАм/тАл┘И┘КтАм

LHW

Community Volunteer

Radio / TV

Newspaper

Other (Specify)________________

тАля║Ш┘И┌╛я║О┘Ж я║ая╗▓ я╗д╪╖я║Оя║Т┘В я║Ш┘И┌╛я║О┘Ж я║ая╗▓ яоЩ┘И┘║ █╛ я╗дя║О ┘П╪б █╜ я╗ия║Мя╗┤┘ЖтАм тАлян╡я║О┘И┘Д янХя║О╪▒ я║ая╗▓ я╗дя║Оя╗Яя╗▓ я╗д╪п╪п я║ая╗▓ я║д┘И╪зя╗Яя╗▓ я║┤я║О┘Ж ┘ИтАм тАл╪╖я║оя╗┤я╗Шя╗┤ я║О╪▒ ╪в┌╛я╗▓╪ЯтАм

тАляоЩ┘Иянбя║Оянй┘И ╪▒я╗Ая║О я║О╪▒тАм тАл ┬Тя╗┤я╗ая╗┤┘Ия╗┤я║░┘ЖтАм/ тАл╪▒я╗┤┌Кя╗┤┘ИтАм тАл╪зя║ия║Тя║О╪▒тАм

: тАл╪зя╗┤я╗дя║оя║ая╗ия║┤я╗▓ █╛ яоЩ┘Иянбя║Оянйя╗▓ я╗д╪п╪птАм

тАля║┤┘И╪з┘ДтАм

In your opinion is there any mechanism in the community to provide financial support for eligible families for EmONC services?

тАля╗Яя╗┤┌К┘К ┌╛я╗┤я╗а┘┐ ┘И╪▒ я║отАм

___________(тАл я║аяоня╗к янХя╗┤┘И )я╗ЯяоС┘ИтАм

Section 8: Community support for emergency services: No.

________ тАл я╗╝┌ктАм

Response 3.

Yes

Skip

тАля║а┘И╪з╪итАм

тАляоБ┌П┘К ┌Пя╗┤┘ИтАм тАл┌╛я║ОтАм тАля╗ия╗ктАм

99. DonтАЩt Know

:8 тАля║┤я╗┤ я║╕┘ЖтАм

If 2 or 99 then go to 803

99 тАл я╗┤я║ОтАм2 тАля║ая╗┤ ┌П┌╛┘ЖтАм тАля║Шя╗к янЩ┘И ┘Р╪б я║┤┘И╪з┘ДтАм тАл я║Шя╗▓тАм803 тАля╗ия╗дя║Тя║отАм тАл┘Иян╣┘ИтАм

тАля║ия║Тя║о я╗ия║О┌╛я╗▓тАм 23

Addressing Delays for Access to EmONC 98 in Non-LHW Areas of Pakistan

802.

If yes, who provided you information about community based mechanism?

â&#x20AC;Ť ďş&#x2DC;ďťŞ ďŽ&#x2122;Ů&#x2C6;Ůş Űž ďť¤Ů&#x2C6;ďş Ů&#x2C6;ŘŻ ŘˇďşŽďť´ďť&#x2DC;ďť˛ ďş&#x17D;Řą ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞâ&#x20AC;ŹŘ&#x152;â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; Úžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽ&#x2018;ďť˛ ďť¨ďŽŮ&#x2020; ďľďş&#x17D;Úť Ú?ďť¨ďť˛Ř&#x;â&#x20AC;Ź

803.

In your opinion is there any community mechanism to provide the support for timely referral?

â&#x20AC;Ťďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďş ďť˛ ďť¤Řˇďş&#x17D;ďş&#x2019;Ů&#x201A; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďş ďť˛ ďŽ&#x2122;Ů&#x2C6;Ůş Űž Řąďť´ďť&#x201D;ďşŽŮ&#x201E; ďş ďť˛â&#x20AC;Ź â&#x20AC;Ťďş¤Ů&#x2C6;Ř§ďť&#x;ďť˛ ďş´ďş&#x17D;Ů&#x2020; Ů&#x2C6; ŘˇďşŽďť´ďť&#x2DC;ďť˛ ďş&#x17D;Řą Ř˘Úžďť˛Ř&#x;â&#x20AC;Ź

Friend or relative

Community Volunteers

TBA/ Dai

Doctor/ Nurse/LHV

LHW

Husband

Village Health Committee member

Other (Specify)_______________

Yes

Did you receive any support from community for EmONC services?

â&#x20AC;ŤďŽ ďş&#x17D; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; Ř§ďť´ďť¤ďşŽďş ďť¨ďş´ďť˛ Űž ďť¤ďş&#x17D; Ů?ŘĄ Ű˝ ď&#x2022;ďş&#x17D;Řą ďş ďť˛ ďş´ďŽŮ&#x2C6;ďť&#x;ďş&#x2DC;Ů&#x2020; ďş&#x2019;ďş&#x17D;ďş&#x2019;ŘŞâ&#x20AC;Ź

â&#x20AC;ŤďŽ&#x2122;Ů&#x2C6;ďĄďş&#x17D;ďŠŮ&#x2C6; Řąďť&#x20AC;ďş&#x17D; ďş&#x17D;Řąâ&#x20AC;Ź â&#x20AC;ŤŘŻŘ§ďş&#x152;ďť˛â&#x20AC;Ź

â&#x20AC;Ť Ř§ďť´Ů&#x201E; Ř§ďť´ďż Ů&#x2C6;Ů&#x160;â&#x20AC;Ź/â&#x20AC;Ť ďť¨ďşŽŘłâ&#x20AC;Ź/â&#x20AC;ŤÚ&#x160;Ř§ Â&#x192;ďşŽâ&#x20AC;Ź â&#x20AC;Ťďť&#x;ďť´Ú&#x160;Ů&#x160; Úžďť´ďť Ůż Ů&#x2C6;Řą ďşŽâ&#x20AC;Ź â&#x20AC;Ťďť¤Â&#x2C6;Řłâ&#x20AC;Ź

â&#x20AC;ŤďŽ&#x2122;Ů&#x2C6;ďĄďş&#x17D;ďŠďť˛ ďşźďş¤ŘŞ ďť¤ďť´Â&#x192;ďť˛â&#x20AC;Ź

___________(â&#x20AC;Ť ďş ďŽďťŞ ď&#x2022;ďť´Ů&#x2C6; )ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99. Donâ&#x20AC;&#x2122;t Know 804.

â&#x20AC;ŤŘŻŮ&#x2C6;ďş´ŘŞ ďť´ďş&#x17D; ďť&#x2039;ďş°ďť´ďş°â&#x20AC;Ź

Yes

â&#x20AC;ŤÚžďş&#x17D;â&#x20AC;Ź â&#x20AC;Ťďť¨ďťŞâ&#x20AC;Ź

â&#x20AC;ŤďŽ&#x2122;Ů&#x2C6;Ůş Ů&#x2C6;Ř§ŘąŮ&#x2020; ďŽ&#x2018;ďş&#x17D;Ů&#x2020; ďş&#x17D; ďť¤ŘŻŘŻ ďş¤ďş&#x17D;ďşźŮ&#x201E; ďş&#x152;ďť˛Ř&#x;â&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99. Donâ&#x20AC;&#x2122;t Know

805.

If yes, what support you received from community for services in case of emergency?

â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020; Úžďş&#x17D; ďş&#x2DC;Ů&#x2C6;Úžďş&#x17D;Ů&#x2020; ďŽ&#x2122;Ů&#x2C6;Ůş Ů&#x2C6;Ř§ŘąŮ&#x2020; ďŽ&#x2018;ďş&#x17D;Ů&#x2020; Ř§ďť´ďť¤ďşŽďş ďť¨ďş´ďť˛ Űžâ&#x20AC;Ź â&#x20AC;Ť ďŽÂ&#x2020;Ů&#x160; ďť¤ŘŻŘŻ ďş¤ďş&#x17D;ďşźŮ&#x201E; ďş&#x152;ďť˛Ř&#x;â&#x20AC;Ź

Fund for transport

Transport

Fund for treatment

Referral advise

Other (Specify)________________

99. Donâ&#x20AC;&#x2122;t know

If 2 or 99 then end the interview and thank the respondent

99 â&#x20AC;Ť ďť´ďş&#x17D;â&#x20AC;Ź2 â&#x20AC;Ťďş ďť´ Ú?ÚžŮ&#x2020;â&#x20AC;Ź â&#x20AC;ŤďşŽŮ&#x2C6;ďť´Ů&#x2C6;â&#x20AC;ŹÂ â&#x20AC;Ťďş&#x2DC;ďťŞ ď&#x2122;Ů&#x2C6; Ů?ŘĄ Ř§ďť¨â&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2DC;Ů&#x2026; ďşŽďť´Ů&#x2C6; Ű˝â&#x20AC;Ź â&#x20AC;ŤďşŽŮ&#x2C6;ďť´Ů&#x2C6; Ú?ďť´Úť Ů&#x2C6;Ř§ŘąŮ&#x160;â&#x20AC;ŹÂ â&#x20AC;ŤŘ§ďť¨â&#x20AC;Ź â&#x20AC;Ťďş Ů&#x2C6; ďş¸ ďşŽďť´Ů&#x2C6; Ř§ŘŻŘ§â&#x20AC;Ź â&#x20AC;Ť ďşŽďť´Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;ŤďŽ&#x2022;ďş&#x17D;Ú?Ů&#x160; ďş Ů&#x2C6; ďşŽŘ§ďť´Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďş´Ů&#x2C6;Ř§ŘąŮ&#x160; Ů&#x17D;ŘĄâ&#x20AC;Ź â&#x20AC;Ťďť&#x2039;ďťźŘŹ ďş Ů&#x2C6; ďş¨ďşŽÚ&#x2020;â&#x20AC;Ź

â&#x20AC;ŤŘąďť´ďť&#x201D;ďşŽŮ&#x201E; ďş Ů&#x2C6; ďť¤ďş¸Ů&#x2C6;ŘąŮ&#x2C6;â&#x20AC;Ź

__________(â&#x20AC;Ť ďş ďŽďťŞ ď&#x2022;ďť´Ů&#x2C6; )ďť&#x;ďŽ&#x2018;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;Ťďş¨ďş&#x2019;ďşŽ ďť¨ďş&#x17D;Úžďť˛â&#x20AC;Ź

99 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

7.3 BIRTH AUDIT QUESTIONNAIRE â&#x20AC;Ť ŘąŘ§ŘśŮžŮ&#x2C6;â&#x20AC;Ź

â&#x20AC;Ť ŮžŮ&#x160;ŘŻŘ§ŘŚŘ´ Ř¨Ř§Ř¨ŘŞ Ů&#x2026;ŘšŘ§ŘŚŮ&#x2020;Ů&#x2C6;â&#x20AC;Ź #! % !# % !

Â Â? Â? Â?

Â? Â? Â Â Â&#x20AC;Â&#x201A;

Â&#x192; Â&#x201A; Â&#x201E;Â&#x201A; Â? Â&#x2026; Â? Â&#x2020; Â&#x201E;Â? Â&#x2021;

Â? Â&#x2C6;Â&#x2030;Â&#x160; Â&#x2039;Â&#x152;Â&#x2039;Â&#x2039;Â&#x17D;Â&#x2018;Â&#x2019;

Invitation to Participate:

.1Purpose of the Study 2. Procedures and Process of the Research Study Possible Risks and Discomforts .3 Possible Benefits .4 Financial Consideration .5 Termination of this Research Study & Voluntary Participation .6 Available Sources of Information & Questions .7 Authorization (VERBAL) .8

â&#x20AC;Ť ÚŻÚžŘą ŘŹŮ&#x160; Ř´Ů&#x2020;Ř§ŘŽŘŞâ&#x20AC;Ź

' 1.

â&#x20AC;ŤŮ&#x160;â&#x20AC;Ź

â&#x20AC;ŤÚŻÚžŘą ŘŹŮ&#x160; Ř˘ŘŚŮ&#x160; Ú&#x160;â&#x20AC;Ź:

â&#x20AC;Ť ŘŞŘšŮ&#x201E;Ů&#x201A;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;ŤŮžŘŞŮ&#x2C6;â&#x20AC;Ź

â&#x20AC;Ť Ř°Ř§ŘŞâ&#x20AC;Ź

â&#x20AC;Ť ÚłŮ&#x2C6;Ůşâ&#x20AC;Ź

â&#x20AC;Ť ÚŻÚžŘą ŘŹŮ&#x2C6;â&#x20AC;Ź â&#x20AC;Ť Ů&#x2026;Ř°ÚžŘ¨â&#x20AC;Ź

â&#x20AC;Ť ŘłŮ&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź 201. Distance to facility with maternity services:

â&#x20AC;ŤŘľŮ&#x201E;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;ŤŮ&#x2020;Ů&#x2026; Ů Ř§â&#x20AC;Ź â&#x20AC;ŤÚŞŘŞ Ř§ŘŚŮ&#x160;â&#x20AC;Ź â&#x20AC;ŤŘŞŮ&#x2026;Řą Ř˛â&#x20AC;Ź â&#x20AC;ŤŘľŘâ&#x20AC;Ź â&#x20AC;ŤŮ&#x2026;Ř§ŘĄ Ů? Ű˝ ŮťŘ§ŘąŘŹâ&#x20AC;Ź â&#x20AC;ŤŮ&#x160;â&#x20AC;Ź

(Maternity services include care of mother during pregnancy, birthing and immediately post birth) RSPN

Page 1

<5 km

â&#x20AC;ŤŘŽŘľŮ&#x2C6;ŘľŮ&#x160;ŘŞŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;Ť ŘŹŮ&#x2C6;Ř§Ř¨â&#x20AC;Ź

â&#x20AC;Ť ÚŻÚžŘą ŘŹŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź

â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ŘŞŘ§ŘŚŮ&#x160;Ů&#x2020; Ů&#x160;Ř§ ÚŻÚžŮ˝â&#x20AC;Ź5 â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ÚŠŘ§Ů&#x2020;â&#x20AC;Ź5

>5 km â&#x20AC;ŤŮ&#x2026;ŮżŮ&#x160;â&#x20AC;Ź

Birth Audit Questionnaire

Addressing Delays for Access to EmONC 100 in Non-LHW Areas of Pakistan

â&#x20AC;ŤŮ&#x2026;Ř§ŘĄŮ?ŘŹŮ&#x160;ŘŮ&#x2026;Ů&#x201E;ŘŻŮ&#x2C6;ŘąŘ§Ů&#x2020;ŘłŘ§ŘąŘłŮ&#x2020;Ú&#x20AC;Ř§Ů&#x201E;ŮžŮ&#x160;ŘŻŘ§ ŘŚâ&#x20AC;ŹŘ&#x152; â&#x20AC;ŤŘŘŞŘłÚžŮ&#x2C6;Ů&#x201E; ŘŞŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź â&#x20AC;ŤŘ´â&#x20AC;Ź â&#x20AC;Ť)Ů&#x2026;Ř§ŘĄ Ů? Ű˝ ŮťŘ§ŘąŘŹŮ&#x2C6;Ů&#x2020;Řľâ&#x20AC;Ź

(Ů?â&#x20AC;ŤŘ´ÚŠ Ř§Ů&#x2020;ŮžŮ&#x2C6;ŘĄâ&#x20AC;Ź â&#x20AC;ŤŰ˝ Ů&#x160;ŮžŘŻŘ§ŘŚâ&#x20AC;Ź

202. If <5 km, describe approximate distance to facility w/ maternity services:

â&#x20AC;ŤŘŞâ&#x20AC;Ź â&#x20AC;ŤŮ&#x160;Řľ Řâ&#x20AC;Ź â&#x20AC;ŤŘ˘ÚžŮ&#x160;ŘŞŮ&#x2021;Ů&#x2026; Ř§ŘĄ Ů? Ű˝ Ř§ŮťŘą ŘŹâ&#x20AC;Ź

â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ÚŠŘ§Ů&#x2020; ÚŻÚžŮ˝â&#x20AC;Ź5 â&#x20AC;ŤŘŹŮ&#x160;ÚŞÚ?ÚžŮ&#x2020; Ů&#x2026;Ů Ř§ŘľŮ&#x201E;Ů&#x2C6;â&#x20AC;Ź .â&#x20AC;ŤŮ&#x2026;ŘąÚŞŘ˛ ŘŞŘ§ŘŚŮ&#x160;Ů&#x2020; ŘŞŮ&#x201A;ŘąŮ&#x160;Ř¨Ů&#x2020; Ů&#x2026;Ů Ř§ŘľŮ&#x201E;Ů&#x2C6; Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź

203. Distance of TBA who provides maternity services:

â&#x20AC;ŤŘŻŘ§ŘŚŮ&#x160; ŘŹŮ&#x160;ÚŞŘ§ ŘŮ&#x2026;Ů&#x201E; ŘŹŮ&#x2C6;Ů&#x2020; ŘłÚžŮ&#x2C6;Ů&#x201E;ŘŞŮ&#x2C6;Ů&#x2020; Ú?Ů&#x160; ŮżŮ&#x160; Ř§Ů&#x2020; ŘŹŮ&#x160; ÚŻÚžŘą ŘŞŘ§ŘŚŮ&#x160;Ů&#x2020; Ů&#x2026;Ů Ř§ŘľŮ&#x201E;Ů&#x2C6;â&#x20AC;Ź

204. If <5 km, describe approximate distance to TBA w/ maternity services:

â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ÚŠŘ§Ů&#x2020; ÚŻÚžŮ˝ Ř˘ÚžŮ&#x160; ŘŞŮ&#x2021; ŘŻŘ§ŘŚŮ&#x160; ŘŹŮ&#x160; ÚŻÚžŘą ŘŞŘ§ŘŚŮ&#x160;Ů&#x2020;â&#x20AC;Ź5 â&#x20AC;ŤŘŹŮ&#x160;ÚŞÚ?ÚžŮ&#x2020; Ů&#x2026;Ů Ř§ŘľŮ&#x201E;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;ŤŘŞŮ&#x201A;ŘąŮ&#x160;Ř¨Ů&#x2020; Ů&#x2026;Ů Ř§ŘľŮ&#x201E;Ů&#x2C6; Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź

205.

â&#x20AC;Ť ÚŻÚžŘą ŘŹŮ&#x160; Ů&#x2026;Ř§ÚžŘ§Ů&#x2020;Ů&#x2021; Ř˘Ů&#x2026;ŘŻŮ&#x2020;Ů&#x160;â&#x20AC;Ź

1. 2.

â&#x20AC;ŤÚ&#x20AC;ŘŞŮ&#x160;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź

Use observation to see what the primary construction material is used to build the house? Mark all that apply 206.

â&#x20AC;Ť Ů&#x2026;Ř´Ř§ÚžŘŻŮ&#x2C6; ÚŞŘąŮ&#x160; Ú?ŘłŮ&#x2C6; ŘŞŮ&#x2021; ÚŻÚžŘą ŘŹŮ&#x160; ŘŞŘšŮ&#x2026;Ů&#x160;Řą Űž ÚŞÚžÚ&#x2122;Ů&#x2C6; Ř¨Ů&#x2020;Ů&#x160;Ř§ŘŻŮ&#x160; ŘłŘ§Ů&#x2026;Ř§Ů&#x2020;â&#x20AC;ŹRoof â&#x20AC;Ť Ú&#x2021;ŘŞŮ&#x160;Ů&#x2C6;Ů&#x2020; Ř§ŘłŘŞŘšŮ&#x2026;Ř§Ů&#x201E; ŮżŮ&#x160;Ů&#x201E; Ř˘ÚžŮ&#x160; )Ř§ÚžŮ&#x160; ŘłÚ&#x20AC; ÚŞŘŹÚžŮ&#x2021; Ů&#x201E;ÚŠŮ&#x2C6; ŘŹŮ&#x160;ÚŞŮ&#x2C6; Ř§ŘłŘŞŘšŮ&#x2026;Ř§Ů&#x201E; ŮżŮ&#x160;Ů&#x201E;â&#x20AC;Ź (â&#x20AC;ŤŘ˘ÚžŮ&#x160;â&#x20AC;Ź

Floor

â&#x20AC;Ť Ůžâ&#x20AC;Ź Ů?â&#x20AC;ŤŮ˝â&#x20AC;Ź

How many rooms are there in the household? 207.

(excluding toilet, kitchen, and garage)

â&#x20AC;ŤÚŻÚžŘą Űž ÚŞŮ&#x160;ŘŞŘąŘ§ ÚŞŮ&#x2026;ŘąŘ§ Ř˘ÚžŮ&#x2020; Ř&#x;â&#x20AC;Ź

What is the ownership status of the house?

â&#x20AC;ŤÚŻÚžŘą ŘŹŮ&#x160; Ů&#x2026;Ř§Ů&#x201E;ÚŞŘ§ŮšŮ&#x160; ŘŮ&#x160;ŘŤŮ&#x160;ŘŞ ÚŞÚžÚ&#x2122;Ů&#x160; Ř˘ÚžŮ&#x160;Ř&#x;â&#x20AC;Ź

210.

RSPN

What is the main source of drinking water?

â&#x20AC;ŤŮžŮ&#x160;ŘŚÚť ŘŹŮ&#x160; ŮžŘ§ŮšŮ&#x160; ŘŹŮ&#x160; Ř§ÚžŮ&#x2026; Ř°ŘąŮ&#x160;ŘšŮ&#x2C6; ÚŞÚžÚ&#x2122;Ů&#x2C6; Ř˘ÚžŮ&#x160;Ř&#x;â&#x20AC;Ź

What do you do to make the water safer to drink?

â&#x20AC;ŤÚŞŮ&#x2020;ŘŻ Ř§ÚžŘ˘Ů&#x160;Ů&#x2C6;Ř&#x;â&#x20AC;Ź â&#x20AC;ŤŘ§Ů&#x201E; Ů?Ú&#x2021;Ř§â&#x20AC;Ź â&#x20AC;ŤŮ&#x201E;Ř§Ů&#x201E;ŘĄŮ? Ř¨Ů&#x2020;Ř§ŘŚÚť ŘĄâ&#x20AC;Ź â&#x20AC;ŤŮ&#x160; Ř§ŘłŘŞŘšŮ&#x2026;Ř§â&#x20AC;Ź â&#x20AC;ŤŮ&#x2020;ŮžŘ§ŮšŮ&#x160; ÚŠâ&#x20AC;Ź â&#x20AC;ŤŘŞÚžŮ&#x2C6;Ř§â&#x20AC;Ź

Page 2

â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ŘŞŘ§ŘŚŮ&#x160;Ů&#x2020; Ů&#x160;Ř§â&#x20AC;Ź5 â&#x20AC;Ť ÚŞŮ&#x201E;Ů&#x2C6;Ů&#x2026;Ů&#x160;Ů˝Řą ÚŠŘ§Ů&#x2020;â&#x20AC;Ź5

______________â&#x20AC;Ť ŮžŘ§ÚŞŘłŘŞŘ§Ů&#x2020;Ů&#x160; ŘąŮžŮ&#x160;Ř§â&#x20AC;Ź â&#x20AC;ŤÚŞÚ&#x2020;Ů&#x160;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź 2. Bricks and cement / â&#x20AC;ŤŘłŮ&#x160;Ů&#x2026;Ů&#x160;Ů&#x2020;Ů˝ Ű˝ ŘłŘąŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź 3. Wood / â&#x20AC;ŤÚŞŘ§Ůşâ&#x20AC;Ź 4. Thatch / â&#x20AC;ŤÚŞÚŠŮ&#x2020; Ů&#x2C6;Ř§ŘąŮ&#x160; Ú&#x2021;ŘŞâ&#x20AC;Ź 5. Mud / â&#x20AC;ŤÚŻŘ§ŘąŮ&#x160; Ů&#x2C6;Ř§ŘąŮ&#x160; Ú&#x2021;ŘŞâ&#x20AC;Ź 6. Other (specify) / (â&#x20AC;ŤÚŞŘ§ ŮťŮ&#x160;) Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź 1. Tin sheets / â&#x20AC;ŤŮ˝Ů&#x160;Ů&#x2020; ŘŹŮ&#x160; Ř´Ů&#x160;Ů˝â&#x20AC;Ź 2. Roofing tiles / â&#x20AC;ŤÚ&#x2021;ŘŞ Ů&#x2C6;Ř§ŘąŮ&#x160; Ů˝Ř§ŘŚŮ&#x160;Ů&#x201E;â&#x20AC;Ź 3. Concrete / (â&#x20AC;ŤŮžŘŽŘŞŘ§ )ŘłŮ&#x160;Ů&#x2026;Ů&#x160;Ů&#x2020;Ů˝ Ů&#x2C6;Ř§ŘąŮ&#x160;â&#x20AC;Ź 4. Wood / â&#x20AC;ŤÚŞŘ§Ůşâ&#x20AC;Ź 5. Thatch / â&#x20AC;ŤÚŞÚŠ Ű˝ ŮžŮ&#x2020;â&#x20AC;Ź Other (specify) / ( â&#x20AC;Ť ÚŞŘ§ ŮťŮ&#x160;) Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź 1. Cement /â&#x20AC;ŤŘłŮ&#x160;Ů&#x2026;Ů&#x160;Ů&#x2020;Ů&#x160;Ů˝â&#x20AC;Ź 2. Sand/ mud /â&#x20AC;ŤŮ&#x2026;Ů˝Ů&#x160; Ű˝ ÚŻŘ§ŘąŮ&#x2C6;â&#x20AC;Ź 3. Concrete / â&#x20AC;ŤŮžÚŞŮ&#x2C6;â&#x20AC;Ź 4. Tiles /â&#x20AC;ŤŮ˝Ř§ŘŚŮ&#x160;Ů&#x201E;Ř˛â&#x20AC;Ź 5. Wood / â&#x20AC;ŤÚŞŘ§Ůşâ&#x20AC;Ź Other (specify) / (â&#x20AC;Ť ÚŞŘ§ ŮťŮ&#x160; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Bricks â&#x20AC;&#x201C; un-plastered / â&#x20AC;ŤŘłŘąŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź

________________

â&#x20AC;ŤŮžŮ&#x2020;ÚžŮ&#x2020;ŘŹŮ&#x2C6;â&#x20AC;Ź â&#x20AC;ŤÚŞŘąŘ§ŘŚŮ&#x160; ŘŞŮ&#x160;â&#x20AC;Ź Other (specify) / (â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Piped â&#x20AC;ŤŮžŘ§ŘŚŮ&#x160;Ůž Ř§Ů&#x201E;ŘŚŮ&#x160;Ů&#x2020;â&#x20AC;Ź

Owned /

Rented /

3. 1. 2.

209.

>5 km â&#x20AC;ŤŮ&#x2026;ŮżŮ&#x160;â&#x20AC;Ź

(Ů?â&#x20AC;ŤŘłŮ&#x2C6;Ř§ŘĄâ&#x20AC;Ź â&#x20AC;ŤÚ&#x2020;Ů&#x160;ŘŽŘ§ Ů&#x2020;Ů&#x2C6;Ű˝ Ů&#x160;ÚŻŘąŘ§ŘŹ Ř§ÚŠŮ&#x2020;â&#x20AC;Ź â&#x20AC;ŤŮ&#x2C6;Ř¨Řąâ&#x20AC;ŹŘ&#x152;â&#x20AC;ŤŮ&#x201E;ŘŽ Ř§Ů&#x2020;Ů&#x2C6;â&#x20AC;Ź â&#x20AC;ŤŘşŘłâ&#x20AC;Ź )

208.

<5 km â&#x20AC;ŤÚŻÚžŮ˝â&#x20AC;Ź

1. 2. 3. 4. 5.

Walls

Open/ closed well/ hand pump

â&#x20AC;ŤŮ&#x2020;Ů&#x201E;ÚŞŮ&#x2C6;â&#x20AC;Ź/ â&#x20AC;Ť Ř¨Ů&#x2020;ŘŻ ÚŠŮ&#x2C6;ÚžŮ&#x2021;â&#x20AC;Ź/â&#x20AC;ŤÚŠŮ&#x201E;Ů&#x160;Ů&#x201E;â&#x20AC;Ź

3. 4. 5.

Tube well/ bore / â&#x20AC;Ť Ř¨Ů&#x2C6;ŘąŮ&#x160;Ů&#x2020;ÚŻâ&#x20AC;Ź/ â&#x20AC;ŤŮ&#x2C6;Ů&#x160;Ů&#x201E;â&#x20AC;Ź Mineral water / â&#x20AC;ŤŮ&#x2026;Ů&#x2020;ŘąŮ&#x201E; Ů&#x2C6;Ř§Ů˝Řąâ&#x20AC;Ź River/ stream/ canal/ spring

â&#x20AC;ŤŮ˝Ů&#x160;Ů&#x2C6;Ř¨â&#x20AC;Ź

6. 1. 2. 3. 4.

Other (specify) / (â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Use mineral water / â&#x20AC;ŤŮ&#x2026;Ů&#x2020;ŘąŮ&#x201E; Ů&#x2C6;Ř§Ů˝Řą ŘŹŮ&#x2C6; Ř§ŘłŘŞŘšŮ&#x2026;Ř§Ů&#x201E;â&#x20AC;Ź Boil it / â&#x20AC;ŤŘ§Ů&#x2C6;ŮťŘ§ŘąŮ&#x160; ÚŞŘąŮ&#x160;â&#x20AC;Ź Use water filter / â&#x20AC;ŤŮ Ů&#x201E;Ů˝Řą Ů&#x2C6;Ř§Ů˝Řą ŘŹŮ&#x2C6; Ř§ŘłŘŞŘšŮ&#x2026;Ř§Ů&#x201E;â&#x20AC;Ź Use chlorination/ tablets

â&#x20AC;Ť Ů&#x2026;Ů&#x160;Ů&#x2020;ÚžŮ&#x2020; ŘŹŮ&#x2C6; ŮžŘ§ŮšŮ&#x160;â&#x20AC;Ź/ â&#x20AC;Ť ÚŞŘŚŮ&#x2020;Ř§Ů&#x201E;â&#x20AC;Ź/ â&#x20AC;Ť Ů&#x2C6;Ř§Ů˝Řąâ&#x20AC;Ź/ â&#x20AC;ŤŮ&#x2020;ŘŻŮ&#x160;â&#x20AC;Ź

Birth Audit Questionnaire

101 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

â&#x20AC;ŤŮžŘ§ŮšŮ&#x160; ŘľŘ§Ů ÚŞŘąÚť Ů&#x2C6;Ř§ŘąŮ&#x160;Ů&#x2C6;Ů&#x2020; ÚŻŮ&#x2C6;ŘąŮ&#x160;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź

5. 6. 211.

Does the household have electricity?

â&#x20AC;ŤÚ&#x2021;Ř§ ÚŻÚžŘą Űž Ř¨ŘŹŮ&#x201E;Ů&#x160; Ů&#x2026;Ů&#x2C6;ŘŹŮ&#x2C6;ŘŻ Ř˘ÚžŮ&#x160;Ř&#x;â&#x20AC;Ź

1. 2. 1.

212.

213.

What fuel type is used for cooking?

â&#x20AC;ŤŮ&#x201E;Ůż Ů&#x160;Ů&#x2020;ŘŻÚ&#x2122; Ř§Ů&#x160;Ů&#x2020;Ú&#x152;ÚťŘ&#x;â&#x20AC;Ź â&#x20AC;ŤÚŻÚžŘąŰžŘą Ú&#x152;ŮžÚ&#x2020;Ř§ŘĄŮ?Ř§Ů&#x201E;ŘĄŮ? Ř§ŘłŘŞŘšŮ&#x2026;Ř§â&#x20AC;Ź

What kind of toilet facility is available in the household?

â&#x20AC;Ť ŘłŮ&#x2020;ŘŻŘ§Řł ŘŹŮ&#x2C6; Ů&#x201A;ŘłŮ&#x2026; ÚŞÚžÚ&#x2122;Ů&#x2C6; Ř˘ÚžŮ&#x160;Ř&#x;â&#x20AC;Ź/ â&#x20AC;ŤÚŻÚžŘą Űž Ř§ŘłŘŞŘšŮ&#x2026;Ř§Ů&#x201E; ŮżŮ&#x160;Ů&#x2020;ŘŻÚ&#x2122; ŘşŘłŮ&#x201E; ŘŽŘ§Ů&#x2020;Ů&#x2C6;â&#x20AC;Ź

5. 1. 2. 3. 4. 1.

214.

How is the household waste disposed?

â&#x20AC;ŤÚŻÚžŘą ŘŹŮ&#x2C6; ÚŻŮ&#x2020;ŘŻ ÚŞÚ&#x2020;ŘąŮ&#x2C6; ÚŞŮżŮ&#x160; Ř§Ú&#x2021;Ř§Ů&#x201E;Ů&#x160;Ů&#x2C6; Ů&#x2C6;Ú&#x192;Ů&#x160; ŮżŮ&#x2C6; Ř&#x;â&#x20AC;Ź

3. 4. 5. 6. 7. 8. 9. Does the household have any of the following?

10.

(tick all that apply)

12.

11. 13. 14. 15. 16. 17. 18.

19.

301.

RSPN

& $% ! ( â&#x20AC;Ť ŘłŮ&#x2C6;Ř§Ů&#x201E;â&#x20AC;Ź How old are you?

Municipal committee collects

â&#x20AC;ŤŮ&#x2026;Ů&#x160;Ů&#x2C6;Ů&#x2020;ŘłŮžŮ&#x201E; ÚŞŘ§Ů&#x2026;Ů&#x160;Ů˝Ů&#x160; ÚŠŮšŮ&#x160; Ů&#x2C6;Ú&#x192;Ů&#x160; ŮżŮ&#x160;â&#x20AC;Ź

â&#x20AC;ŤŮžŮ&#x2C6;ŘąŮ&#x160;Ů&#x2C6; Ů&#x2C6;Ú&#x192;Ů&#x160; ŮżŮ&#x2C6;â&#x20AC;Ź (â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Radio / â&#x20AC;ŤŘąŮ&#x160; Ů&#x160;Ů&#x2C6;â&#x20AC;Ź Television / â&#x20AC;ŤŮ˝Ů&#x160;Ů&#x201E;Ů&#x160;Ů&#x2C6;Ů&#x160;Ř˛Ů&#x2020;â&#x20AC;Ź Iron / â&#x20AC;ŤŘ§ŘłŘŞŘąŮ&#x160;â&#x20AC;Ź Mobile phone / â&#x20AC;ŤŮ&#x2026;Ů&#x2C6;Ř¨Ř§ŘŚŮ&#x160;Ů&#x201E;â&#x20AC;Ź Land line/ phone / â&#x20AC;ŤŮ Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź Refrigerator / â&#x20AC;ŤŮ ŘąŮ&#x160;ŘŹâ&#x20AC;Ź Air conditioner / â&#x20AC;ŤŘ§Ů&#x160;ŘŚŘą ÚŞŮ&#x2020; Ů&#x160;Ř´Ů&#x2020;Řąâ&#x20AC;Ź Gas stove / â&#x20AC;ŤÚŻŘŚŘł Ů&#x2C6;Ř§ŘąŮ&#x2C6; Ú&#x2020;Ů&#x201E;ÚžŮ&#x2C6;â&#x20AC;Ź Microwave oven / â&#x20AC;ŤŮ&#x2026;Ř§ŘŚŮ&#x160;ÚŞŘąŮ&#x2C6; Ů&#x2C6; Ů&#x160;Ů&#x2C6; Ř§Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź Sewing machine / â&#x20AC;ŤŘłŘ§Ů&#x201E;ŘŚŮ&#x160; Ů&#x2026;Ř´Ů&#x160;Ů&#x2020;â&#x20AC;Ź Washing machine â&#x20AC;ŤŮ&#x2C6;Ř§Ř´Ů&#x2020;ÚŻ Ů&#x2026;Ř´Ů&#x160;Ů&#x2020;â&#x20AC;Ź Computer / â&#x20AC;ŤÚŞŮ&#x2026;ŮžŮ&#x160;Ů&#x2C6;Ů˝Řąâ&#x20AC;Ź Bicycle / â&#x20AC;ŤŘłŘ§ŘŚŮ&#x160;ÚŞŮ&#x201E;â&#x20AC;Ź Motorbike / â&#x20AC;ŤŮ&#x2026;Ů&#x2C6;Ů˝ŘąŘłŘ§ŘŚŮ&#x160;ÚŞŮ&#x201E;â&#x20AC;Ź Motor car / â&#x20AC;ŤŮ&#x2026;Ů&#x2C6;Ů˝ŘąÚŞŘ§Řąâ&#x20AC;Ź Tractor / â&#x20AC;ŤŮ˝ŘąŮ&#x160;ÚŞŮ˝Řąâ&#x20AC;Ź Donkey cart / â&#x20AC;ŤÚŻÚ? ÚžŮ&#x2021; ÚŻŘ§Ú?Ů&#x2C6;â&#x20AC;Ź Livestock / â&#x20AC;ŤÚ&#x2020;Ů&#x2C6;ŮžŘ§Ů&#x160;Ů&#x2C6;â&#x20AC;Ź a. Cow/ buffalo / â&#x20AC;ŤŮ&#x2026;Ů&#x160;Ů&#x2020;ÚžŮ&#x2020;â&#x20AC;Ź/â&#x20AC;ŤÚłŘŚŮ&#x2C6;Ů&#x2020;â&#x20AC;Ź b. Sheep/ goat / â&#x20AC;Ť ŮťÚŞŘąŮ&#x160;â&#x20AC;Ź/â&#x20AC;ŤŘąÚ?â&#x20AC;Ź c. Poultry / â&#x20AC;ŤÚŞÚŞÚ&#x2122;Ů&#x160;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź Other (specify) / (â&#x20AC;ŤŮťŮ&#x160;Ů&#x2C6; ÚŞŘŹÚžŮ&#x2021; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Buried /

Other (specify) /

$"! $ ( â&#x20AC;Ť ŘŹŮ&#x2C6;Ř§Ř¨â&#x20AC;Ź

" ( â&#x20AC;ŤÚ?Ů&#x160;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;Ť ŘłŘ§Ů&#x201E;Ů&#x2020; Űž ŘŞŮ&#x2C6;ÚžŘ§Ů&#x2020; ŘŹŮ&#x160; ŘšŮ&#x2026;Řą ÚŞŮ&#x160;ŘŞŘąŮ&#x160; Ř˘ÚžŮ&#x160;â&#x20AC;Ź

Page 3

â&#x20AC;ŤÚ&#x20AC;Ů&#x2020;ÚŻŮ&#x160; ÚŠŮšŮ&#x160; Ů&#x2C6;Ú&#x192;Ů&#x160; ŮżŮ&#x2C6;â&#x20AC;Ź â&#x20AC;ŤŮťŘ§ÚžŘą Ř§Ú&#x2021;Ř§Ů&#x201E;Ů&#x160;Ů&#x2C6; Ů&#x2C6;Ú&#x192;Ů&#x160; ŮżŮ&#x2C6;â&#x20AC;Ź

Garbage man collects /

â&#x20AC;ŤŮ&#x2020;Ů&#x2021;â&#x20AC;Ź â&#x20AC;ŤÚŻŮ&#x160;Řłâ&#x20AC;Ź Wood / â&#x20AC;ŤÚŞŘ§ŮşŮ&#x160;Ů&#x2C6;Ů&#x2020;â&#x20AC;Ź Oil /â&#x20AC;ŤŘŞŮ&#x160;Ů&#x201E;â&#x20AC;Ź Animal Dung / â&#x20AC;ŤÚ&#x2021;Ů&#x160;ŮşŘ§â&#x20AC;Ź Other (specify) / (â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź Flush latrine / â&#x20AC;ŤÚŞŘ§Ů&#x2026;Ů&#x2C6;Ú&#x160;â&#x20AC;Ź Pit latrine / â&#x20AC;ŤŮžŮ˝ Ů&#x201E;Ů&#x160;Ů˝ŘąŮ&#x160;Ů&#x2020;â&#x20AC;Ź Open field / â&#x20AC;ŤÚŠŮ&#x201E;Ů&#x160;Ů&#x201E; Ř˛Ů&#x2026;Ů&#x160;Ů&#x2020;â&#x20AC;Ź Other (specify) / (â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6; )Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź No /

Gas /

Thrown outside in open /

(â&#x20AC;Ť)Ů&#x2026;Ů&#x2C6;ŘŹŮ&#x2C6;ŘŻ Ř´Ů&#x160;Ů&#x2020; ŘŹŮ&#x160; Ů&#x2020;Ř´Ř§Ů&#x2020; Ů&#x201E;ÚłŘ§Ů&#x160;Ů&#x2C6;â&#x20AC;Ź

â&#x20AC;ŤÚŞŮ&#x2C6; ŮťŮ&#x160;Ů&#x2C6;â&#x20AC;Ź

2. 4.

â&#x20AC;ŤÚ&#x2021;Ř§ ÚŻÚžŘą Űž ŘłŘ§Ů&#x2026;ÚžŮ&#x2C6;Ů&#x2020; Ú?Ů&#x2020;Ů&#x201E; Ů&#x2026;Ř§Ů&#x2020; ÚŞŘŹÚžŮ&#x2021; Ů&#x2026;Ů&#x2C6;ŘŹŮ&#x2C6;ŘŻ Ř˘ÚžŮ&#x160;Ř&#x;â&#x20AC;Ź

Yes / â&#x20AC;ŤÚžŘ§â&#x20AC;Ź

3. 5.

215.

Nothing / â&#x20AC;ŤÚŞŘŹÚžŮ&#x2021; Ř¨Ů&#x2021; Ů&#x2020;Ů&#x2021;â&#x20AC;Ź Other (specify) / (â&#x20AC;Ť)Ů&#x201E;ÚŠŮ&#x2C6;â&#x20AC;Ź

â&#x20AC;Ť Ú&#x2021;Ú?Ů&#x160;â&#x20AC;Ź

Birth Audit Questionnaire

‫‪Addressing Delays for Access to EmONC 102‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ ‬

‫جيڪڏھن ‪ 3‬ته سوال نمبر‬ ‫ ‪ 304‬تي وڃو‬

‫ عام تعليمي ‬ ‫ مذھبي تعليم تعليم جو قسم؟‬ ‫ ڪو به نه ‪/‬اٹپڙھيل ‬ ‫ٻيو ڪو لکو ‪4.‬‬

‫ ‬

‫ سالن‬

‫ ‬

‫ ‪302.‬‬

‫ ( ‪ . -"(' % / %6 ='.& + ( 2 +,‬‬ ‫ >'("‪ (&)% - . -‬‬ ‫۾ ‪<<<<<<<<<<< 2 +,‬‬ ‫ تعليمي سطح ) تعليم مڪمل ڪرڻ جا سال(‬

‫ ‪303.‬‬

‫ (‪ ( 2(. ! / "+-! +-" " - 4 =" 2 ,5 ,$ -‬‬ ‫ >‪, ' ()2 - "%,‬‬

‫ ‪304.‬‬

‫ ھا ‪C7 , 9‬‬ ‫ نه ‪D7 ( 9‬‬

‫ ‬

‫ ‪ (0 %(' ! / 2(. ' & ++" 4 = .& +‬‬ ‫ >‪( 2 +,‬‬

‫ ‬ ‫ سال ‪<<<<<<<<<<< 2 +,‬‬ ‫ توھان‬

‫ ‬

‫‪1.‬‬

‫ ‪ (& 09‬‬

‫‪2.‬‬ ‫‪3.‬‬

‫ ‬ ‫ ‬

‫ خود گھر ۾ ‪/‬مائٽن ۾‬ ‫گھر ۾ دائي ھٿان ‪ (& 09 9‬‬ ‫جي گھر ‪ !(& 9‬‬ ‫ ‪ +"/ - %-! "%"-2‬‬

‫‪4.‬‬ ‫‪5.‬‬

‫ ‪ . %" %-! "%"-2‬‬

‫‪6.‬‬

‫ٻيو_______ ‪ -! + =,) " 2> 9‬‬

‫‪7.‬‬

‫ ‬

‫ ‬ ‫ ‬

‫ ‬

‫خانگي صحت مرڪز‬

‫ سرڪاري صحت مرڪز‬ ‫ڪو‬

‫ بيروزگار ‪ /‬گھريلو ڪم ڪار‬ ‫ ھارپو ‬ ‫ سوئيٽر سبھڻ‬

‫رسي ٺاھڻ‪ /‬ڪپھه ڇن ڻ‬

‫ ‪305.‬‬

‫ڪڏھن شادي ڪئي آھي؟ )سالن ۾ لکو(‬

‫ ‬

‫گھر ۾ سي ايم ڊبليو ھٿان‬ ‫ سي ايم ڊبليو‬

‫ ‬

‫ڇا توھان وٽ پيدائش جو سرٽيفيڪيٽ‬ ‫صي‬ ‫ل‬ ‫سڻالء ِچئو۽ تف‬ ‫نھا ته ڏ‬ ‫ي ؟)جيڪڏھ‬ ‫آھ‬ ‫ جو نقل ڪريو(‬

‫ گذريل ويم ڪٿي ٿيو؟‬

‫ ‪306.‬‬

‫ٽ ‪ :‬اينوم رٽيرال ِء ھدايت‪:‬ان اڳلھ هي‬ ‫ج‬ ‫نو‬ ‫خاطري ڪريو ته گذريل ويم گذريل ھڪ‬ ‫ سال اندر ٿيو ھجي‪.‬‬

‫ ‬

‫ توھان ڪھڙو ڪم ڪريو ٿا؟‬

‫ ‪307.‬‬

‫ قالين ٺاھڻ يا ھٿ جو پکو ٺاھڻ‬

‫ استاد ‪ /‬ٽيوشن پڙھائڻ ‪ ‬‬ ‫ ڍور ڍڳو پالڻ ‬ ‫ صحت ڪارڪن ‬ ‫ دائي ‬ ‫ گھريلو مالزم ‬ ‫ٻيو ڪو ‪11.‬‬ ‫ ڪا خبر ناھي

‬

‫ ‬

‫جيڪڏھن ‪ 3‬ته سال نمبر‬ ‫‪Birth Audit Questionnaire‬‬

‫ ‬

‫ سالن ۾ لکو ______________‬ ‫ خبر ناھي

‬

‫ ‪ ‬‬

‫ ‪308.‬‬

‫ ‬

‫ ‪309.‬‬

‫ توھان جي مڙس جي عمر ڪيتري آھي؟‬

‫ عام تعليم ‬ ‫ مذھبي تعليم مڙس جي تعليم حاصل ڪرڻ جو قسم‬ ‫‪Page 4‬‬

‫‪RSPN‬‬

‫‪103 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ ڪابه نه‪ /‬اٹپڙھيل ‪ (' 9 "%%"- + - 9‬‬ ‫ ڪو ٻيو لکو ‪ -! + =,) " 2>9‬‬ ‫ ‬

‫ ‪ 311‬تي وڃو‬

‫ ‬

‫ سالن‬

‫‪E7‬‬ ‫‪F7‬‬

‫۾ ‪<<<<<<<<<<< 2 +,‬‬

‫ ‪ +, ( . -"(' = ., ' >4‬‬

‫ تعليم حاصل ڪرڻ جا سال )مڙس(‬

‫ ‪310.‬‬

‫ ‬ ‫ ‬

‫ بيروزگار ‬ ‫ مزدور ان جو روزگار ڪھڙو آھي؟‬ ‫ ھاري ‬ ‫ آفيس ۾ ڪم ڪندڙ ‬

‫ ‬

‫ سرڪاري مالزم‬ ‫ ڊاڪٽر‪ /‬ڊسپينسر‬

‫ ‬

‫ ‪311.‬‬

‫ وڏو ڪاروبار ‪ ‬‬ ‫ ننڍو ڪاروبار ‬ ‫ مزدور ‬ ‫ رٽائرڊ ‬ ‫ گھريلو مالزم ‬ ‫ مولوي ‪ /‬قاري ‬ ‫ ڪو ٻيو لکو ‬ ‫ خبر ناھي ‪ ‬‬ ‫

‪ ‬‬ ‫ ‬

‫ ‬

‫ _____________‬ ‫گذريل حملن جو تعداد‪ /‬ھن آخري ٻارجي پيدائش کان پھرين توھان‬ ‫ڪيترا دفعو پيٽ سان ٿياھئا؟‬ ‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 315‬تي وڃو‬

‫ خبر‬

‫ ھا ‬ ‫ نه ‬ ‫ناھي ‬

‫ ‪312.‬‬

‫ ‬

‫ ‬ ‫ ‬

‫ ‪313.‬‬

‫ڇا توھان جو ڪو به حمل اوچتو ضايع ٿي‬ ‫ ويو؟‬

‫ ‬ ‫ ‬ ‫ ‬

‫ضايعٿيڻجو‬ ‫چتو پي‬ ‫ٽ‬ ‫انيوم يرنٽرالء ِھد ايت‪ :‬او‬ ‫ مطلب قدرتي طور حمل جو ختم ٿيڻ آھي‬ ‫ ‬

‫ تعداد ‬

‫ ‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 317‬تي وڃو‬

‫ جيڪڏھن ھا ته‬

‫ڪيترا؟ ‬

‫ ‪314.‬‬

‫ ھا ‬ ‫ نه ڇا توھان ھٿراڌو طور ڪو حمل ضايع ڪرايو؟‬

‫ ‪315.‬‬

‫ خبر‬

‫ناھي ‬

‫ ‬ ‫

‬ ‫ ‬

‫ضاعي‬ ‫ت ‪ :‬ھٿر اڌوطور حمل‬ ‫نايومرينٽرالءِھ اد ي‬ ‫ڪرائڻ مان مطلب عالج ذريعي حمل کي ختم‬ ‫ ڪرائڻ آھي‬ ‫ تعداد ‬ ‫ ‬ ‫‪Birth Audit Questionnaire‬‬

‫ ھا ‬ ‫‪Page 5‬‬

‫ جيڪڏھن ھا ته‬

‫ڪيترا؟ ‪316.‬‬

‫ ‬

‫ ‪317.‬‬ ‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 104‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ نه ‪D7 ( 9‬‬ ‫ خبر ناھي ‪ KK7 ('8- $'(0 9‬گذريل دفعي پيٽ سان ٿيڻ ۾ ڇا توھان جي‬ ‫ مرضي شامل ھئي ؟‬

‫ ‪.'0 '- 4‬‬

‫ ‬

‫ ‪ (0 & '2 &('-!, " -! )+ ' ' 2 % ,-‬‬ ‫ ‪ (+4‬‬

‫ ‪318.‬‬

‫ ‬ ‫ ‬

‫ ‪319.‬‬

‫ مھينا لکو____________‬ ‫ خبر ناھي گذريل پيٽ ڪيترن مھينن تائين رھيو؟‬

‫ ‬

‫ اسقاط‬

‫ زندھه ٻار ‬ ‫ مرده ٻار ‬ ‫حمل ‬ ‫ ‬

‫ ليبر‪/‬ويم جي سورن‬

‫کان پوءِ اٻ ررميويو‬

‫ ‬ ‫ ‬ ‫ ھن پيدائش‬ ‫ ‪ ‬نڪتو؟‬

‫کان پھرين گذريل ويم جو ڇا نتيجو‬

‫ ڪو ٻيو ‬ ‫ خبر ناھي ‬ ‫ ھا ‬ ‫نه گذريل ويم مان جيڪو ٻار پيدا ٿيو اھو زنده آھي‬ ‫؟‬

‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 322‬تي وڃو‬

‫ ‪320.‬‬

‫ ‬ ‫ ‬

‫طير‬ ‫يخ ا‬ ‫اينومرينٽرالء ِھدايت‪ :‬ان ڳالھ هج‬ ‫ڪريو ته گذريل ٻار ھڪ سال اندر پيدا ٿيو‬ ‫ ھجي‬ ‫ ‬

‫ ‬

‫ ‬ ‫ناھي

‬

‫ ‬ ‫ ‬

‫ ڏينھن يا مھينا ______________ ان ٻار جي ڪيتري عمر آھي؟‬ ‫ خبر‬

‫ لکو‬ ‫ ‬

‫ ‪321.‬‬

‫ن۾‬ ‫ت ‪ :‬عمر ڏينھنيام ھين‬ ‫انيو مر ينٽرالءِھ ادي‬

‫ ھا ‬ ‫ نه ڇا توھان کي ڪو مرده ٻار پيدا ٿيو؟‬

‫ ‪322.‬‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 401‬تي وڃو‬

‫ خبر‬

‫ناھي ‬

‫ ڪل ‬ ‫ پٽ توھان کي ڪيترا مرده ٻار پيدا ٿيا؟‬

‫ ‪323.‬‬

‫ نٿي ٻڌا‬

‫ ڌيئرون ‬ ‫ئي سگھان ‬

‫ ‬ ‫ ‬

‫ ڇڏي‬

‫ڏيو ‬

‫ سوال ‬

‫ جواب ‬

‫ ‬

‫ ھا ‬ ‫ نه ‬

‫ ‬ ‫ ‬

‫ ‬

‫ ھا ‬ ‫ نه ‬

‫ ‬ ‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 404‬تي وڃو‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 6‬‬

‫ ‬ ‫ ‪401.‬‬

‫ڇا توھان وٺ ڪا ڪميونٽي ريسورس پرسن‬ ‫)سي‪.‬آر‪.‬پي( يا ڳوٺ ۾ صحت تي ڪم ڪندڙ‬ ‫ڪارڪن دورو ڪيو ؟‬

‫ ‪402.‬‬

‫ڇا توھان تصويرن وارو معلوماتي ڪاغذ‬ ‫ حاصل ڪيو؟‬

‫‪RSPN‬‬

‫‪105 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ ‬

‫ ‪C7 '- ' - % +‬‬

‫حمل جي دوران جي سار سنڀال‬

‫ !‪ ! - "' (+& -"(' " "' +(& -‬‬ ‫ ‪& - +" %4‬‬

‫ ‪403.‬‬

‫ي ڪاغذ مان ڪھڙي‬ ‫ص يو ر‬ ‫ي َت‬ ‫ن انھ ء‬ ‫توھا‬ ‫ معلومات حاصل ڪئ؟‬

‫ ‪D7 "+-! + ) + ' ,, ' ,‬‬ ‫ ‪ %"/ +2‬‬

‫ ويم الء تياري ۽ ويم کي محفوظ ٺاھڻ‬ ‫ ‬ ‫ ‬

‫ن ڄاول ٻار جي سار‬ ‫ويمکانپو۽مءا ٌ۽ني ي‬ ‫ سنڀال‬ ‫ ھا ‪ , 9‬‬ ‫ نه‪ ( 9‬‬

‫ ‪ D -! ' ( -( GBC‬‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 501‬تي وڃو‬ ‫ ‬

‫ '(‪ (&&.'"-2 ,(.+ +,‬‬

‫ڪميونٽي ريسورس پرسن )سي‪.‬آر‪.‬پي( يا‬ ‫ڳوٺ ۾ صحت تي ڪم ڪندڙڪارڪن‬ ‫ ‪ % -"/ (+ (&&.'"-2 % +‬‬

‫ رشتيدار يا ڳوٺ جي بزرگ‬

‫‪1.‬‬

‫ ‬ ‫ ‬

‫‪1.‬‬

‫ ‪ !(& " 2(. , )+"(+ -( %"/ +2 (+‬‬ ‫ ‪ '- ' - % ! $.)4‬‬

‫‪2.‬‬

‫ ‪ 2 %-! (+$ +‬‬

‫‪3.‬‬

‫ دائي ‪ (+ " 9‬‬ ‫ ڊسپينسري ‪ ",) ', +2 9‬‬ ‫ ‪ 9‬‬

‫‪4.‬‬ ‫‪5.‬‬ ‫‪6.‬‬

‫ ‬

‫‪7.‬‬

‫ ‬

‫‪8.‬‬

‫ ‬

‫‪9.‬‬

‫ لي ي ھيلٿ ورڪر‬

‫بنيادي صحت مرڪز‪ /‬ڳوٺاٹو صحت‬ ‫ مرڪز‬

‫ڪز‪/‬خاندا ن‬ ‫ي‬ ‫حت مر‬ ‫ص‬ ‫ماءُ۽ ٻ ارجو‬ ‫ بھبودآبادي جو مرڪز‬ ‫ تعلقا‪ /‬ضلعا اسپتال‬

‫ خانگي صحت مرڪز يا اسپتال‬ ‫ خانگي‬ ‫ فارماسسٽ ‬ ‫ پير ‪ /‬فقير ‬

‫ ‪404.‬‬

‫ڇا توھان ويم کان پھرين دوران حمل‬ ‫ال ِويا؟‬ ‫ معائني‪ /‬چڪاس ء‬

‫ ‪405.‬‬

‫توھان ويم کان پھرين دوران حمل معائني‪/‬‬ ‫ٽويا؟‬ ‫الء ِڪ نھنو‬ ‫ چڪاس‬

‫ڊاڪٽر ‪10.‬‬ ‫‪11.‬‬

‫‪12.‬‬ ‫ ‪13.‬‬

‫ ‬

‫ روايتي عالج )حڪيم يا ھيموپٿڪ(‬ ‫ ڪو ٻيو‬ ‫ خبر ناھي ‬ ‫ ‪14.‬‬

‫ ‬

‫ھا ‬ ‫ نه ‪ ‬‬

‫ ‬ ‫ ‬

‫ ‬

‫ ھا ‬ ‫ نه ‪ ‬‬

‫ ‬ ‫ ‬

‫يڪڏھن ‪ 2‬ته سوال نمبر ‪409‬‬ ‫ تي وڃو‬ ‫‪Birth Audit Questionnaire‬‬

‫‪Page 7‬‬

‫ ‪406.‬‬

‫ڇا اھو ساڳيو صحت ڪارڪن )ڊاڪٽر‪/‬نرس‬ ‫ال ِ‬ ‫يم‬ ‫ھيوجنھنسانتوھان وء‬ ‫وغيره(‬ ‫ رابطو ڪيو؟‬

‫ڇا‬

‫ ‪407.‬‬

‫ي۾‬ ‫تجي بار‬ ‫صح‬ ‫ج‬ ‫اھن يء َ مائرني‬

‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 106‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ معلومات ڏني؟‬ ‫ ‬

‫ ‬

‫ ‬ ‫ جيڪڏھن ھا ته ڪھڙي معلومات ملي؟‬

‫ ‪408.‬‬

‫ ‪ '(5 ,$") -( F‬‬

‫ ھا ‪C7 , 9‬‬ ‫ نه ‪D7 ( 9‬‬

‫ ‬ ‫ ‬

‫ ‪409.‬‬

‫ ‬

‫ ‪ 2 ,5 0! - "' (+& -"(' " -! 2 )+(/" 4‬‬ ‫ جيڪڏھن ھا ته ڪھڙي معلومات ملي؟‬

‫ ‪410.‬‬

‫‪Bleeding‬‬

‫‪1.‬‬

‫ ( ‪ ' 2(.+ ()"'"('5 0! - + -! ," ',‬‬ ‫ ‪ ' + .+"' )+ ' ' 24‬‬

‫ ‪411.‬‬

‫‪Severe headache‬‬

‫‪2.‬‬

‫‪Blurred vision‬‬

‫‪3.‬‬

‫‪Convulsions‬‬

‫‪4.‬‬

‫‪Swollen hands/face/feet‬‬

‫‪5.‬‬

‫‪High fever‬‬

‫‪6.‬‬

‫‪Loss of consciousness‬‬

‫‪7.‬‬

‫‪Difficulty breathing‬‬

‫‪8.‬‬

‫‪Severe weakness‬‬

‫‪9.‬‬

‫يڪڏھن ‪ 2‬ته سوال نمبر ‪411‬‬ ‫ تي وڃو‬

‫ ‬

‫رت اچڻ‬ ‫شديد مٿي ۾ سور‬ ‫اکين اڳيان انڌيرو‬ ‫جھٽڪا‬ ‫ھٿن‪ ،‬پيرن ۽ منھن تي سوڄ‬ ‫تيز بخار‬ ‫بيھوشي‬ ‫ساھه ۾ تڪليف‬ ‫گھٹي ڪمزوري‬

‫ڇا‬

‫ن ڄاول ٻار جي صحت جي باري‬ ‫ي َنئ ي‬ ‫انھء‬ ‫ ۾ معلومات ڏني؟‬

‫توھان جي خيال ۾حمل دوران ڪھڙا خطره‬ ‫ٿي سگھن ٿا؟‬

‫‪10. Severe abdominal pain‬‬

‫گھٹو پيٽ ۾ سور‬

‫‪11. Accelerated/ reduced fetal movement‬‬

‫پيٽ ۾ ٻار جي حرڪت ۾ تيزي ‪ /‬گھٽتائي‬

‫‪12. Water breaks without labor‬‬

‫چڻ‬ ‫سواءِ پاٹي ا‬ ‫ليبرکان‬

‫‪13. Other‬‬ ‫_____________________‪(specify‬‬

‫ڪو ٻيو )لکو(______________‬ ‫ خبر ناھي‬

‫‪99. Don’t know‬‬

‫ ‬

‫ خبر‬

‫ ‬

‫جيڪڏھن ‪ 1‬يا ‪ 99‬ته سوال‬ ‫ نمبر‪ 416‬تي وڃو‬

‫ <<<<<<<<<<<<‬ ‫ ‬ ‫ناھي ‪KK7 ('8- $'(0 9‬‬

‫ ‬

‫يالء ِويس‬ ‫طم عا ئن‬ ‫ڪوم سئلو نهھيوف ق‬

‫ ‬

‫ ويا؟‬

‫ڪ يترا دفعا‬ ‫لم عائنيالء ِ‬ ‫حم‬ ‫توھانود را ن‬ ‫ي‬

‫‪1.‬‬

‫ ‪ " 2(. ( (+ '- ' - % + ., 2(.‬‬ ‫ ‬ ‫ ‬

‫ ‬

‫‪2.‬‬

‫ ‪413.‬‬

‫ڇا توھان ڪنھن مسئلي يا سڀ ٺيڪ آھي‬ ‫ ھا‪ ،‬ڪو مسئلو ھو‬ ‫ل ي‬ ‫ج‬ ‫لساسرنڀا‬ ‫يحم‬ ‫ب ابتڄ اٹڻالء ِ دورا ن‬ ‫ خبر ناھي ‬ ‫ ‬ ‫م نئعايالء ِويا؟‬ ‫ ‬

‫‪Birth Audit Questionnaire‬‬

‫ ‪ (0 & '2 -"& , " 2(. ( (+ '- ' - %‬‬ ‫ ‪ + 4‬‬

‫ ‪412.‬‬

‫‪Page 8‬‬

‫ ‪414.‬‬ ‫‪RSPN‬‬

‫‪107 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ جيڪڏھن ھا ته ڪھڙو مسئلو ھو؟‬ ‫‪Check the woman’s weight‬‬

‫‪1.‬‬

‫)‪Check for anemia (looked at the eyes‬‬

‫‪2.‬‬

‫‪Urine test‬‬

‫‪3.‬‬

‫‪Check the position and movement of‬‬ ‫‪the fetus‬‬

‫‪1.‬‬

‫وزن ڪرائڻ‬

‫رت جي کوٽ چيڪ ڪرائڻ‬ ‫پيشاب جي چڪاس‬

‫ ‬ ‫

‬

‫ ‪415.‬‬

‫معائني دوران توھان ڪھڙيون‬ ‫خدمتون حاصل ڪيون؟‬

‫پيٽ ۾ ٻار جي جڳھه ۽ حرڪت بابت ڄاڻ‬ ‫‪Ultrasound of the abdomen‬‬

‫‪4.‬‬

‫‪Counseling for nutrition‬‬

‫‪5.‬‬

‫‪Counseling about where to deliver‬‬

‫‪6.‬‬

‫)‪Other ---- (please specify‬‬

‫‪7.‬‬

‫پيٽ جو الٽ راساوُن ‬

‫کاڌي بابت صالح مشورو‬

‫ويم جي جڳھه بابت صالح مشورو‬

‫ٻيو ڪجھه‬

‫ ھا ‪C7 ,‬‬

‫ (‪ D -! ' ( -‬‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 501‬تي وڃو‬

‫ ‬

‫ نه ‪D7 ( 9‬‬

‫ ‪ + '2 (&)%" -"(', + ( '"3 (+‬‬ ‫ )‪2(.+ )+ ' ' 2 .+"' '- ' - % ! $.‬‬ ‫ ‪(+ .+"' -! )+ ' ' 24‬‬

‫‪1.‬‬

‫ ‪ ! - $"' ( )+( % &=,> " 2(. ! / 4‬‬

‫ون ‪ (&"-"' 9‬‬ ‫ اُلي ٽ‬ ‫ ساھه ۾ تڪليف ‪ !(+-' ,, ( + -! 9‬‬ ‫ور ‪ / + ! ! 9‬‬ ‫س ُ‬ ‫ي۾‬ ‫ھگٹومٿ‬ ‫ ‬ ‫ منھن تي سوڄ ‪ 0 %%"' ( 9‬‬ ‫ '" ) ‪ / + %(0 + (&"' %‬‬

‫‪4.‬‬ ‫‪5.‬‬

‫ '" ‪ /2 & ',-+. % %‬‬

‫‪6.‬‬

‫ي ۾سُور‬ ‫ص‬ ‫ٺح‬ ‫يھ ي‬ ‫پي ٽ ج‬

‫ گھٹو رت اچڻ‬

‫‪2.‬‬ ‫‪3.‬‬

‫ ‪416.‬‬

‫ڇا حمل يا دوراني حمل سارسنڀال جي‬ ‫معائني دوران ڪو مسئلو ‪ /‬پيچيدگي‬ ‫ سامھون آئي؟‬ ‫ توھان کي ڪھڙا مسئال پيش آيا؟‬

‫ ‪417.‬‬

‫ ‬ ‫

‬

‫ڪ کانوڌڪي‬ ‫ت‪ :‬ھ‬ ‫ان يورمنيٽرالءِھ ادي‬ ‫جواب اچي سگھن ٿا جيڪي الڳو ٿين انھن‬ ‫ تي نشان لڳايو‬

‫ بل پريشر ۾ واڌ ‪ " ! %(( )+ ,,.+ 9‬‬ ‫ جھٽڪا ‪8. "-, (+ ('/.%,"(', 9‬‬ ‫ رت ۾ گھٽتائي ‪9. ' &" 9‬‬ ‫ سائي ‪10.‬‬ ‫ ڪو ٻيو ‪11.‬‬ ‫ خبر ناھي ‬ ‫‪7.‬‬

‫ ھلڪو ‬ ‫ وچولو مسئلي جي شدت ڇا ھئ ؟‬ ‫ شديد ‪Severe /‬‬

‫ ‬

‫ ‪418.‬‬

‫?‪Were you referred to a health facility‬‬

‫ ‪419.‬‬

‫ ‬ ‫ ‬

‫ ‪420.‬‬

‫ ھا ‬ ‫ نه ڇا انھن توھان کي ڪنھن ٻي سھولت مرڪز‬ ‫ ڏانھن موڪليو؟‬

‫ ‬

‫خبر‬

‫ ھا ‬ ‫ نه ‬ ‫ناھي ‬

‫ڇا توھان کي خبر آھي ته حمل دوران‬ ‫ ٻچيداني جو معائنو ڪيو ويو؟‬

‫ ‬ ‫‪Birth Audit Questionnaire‬‬

‫‪Page 9‬‬

‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 108‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫

' ‬

‫ ڇڏي‬

‫ڏيو ( " ‬

‫ جواب ( ‪ $"! $‬‬

‫ ‬

‫جيڪڏھن ‪ 1‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 506‬تي وڃو‬

‫ سوال ( ! ‪ & $%‬‬

‫ ‬

‫گھر ۾ ‬ ‫ ‬

‫ ‬ ‫ ‬

‫اسپتال ‬ ‫ ‪ ‬‬

‫ ‬ ‫ ‬

‫ ان باري ۾ ڪڏھن به نه سوچيو‬ ‫ پنھنجي يا مائٽ جي گھر ۾‬ ‫ دائي جي‬

‫ سي ايم ڊبليو جي گھر يا مرڪز تي‬ ‫ خانگي‬ ‫ بنياد‪ /‬ڳوٺاٹو صحت مرڪز‬ ‫ تعلقا‬

‫ ‬

‫ اصل ۾ توھان ڪٿي ويم ڪرائڻ چاھيو ٿي؟‬

‫ '! ‬ ‫ ‪501.‬‬

‫‪ /‬ضلعا اسپتال ‬ ‫ ڪو ٻيو ‬ ‫ خبر ناھي ‬ ‫ ھا ‬ ‫ نه ڇا توھان اتي ئي ٻار کي جنم ڏنو؟‬

‫ ‬

‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 506‬تي وڃو‬

‫ ‬

‫ڪميونٽي ريسورس پرسن )سي‪.‬آر‪.‬پي( يا‬ ‫ڳوٺ ۾ صحت تي ڪم ڪندڙ ڪارڪن‬ ‫جي صالح تي‬ ‫ ‬

‫ مڙس جي صالح تي‬

‫ ‪ ‬‬

‫ ‪502.‬‬

‫‪ 1.‬‬ ‫ ‬ ‫ ‬ ‫

‬

‫ ‪503.‬‬

‫‪2.‬‬

‫ ‪ ", .,,"(' 0"-! +" ' (+ + % -"/ ,‬‬

‫‪3.‬‬

‫تي ‪ /", 2 % +, 9‬‬ ‫ " ‪ /", 2 9‬‬

‫‪4.‬‬ ‫‪5.‬‬

‫ ‪ /", 2‬‬

‫‪6.‬‬

‫ '" ‪ /", 2 ! %-! )+(/" + "' %.‬‬

‫‪7.‬‬

‫ ‬

‫‪8.‬‬

‫ ‬

‫‪9.‬‬

‫ عزيز يا مٽ مائيٽ جي صالح تي‬ ‫ وڏن جي صالح‬ ‫ دائي جي صالح تي‬

‫سي ايم ڊبليو جي صالح تي‬

‫صحت ڪارڪن جي صالح مشوري‬ ‫ مطابق ڇاڪاڻ جو‬ ‫ مسئال پيدا ٿيا‬

‫ پئسا نه ھجڻ ڪري‬ ‫ ڪو‬

‫جيڪڏھن توھان اصل ۾ سوچيل جڳھه تي‬ ‫نجڳھه تبد ي‬ ‫ل‬ ‫ڪرايو ته پءو ِ ‪ ،‬تھوا‬ ‫ويمنه‬ ‫ ڪرڻ جو فيصلو ڇو ورتو؟‬

‫ٻيو ‪10.‬‬

‫ ‪ ‬‬

‫جيڪڏھن ‪ 2‬يا ‪ 3‬ته سوال‬ ‫ نمبر ‪ 506‬تي وڃو‬

‫ ليبر ۾ مسئلو ‬ ‫ جڳھه جي تبديلي ڇا جي ڪري ٿي؟‬

‫ ‬

‫ ‪504.‬‬

‫ ‬

‫ح ام ٹھو‬ ‫حي‬ ‫ڻالءِص‬ ‫گ ھر ۾ويمڪ رائ‬ ‫ جي نه ھجڻ ڪري‬ ‫ ڪجھه ٻيو ‬ ‫ ‬ ‫ ‬

‫ ‬

‫ ‪505.‬‬

‫جيڪڏھن ليبر‪/‬ويم جي سورن ۾ تڪليف ھئي‬ ‫ڪھڙو مسئلوھيو؟‬ ‫تهپوء ِ‬ ‫ ‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 10‬‬

‫‪RSPN‬‬

‫‪109 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ انھي‬

‫ ‬

‫وقت‪/‬جلدئي ‪ && " - %29‬‬ ‫ ‪ - + C:H !(.+,‬‬

‫‪61‬‬

‫نک انپوءِ‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬

‫ ‪12 6‬‬ ‫ ‪12‬‬

‫نک ناپوءِ‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬

‫‪ %"/ +2 '(- (' . - - !(& !(0 1.‬‬ ‫‪%(' " "- - $ -( " -! - -! 2(. 2.‬‬ ‫ ‪,!" - -( -! )% ( %"/ +24‬‬

‫ ‪ - + H:CD !(.+,‬‬

‫‪3.‬‬

‫ءِ ‪ - + :CD !(.+, 9‬‬ ‫نک انپو‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬ ‫ ‪ -0 ' C ' D 2,‬‬

‫‪4.‬‬ ‫‪5.‬‬

‫ ‪ (+ -! ' D 2,‬‬

‫‪6.‬‬

‫ ھڪ يا ٻن ڏينھن جي وچ ۾‬ ‫ ٻن ڏينھن کان وڌيڪ‬ ‫ خبر‬

‫جيڪڏھن گھر ۾ ويم نه ٿيو ته توھان کي‬ ‫ويم جي الء ڪنھن ٻي جڳھه ڏانھن منتقل‬ ‫ ڪرڻ جي فيصلي وٺڻ ۾ ڪيترو ٽائيم لڳو؟‬

‫ناھي ‪KK7 ('?- $'(0 9‬‬

‫ خود عورت ‪ (& ' ! +, % 9‬‬ ‫ مڙس ‪ ., ' 9‬‬ ‫ءُ ‪3. -! + 9‬‬ ‫ پ‬ ‫ي‬ ‫ءُ ‪4. (-! + 9‬‬ ‫ ما‬ ‫ سھرو ‪5. -! + "' % 0 9‬‬ ‫ سس ‪6. (-! + "' % 0 9‬‬ ‫ءُ ‪7. +(-! + 9‬‬ ‫ ڀا‬ ‫ ڀيڻ ‪8. ",- + 9‬‬ ‫ ڏير ‪9. +(-! + "' % 0 9‬‬ ‫ ڏيراٹي ‪10. ",- + "' % 0 9‬‬ ‫ ‪11. +" ' (+ (-! + + % -"/ ,‬‬

‫ ‬

‫ ‪506.‬‬

‫‪1.‬‬ ‫‪2.‬‬

‫ ‬ ‫ ‬ ‫ ڪٿي ويم ڪرائڻ آھي بابت فيصلو ڪنھن ورتو؟‬ ‫ ‬ ‫ ‬ ‫ڪ جواب اچي‬ ‫ڪ کانوڌ ي‬ ‫ت‪ :‬ھ‬ ‫ان يومرينٽرالءِھ داي‬ ‫ سگھن ٿا جيڪي الڳو ٿين انھن تي نشان لڳايو‬

‫ ‪507.‬‬

‫ عزيز يا مٽ مائٽ‬

‫ ڳ ‪12. (&&.'"-2 & & +, (+ % +,‬‬

‫ وٺاٹن يا بزرگن‬

‫ ‪13.‬‬

‫ڪميونٽي ريسورس پرسن )سي‪.‬آر‪.‬پي(‬ ‫يا ڳوٺ ۾ صحت تي ڪم ڪندڙ‬ ‫ڪارڪن‬ ‫ ڪو ٻيو ‪14.‬‬ ‫ خبر ناھي ‬ ‫ ‬ ‫ گھر ‬ ‫ ويم ڪٿي ٿيو؟‬ ‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 701‬تي وڃو‬ ‫ صحت مرڪز ڏانھن ويندي‬

‫ ‬

‫ صحت مرڪز )لکو(‬

‫پرائيويٽ ڪلينڪ يا اسپتال‬

‫ مقامي )سرڪاري( اسپتال يا ڪلينڪ‬

‫ ‪508.‬‬

‫ ضلعا اسپتال ‬ ‫ تعلقا اسپتال ‬ ‫ سٽي اسپتال ‪ ‬‬ ‫ منتقل دوران ‬ ‫ ڪو ٻيو ‬ ‫ خبر ناھي ‬

‫ انھي وقت‪/‬‬

‫ ‬

‫‪Birth Audit Questionnaire‬‬

‫جلدئي ‬ ‫ ‬

‫‪61‬‬

‫نک انپوءِ‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬

‫ ‪12 6‬‬

‫نک ناپوءِ‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬

‫ ‬

‫ ‬ ‫‪1.‬‬ ‫‪ 2.‬‬ ‫ ‬ ‫ ‬ ‫‪3.‬‬

‫‪Page 11‬‬

‫ ‪509.‬‬

‫ڪنھن ٻئي جڳھه تي وڃڻ بابت سوچڻ ۾‬

‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 110‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ ‪12‬‬

‫ ‬

‫‪4.‬‬

‫ ‬

‫‪5.‬‬

‫ ‬

‫‪6.‬‬

‫نک انپوءِ‬ ‫ڪ‬ ‫ڪ‬ ‫ال‬

‫ ھڪ يا ٻن ڏينھن جي وچ ۾‬ ‫ ٻن ڏينھن کان وڌيڪ‬ ‫ خبر‬ ‫ ‬

‫ڪيترو وقت لڳو ۽ اصل ۾ اتي پھچڻ ۾‬ ‫ ڪيترو وقت لڳو )سواري جو وقت(؟‬

‫ناھي ‪KK7 ('?- $'(0 9‬‬

‫ ‪ "& - $ ' (+ -! &"%2 -( " 9‬‬ ‫ خاندان جو فيصلو وٺڻ ۾ وقت لڳو‬ ‫ پئسن جي گھٽتائي ‬ ‫ سواري ۾ ڪمي ‬ ‫ ‬

‫ خبر نه ھئي ته ڪٿي وڃٹو آھي‬

‫‪C7‬‬ ‫ ‬

‫ ‪ -! + 0 , % 2 "' --"' -( -! )%‬‬ ‫ ‪0! + %"/ +2 0 , -( - $ )% 5 0! -‬‬ ‫ ‪0 , -! + ,(' (+ -! % 24‬‬

‫ ‪510.‬‬

‫ جيڪڏھن جتي ويم ٿيٹو ھيو اتي پھچڻ ۾‬ ‫ دير ٿي ته ان جو سبب ڇا ھيو؟‬

‫ ڪو ٻيو ‬ ‫ خبر ناھي ‬

‫ ‬

‫ خبر‬

‫ ھا ‬ ‫نه ‬ ‫ناھي ‬

‫ ‬ ‫ ‬

‫ ‪511.‬‬

‫ڻالء ِ پئسا‬ ‫ڪل‬ ‫طرمو‬ ‫جخا‬ ‫يعال‬ ‫ڇاتوھان ک‬ ‫ ھٿ ڪرڻ ۾ مشڪالت پيش آئي؟‬

‫ ‬

‫ ‬ ‫ ‬ ‫ ‬

‫ ‬

‫ ھا ‬ ‫نه ‬

‫ ‬

‫ ‪513.‬‬

‫ ‬

‫‪Dispensary‬‬

‫‪1.‬‬

‫ ‬ ‫ ‬

‫ ‪514.‬‬

‫‪Local government hospital or clinic‬‬

‫‪2.‬‬

‫‪District government hospital‬‬

‫‪3.‬‬

‫‪Tehsil Hospital‬‬

‫‪4.‬‬

‫‪Private Clinic or Hospital‬‬

‫‪5.‬‬

‫‪Private Doctor‬‬

‫‪6.‬‬

‫‪Pharmacist‬‬

‫‪7.‬‬

‫‪Pir/ Faqir‬‬

‫‪8.‬‬

‫& ‪Traditional healer (including Hakim‬‬ ‫)‪homeopath‬‬

‫‪9.‬‬

‫ ‪512.‬‬

‫سا‬ ‫ڻالء ِ پئ‬ ‫ڪل‬ ‫الجخاطر مو‬ ‫ي ع‬ ‫وتھان ک‬ ‫ ڪٿان آيا ؟ )ڪنھن ڏنا(؟‬

‫ڊسپينسري‬

‫لوڪل گورنمينٽ اسپتال يا دوا خانو‬ ‫ضلعا حڪومت اسپتال‬ ‫تعلقا اسپتال‬

‫خانگي دوا خانو يا اسپتال‬ ‫پرائيويٽ ڊاڪٽر‬ ‫مي يڪل اسٽور‬ ‫پير ‪ /‬فقير‬

‫يءَ جي کاتي‬ ‫ڇا توھان ڳوٺاٹي صحت ڪ ا مي ت‬ ‫ مان ڪا روڪ مدد حاصل ڪئي؟‬

‫ھڪ دفعو عالج ڪرائڻ جو فيصلو ٿي ويو‬ ‫ته توھان کي ڪٿي وٺي ويو؟) صحت‬ ‫ مرڪز جو نالو لکو(‬

‫روايتي عالج )حڪيم ۽ ھومپيٿڪ (‬

‫_____________)‪10. Other (Specify‬‬

‫ڪو ٻيو )لکو(______________‬

‫‪99. Don't know‬‬

‫ خبر ناھي‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 12‬‬

‫‪RSPN‬‬

‫‪111 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ (‪ C -! ' ( -‬‬

‫ ھا ‪C7 , 9‬‬ ‫نه ‪D7 ( 9‬‬

‫ ‪515 " 2(. / "% -+ ',)(+- +(& 4‬‬

‫ (‪ C -! ' ( -‬‬

‫ ھا ‪C7 , 9‬‬ ‫نه ‪D7 ( 9‬‬

‫ ‪516 , -! -+ ',)(+- + "%2 / "% % 4‬‬

‫ ‬

‫ ‪<<<<<< "' &"'.- ,‬‬

‫‪517‬‬

‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 518‬تي وڃو‬ ‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 519‬تي وڃو‬

‫ ‬

‫ پيادل ‪ %$ 9‬‬ ‫ پنھنجي سواري ‪ 0' -+ ',)(+- 9‬‬ ‫ ‪ '- =- 1"5 +" $,! 0> -+ ',)(+-‬‬

‫‪2.‬‬ ‫‪3.‬‬

‫ ‪ -+ ',)(+-‬‬

‫‪4.‬‬

‫ ‪ +" ' (+ + % -"/ 8, -+ ',)(+-‬‬

‫‪5.‬‬

‫ڪرائي واري سواري)ٽيڪسي يا‬ ‫ رڪشو(‬

‫يءَ جي طرفان‬ ‫ڳوٺاٹي صحت ڪ ا مي ت‬ ‫سواري‬ ‫ عزيز يا مٽ مائٽ جي سواري‬ ‫ ‬

‫‪1.‬‬

‫ ‬

‫ منٽن يا ڪالڪ ۾ لکو‬

‫ ‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 601‬تي وڃو‬

‫ خبر‬ ‫ ‬

‫يءَ جي‬ ‫ڇا توھان ڳوٺاٹي صحت ڪ ا مي ت‬ ‫ طرفان سواري جي مدد حاصل ڪئي؟‬

‫يءَ جي طرفان‬ ‫ڇا ڳوٺاٹي صحت ڪ ا يم ت‬ ‫سواري جي مدد فورن ڏني وئي؟‬

‫ ‪ '(5 !(0 %(' " "- - $ -( ++ ' 4‬‬

‫جيڪڏھن نه‪ ،‬ته ڪيترو ٽائم لڳيو؟‬

‫ ‪518 (0 " 2(. - -! + 4‬‬

‫ توھان اتي ڪيئن ويو؟‬

‫ ‬

‫‪520‬‬

‫ اتي پھچڻ ۾ ڪيترو وقت لڳو؟‬

‫ھا ‬ ‫ نه ‬ ‫ناھي ‬ ‫ ‬

‫ ‪ (0 %(' " "- - $ -( - -! + 4‬‬

‫‪519‬‬

‫ساڏيٹاپيا؟‬ ‫يالء ِپئ‬ ‫يسوا ر‬ ‫ڇا اتوھنک‬

‫ جيڪڏھن ھا ته ڪيترا؟‬

‫ ‬

‫‪521‬‬

‫ ‬ ‫

' ‬

‫ ڇڏي‬

‫ڏيو ( " ‬

‫ سوال( ! ‪ & $%‬‬

‫ جواب ( ‪ $"! $‬‬ ‫ ‬

‫ ‬

‫ ‬ ‫ ‬ ‫ ‬

‫ ‬

‫ منٽ يا ڪالڪن ۾ ____________‬

‫ '! ‬ ‫ ‪601.‬‬

‫جڏھن توھان ويم گھر ويا ته چڪاس کان‬ ‫پھرين توھان کي ڪيترو انتظار ڪرٹو پيو؟‬ ‫ لي ي ھيلٿ ورڪر‬ ‫ لي ي ھيلٿ وزيٽر ‬ ‫ تربيت يافته دائي‬

‫ غير تربيت يافته دائي‬

‫ توھان جي چڪاس ڪنھن ڪئي؟‬

‫ ‪602.‬‬

‫ نرس ‬ ‫ ڊاڪٽرياٹي ‬ ‫ گائناڪاالجسٽ ‪ ‬‬ ‫ ٻيو ڪو ‬ ‫ الڳو نٿو ٿي ‬ ‫ خبر ناھي ‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 13‬‬

‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 112‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬ ‫ ‬

‫ ‬

‫ ‬ ‫ ‬

‫ ‪603.‬‬

‫ اتي توھان کي ڪيترن ماٹھن رابطو ڪيو؟‬

‫ ‬ ‫ توھان کي ھيٺ الٿو ‬ ‫ انھن ڇا ڪيو؟‬ ‫ ‬ ‫بل پريشر‪ ،‬نبض‪ ،‬حرارت ۽ ساھه جي‬ ‫ ‪ ‬‬ ‫ رفتار جي چڪاس ڪئي‬ ‫ڪ کانوڌ ي‬ ‫ڪ‬ ‫ت‪ :‬ھ‬ ‫ان يورمنيٽرالءِھ ادي‬ ‫ ڊرپ لڳائي ‬ ‫ ڪو ٻيو لکو جواب اچي سگھن ٿا جيڪي الڳو ٿين انھن‬ ‫ تي نشان لڳايو‬

‫ ‪604.‬‬

‫ ‬

‫ ‬ ‫

‬

‫ ‪605.‬‬

‫_____________‪Rs.‬‬

‫ ‬

‫ ‪606.‬‬

‫ ‬

‫ ‪607.‬‬

‫ ‬

‫ ‪608.‬‬

‫ ‬

‫انھن توھان کي ڇا ٻڌايو‪ .‬مثال طور نارمل ويم‬ ‫ ٿيندو يا آپريشن؟‬ ‫ ‬

‫ ‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 609‬تي وڃو‬

‫ ڪيترا پئسا____________‬

‫ھا ‬ ‫نه ڇا توھان کي عالج شروع ڪرڻ کان پھرين‬ ‫ساڏيڻالء ِچيوويو؟‬ ‫پئ‬ ‫ خبر ناھي ‬ ‫ھا ‬ ‫نه جيڪڏھن ھا ته توھان وٽ پئسا ھئا‬

‫ ‬

‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 610‬تي وڃو‬

‫ خبر‬ ‫ ‬

‫ خبر‬

‫ناھي ‬

‫ ھا ‬ ‫ نه ‬ ‫ناھي ‬

‫ ‬

‫ ھا ‬ ‫نه ‬

‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫ ‪ 701‬تي وڃو‬

‫ ‬ ‫ ‬

‫ڏيو ( " ‬

‫ ‬ ‫ ‬

‫ ‪610.‬‬

‫خ يدڪ ر‬ ‫ڻ‬ ‫يڪ اشئير‬ ‫نکناسواء ِٻ‬ ‫ن د او ئ‬ ‫انھ‬

‫ ‪ ‬‬

‫ جيڪڏھن ھا ته ڪيترو خرچ آيو؟‬

‫ ‪611.‬‬

‫ ‬ ‫ ‬ ‫ ‬ ‫ ‬ ‫ ‬ ‫

' ‬

‫ جواب ( ‪ $"! $‬‬ ‫ ‬

‫ ‪609.‬‬

‫جيڪڏھن توھان وٽ پئسا نه ھيا ته ڇا انھن‬ ‫ توھان جو عالج ڪرڻ کان انڪار ڪيو؟‬

‫ ال ءِچيو؟‬

‫ ‬

‫ ڇڏي‬

‫ توھان کي ڪيترا پئسا ڏيٹا پيا؟‬

‫ ‬

‫ ڪنھن به نه‪ /‬مريض خود‬

‫ ‬

‫ رشتيدار )ڪو صحت ڪارڪن نه ھيو(‬ ‫ ‬ ‫ ‬

‫ ‬ ‫ ‬

‫ سوال ( ! ‪ & $%‬‬

‫ '! ‬

‫ ‬

‫ ‪701.‬‬

‫ توھان جو ويم ڪنھن ڪيو؟‬

‫ ‬

‫غيرتربيتي يافته م وائف يا دائي )ڳوٺ‬ ‫‪Birth Audit Questionnaire‬‬

‫‪Page 14‬‬

‫‪RSPN‬‬

‫‪113 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ ۾ موجود(‬

‫ ‬

‫ لي ي ھيلٿ ورڪر‬

‫ ‬

‫ دائي ‬ ‫ نرس ‪ /‬م وائف ‬ ‫ ڊاڪٽرياٹي ‬ ‫ گائناڪاالجسٽ ‬ ‫ ڪو ٻيو ‪ ‬‬ ‫ خبر ناھي ‬

‫ ‬

‫ پنھنجي رستي سان ويم‬

‫ ‬

‫ ‬ ‫ ‬

‫ڪھڙ ا اپاء ُور تاويا؟‬ ‫ويمدوران‬

‫ ‪702.‬‬

‫ ڊرپ‪ /‬بوتل ‬ ‫ ٻيون دوائون ‬ ‫ڪ کانوڌ ي‬ ‫ڪ‬ ‫ت‪ :‬ھ‬ ‫ان يورمنيٽرالءِھ ادي‬ ‫ اوزارن جي ذريعي کولڻ ‬ ‫ مشين جي ذريعي ڇڪڻ جواب اچي سگھن ٿا جيڪي الڳو ٿين انھن‬ ‫ ڪو ٻيو تي نشان لڳايو‬ ‫ خبر ناھي ‬ ‫ نارمل ‪ ‬‬ ‫ ‬

‫ ‬

‫ اوزارن جي ذريعي‬

‫ آپريشن جي ذريعي‬ ‫ خبر‬ ‫ ‬

‫ مھينن ۾ لکو‬

‫ خبر‬

‫‪Birth Audit Questionnaire‬‬

‫ ‪705.‬‬

‫ليبر شروع ٿيڻ وقت توھان صحت مند ھيا؟‬

‫ ‪ (0 %(' 0 + 2(. "' % (+ (+4‬‬

‫ ليبر ڪيتري وقت تائين ھيو؟‬

‫ھا ‬ ‫نه ڇا اورھہ ٻاھر آئي؟‬

‫ ‪706.‬‬

‫ ‪707.‬‬

‫ناھي ‬

‫ ‬

‫ منٽن ۽ ڪالڪن ۾‬ ‫ خبر ناھي ‬

‫ خبر‬ ‫ ‬

‫ناھي ‬

‫ ‪ + 2(. "' (( ! %-! 0! ' % (+‬‬ ‫ ‪ '4‬‬

‫

‬

‫ ‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 711‬تي وڃو‬

‫ھا ‪C7 , 9‬‬ ‫نه ‪D7 ( 9‬‬ ‫ناھي ‪ KK7 ('8- '(0 9‬ڇا‬

‫ ‬

‫ خبر‬ ‫ ‬

‫ ‬ ‫ ‬

‫ ‪704.‬‬

‫ خبر ناھي

جڏھن ليبر شروع ٿيو تڏھن توھان ڪيترن‬ ‫ مھينن جي حمل سان ھيا؟‬

‫ ‪ ‬‬

‫جيڪڏھن ‪ 2‬يا ‪ 99‬ته سوال‬ ‫ نمبر ‪ 709‬تي وڃو‬

‫ اھو ڪھڙي قسم جو ويم ھيو؟‬

‫ ‬

‫ خبر‬ ‫ ‬

‫ ‬

‫ ‪703.‬‬

‫ناھي

‬

‫ ‬

‫ ڪالڪن ۾‬

‫ ‬ ‫ ‪ ‬‬

‫ ‬ ‫ ‬

‫ڪتريديرک انپوءِ‬ ‫شئبعد ي‬ ‫ٻ ارجي يپ دا‬ ‫ اورھہ ٻاھر آئي؟‬

‫ھا ‬ ‫نه ‬ ‫ناھي ‪ ‬ويم‬ ‫ھا ‬ ‫ نه ‬ ‫‪Page 15‬‬

‫ ‪708.‬‬

‫ ‬ ‫ ‬

‫ ‪709.‬‬

‫دوران يا پھرين توھان کي جھٽڪا آيا؟‬

‫ ‬ ‫ ‬

‫ ‪710.‬‬

‫ڪا‬ ‫شاکنپ وء ِج ھٽ‬ ‫يپ يد ائ‬ ‫ڪڏھنھا ته ٻارج‬ ‫جي‬

‫‪RSPN‬‬

‫‪Addressing Delays for Access to EmONC 114‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ بند ٿي ويا؟‬ ‫ھا ‬ ‫نه ڇا انھن توھان کي ڪٿي ٻي ڄڳھه تي‬ ‫ موڪليو‪ /‬منتقل ڪيو؟‬

‫ ‬

‫جيڪڏھن ‪ 2‬سوال نمبر ‪715‬‬ ‫ تي وڃو‬

‫ ‬

‫ ‪711.‬‬

‫ ‪ 6 ! + -(4‬‬

‫ ‪712.‬‬

‫ ‪ " 2(. ( -! + 4‬‬

‫ ‪713.‬‬

‫تهڇ ا‬ ‫ال‬ ‫ءِ ‬

‫ ‪714.‬‬

‫ ‬

‫ ‪715.‬‬

‫ ‬

‫ ‪716.‬‬

‫ جيڪڏھن ھا ته ڪيڏانھن؟‬

‫ھا ‪C7 , 9‬‬ ‫نه ‪ D7 ( 9‬ڇا توھان اتي ويا؟‬

‫ ‪ C -! ' ( -( ICG‬‬

‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 715‬تي وڃو‬

‫ ‬

‫ڪڏھننه‬ ‫جي‬

‫ ‬

‫ اڳيان توھان ڇا ڪيو؟‬

‫ھا ‬ ‫نه جيڪڏھن ضرورت پئي ته توھان وري اتي‬ ‫ ويندا؟‬

‫ ‬

‫ ‬ ‫ ‬

‫ ڇڏي‬

‫ڏيو ‬

‫ جواب ‬ ‫ھا ‪C7 , 9‬‬ ‫نه ‪ D7 ( 9‬‬

‫ ‪ D -! ' ' -! "'- +/" 0‬‬

‫جيڪڏھن ‪ 2‬ته انٽرويو ختم‬ ‫ ڪريو‬

‫ ‬

‫ سوال ‬

‫ ‬

‫ڪميونٽي ريسورس پرسن )سي‪.‬آر‪.‬پي( يا‬ ‫ڳوٺ ۾ صحت تي ڪم ڪندڙ ڪارڪن‬ ‫ ‪ '-+ "' "+-! -- ' '-‬‬

‫‪C7‬‬

‫‪D7‬‬

‫ ‪ " 2(. / + ( (+ )(,-' - % + 4‬‬

‫ ‪801.‬‬

‫ ‪ !( " 2(. ( -( , 4 ) " 26‬‬

‫ ‪802.‬‬

‫ڇاتو ھان وي مکانپوء ِس ارسنڀالالء ِويا؟‬

‫ توھان‬

‫ ‬

‫ڪريو؟‬ ‫حت‬ ‫ض ا‬ ‫ٽ ِوي ا و‬ ‫ڪنھنو‬

‫ ‬ ‫ ‪ & +$ %% -! - ))%2‬‬

‫ڪ کانوڌڪي‬ ‫ت‪ :‬ھ‬ ‫ان يورمنيٽرالءِھ ادي‬ ‫ غير تربيتي يافته دائي‬ ‫ ‪ E7 2 ! %-! 0(+$ +‬جواب اچي سگھن ٿا جيڪي الڳو ٿين انھن‬ ‫ تي نشان لڳايو‬ ‫ لي ي ھيلٿ ورڪر‬ ‫ لي ي ھيلٿ وزيٽر ‪F7 2 ! %-! /","-(+ 9‬‬ ‫ دائي ‪G7 9‬‬ ‫ نرس‪ /‬م وائف ‪H7‬‬ ‫ ڊاڪٽر ‬ ‫ گائناڪاالجسٽ ‬ ‫ ‬

‫ ٻيو ڪو )وضاحت ڪريو(‬ ‫ خبر‬

‫ ‬

‫ناھي ‬

‫ ‬

‫معمول مطابق ‪1.‬‬ ‫ ڪو خاص ‪ ‬‬ ‫ خبر ناھي ‬

‫ ‬ ‫ ‬

‫ ‬

‫ ‪804.‬‬

‫ ‬

‫ھا ‬ ‫نه ‪ ‬‬

‫ ‬ ‫ ‬

‫ ‪805.‬‬

‫جيڪڏھن ‪ 1‬ته سوال نمبر‬ ‫ ‪ 805‬تي وڃو‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 16‬‬

‫ ‪803.‬‬

‫ڇا توھان معمول مطابق چڪاس يا ڪنھن‬ ‫ مسئلي خاطر ويا؟‬ ‫ ڪھڙو مسئلو ھو؟‬

‫‪RSPN‬‬

‫‪115 Addressing Delays for Access to EmONC‬‬ ‫‪in Non-LHW Areas of Pakistan‬‬

‫ ‬ ‫ ‬

‫ڇا توھان ويم دوران مليل سارسنڀال کان‬ ‫ مطمئن ھئا‬ ‫ ‬ ‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫‪ 808‬تي وڃو‬ ‫جيڪڏھن ‪ 99‬ته سوال نمبر‬ ‫ ‪ 809‬تي وڃو‬

‫ خبر‬

‫ھا ‬ ‫نه ‬ ‫ناھي ‬

‫ ‬ ‫ ‬

‫ ‪806.‬‬

‫جيڪڏھن ضرورت پوي ته توھان ساڳي‬ ‫ ماٹھو وٽ ٻيھر ويندا؟‬

‫ڇو ‬

‫ ‪807.‬‬

‫ ‬

‫ جيڪڏھن ھا ته‬

‫نه ‬

‫ ‪808.‬‬

‫ ‬

‫جيڪڏھن نه ته ڇو‬

‫ ‬ ‫ ‬

‫ھا ‬ ‫نه ‬ ‫ناھي ‬

‫ ‬

‫جيڪڏھن ‪ 2‬ته سوال نمبر‬ ‫‪ 811‬تي وڃو‬ ‫جيڪڏھن ‪ 99‬ته انٽرويو ختم‬ ‫ ڪريو‬

‫ خبر‬

‫ ‬ ‫ ‬

‫ ‪809.‬‬

‫جيڪڏھن ضرورت پئي ته توھان ساڳي‬ ‫ صحت مرڪز وري ٻيھر ويندا؟‬

‫ڇو ‬

‫ ‪810.‬‬

‫ ‬

‫ جيڪڏھن ھا ته‬

‫نه ‬

‫ ‪811.‬‬

‫ ‬

‫جيڪڏھن نه ته ڇو‬

‫ ‬ ‫ ‬ ‫ ‬

‫‪Birth Audit Questionnaire‬‬

‫‪Page 17‬‬

‫‪RSPN‬‬

Addressing Delays for Access to EmONC 116 in Non-LHW Areas of Pakistan

7.4 CHECK LIST OF FOCUS GROUP DISCUSSIONS AND INDEPTH INTERVIEWS FGDs

Community

Kamal Khan

Influential persons TBAs

VHCs

Female community Father in law

IDIs

Khudabad

Kamal Khan

Mother in law

Wives

Husbands

Total

117 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

IN DEPTH INTERVIEWS/ FOCUS GROUP DISCUSSION 7.5 FOCUS GROUP DISCUSSIONS AND INDEPTH INTERVIEWS Location --------------------------------------------Date--------------------------------------------------Time: start ------------------ finished------------Interviewer --------------------------------------------

Group 1. Husbands 2. Wives 3. Father in Laws 4. Mother in Laws 5. Religious Leaders 6.TBAs 7. Community members

Number of respondents ----------------------Thanks

I want to thank you for taking time to discuss the topic today.

Intro

My name is ____________________________ and I would like to talk to you about community awareness for emergency obstetrics and neonatal care in non-LHW covered areas and capacity building of public sector health care providers for delivery of EmONC services.

Purpose

Capacity building of health care provider to manage complications during pregnancy, natal, postnatal period and neonates and improve institutional or facility based deliveries, particularly for complicated deliveries, thereby contributing to reduction in maternal and neonatal mortality.

Confidentiality

All responses will be kept confidential. This means that your interview responses will be part of the findings but we will ensure that any information we include in our report does not identify you as the respondent.

Duration

The discussion will last somewhere from 60-90 minutes.

Tape/Notes

I will be taking notes during this interview. We may also tape the sessions because we don’t want to miss any of your comments. Is it okay with you if we tape the discussions? If we are on tape, please be sure to speak up so that we don’t miss your comments. We would also like to inform you that you can refuse to answer any of the questions at any time during the discussion/interview. This will not affect your participation in the rest of the interview.

Clarifications

Are there any questions about what I have just explained?

Consent

Are you willing to participate in this interview?

No.

Question What you know about EmONC?

Probe 1) Knowledge about pregnancy 2) Knowledge about natal, post natal and neonatal

What is the normal practice regarding delivery of your children?

1) Place of delivery (Home by self/ relative, Home w/ TBA, Home w/ CMW ,TBA/ Dai’s home ,CMW/ TBA’s home, BHU/ RHC, THQ/ DHQ, Private Health facility etc

Which place is safer for delivery of your children?

Do you think that you and your family have sufficient knowledge/information about recognizing pregnancies and complicated pregnancies?

Do you think that health facilities of your area are adequately equipped to deal complicated pregnancy cases?

Do you think that Para medical staff of

1) Which place respondents preferred 2) Why is this place preferred by respondent (Ask reason) 3) Any bad experience to not choose other places 1) Information required during pregnancy 2) Knowledge about natal, post natal and Neonatal (prompt for what they know) 3) Knowledge about complications during Pregnancy (prompt for what complications) 1) Need of bed for patients 2) Tools for handling emergency 3) Personnel 4) Electricity, water, other infrastructure 1) Staff Qualification

Addressing Delays for Access to EmONC 118 in Non-LHW Areas of Pakistan

your health facility is properly skilled? 7.

Are there social restraints on womenâ&#x20AC;&#x2122;s movement for care seeking purpose?

What would you like to improve/change overall health service delivery and particularly EmONC?

Any other suggestion that you may have? Thank you for your time 9.

2) Can manage complications 3) Cooperative/ polite 1) Normally who takes decision regarding delivery of children 2) Can women go outside home alone for this purpose 1) More training of staff 2) More equipment need 3) Current equipments are not in good condition 4) Infra structure of your facility 5) Arrangement of transport that may be used to transport women to facilities in emergency 6) Availability of medicines 7) Anything else (prompt) 1) Generating funds on community level for arrangement of transport for emergency

Notes _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________

119 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

7.6 CRP MODEL Communities were linked directly to health facilities using a referral mechanism implemented through trained Community Resource Persons (CRPs). The CRPs were community activists identified from within the community through a process of dialogues with the VHCs and the local community. They were trained by RSPN to undertake community mobilisation activities for health related interventions. They disseminated information in the community through group meetings and household visits and referred women to health facilities.

Selection Criteria for CRPs CRPs were selected on the following criteria: •

Resident of the assigned area.

•

CRPs must be literate (can read and write) and qualify the literacy test given by project team. Higher qualification will be preferred

•

Age between 18- 45 years and preferably married

•

Family support for mobility in the assigned area

•

Willing to go house to house in assigned population (for female CRPs only)

Capacity Building CRPs were trained in a 7 day training course that has been developed by RSPN. The training focused on: a) sensitisation of the CRPs towards maternal and child health situation, discussing reasons of poor health and their roles and responsibilities for improvement in the situation, b) enhancement of CRPs’ knowledge about available modern contraceptive methods, c) building the capacity of CRPs to use the IEC material and undertake behaviour change activities through group meetings and household visits; and d) quality record keeping of their work.

Group Meeting Trained male and female CRPs created awareness among the MWRAs, their spouses and extended family members including mother-in-laws and father-in-laws about the maternal and neonatal health through group meetings. Each pair of CRPs had approximately 75 married couples in their catchment population. Male and female CRPs covered all these target couples in about 5 group meetings. Separate meetings were organized with 15-20 men/women. Each round of group meeting was conducted on the following topics as detailed below: Round-1:

Importance of antenatal care, food and rest for pregnant women, danger signs during the pregnancy and referral

Round-2:

Birth preparedness including the saving at family level for emergency needs, use of clean delivery kit, complicated deliveries and referral

Round-3:

Danger signs during delivery, postpartum period, neonates and referral and neonatal care

Addressing Delays for Access to EmONC 120 in Non-LHW Areas of Pakistan

Household Visits After completion of the group meetings phase (2 months), female were involved for household visits for a period of 10 months. They conducted household visits of the each MWRA at least once in a month as mentioned below: MWRA Status

Discussion/ Information to be provided to MWRA

Non-User (not using any FP methods)

CRPs visited such women once in a month and motivated them to use contraceptive methods by providing them information on benefits of birth spacing. Such women were also provided information regarding nutrition, child health and survival and immunization including polio vaccination.

User (currently using any FP method)

Visited at least once in a month. Discussed the proper use of contraceptive methods. Were motivated the user for continuation of method if side effects are normal or expected, and were referred to MBLCs if the side effects are unusual. Such women were also provided information on nutrition and child survival, health and routine immunization including polio vaccination.

Pregnant Women

Pregnant women (1-8 month of pregnancy): Such women were visited twice in a month and CRPs provided information to them on importance of ANC, danger signs during pregnancy, risky pregnancies, birth preparedness, and importance of CDKs. Pregnant women in last month of pregnancy (9th month): CRPs visited such women thrice in a month and provided them information on natal care, danger signs during delivery, postnatal care, Postpartum Hemorrhage (PPH) and neonatal care

Women with neonates (0-28 days after delivery)

Such women were visited thrice in a month by CRPs. First visit was conducted immediately after or on first day of delivery in case of home delivery. CRP provided information about neonatal care (bathing, initiation of Breast Feeding (BF) immediately after delivery, etc.), information about PPH, will identify the cases of PPH and made arrangements for referral of mother to health facility if she displays signs of PPH. Second and third visit was conducted in the first week and third week after delivery respectively to reinforce the message and practices related to neonatal care.

Referral and Follow-up Female CRPs referred women for services to the health facilities and follow up with each MWRA by giving them a referral slip. Each referral slip had three parts; one for the client (i.e., the pregnant woman), the second to be given to the projectâ&#x20AC;&#x2122;s community mobilisation officers (CMOs) and the third to be retained by CRPs. CMOs would collect these slips from each CRP on a weekly basis, after which the projectâ&#x20AC;&#x2122;s research officers would visit the health facilities and meet with healthcare providers to track whether the referred clients had actually visited the facilities. Additionally, the research officers validated 5% of all clients (selected randomly) who availed services from health facilities through an interview and by tallying information with the CRP record.

Monitoring of the Community Mobilisation Activities The group meetings and household visits conducted by the CRPs were monitored by the social organizers and VHCs. The social organizers monitored the first group meeting of each CRP and validated at least one meeting conducted by each CRP. The findings of the monitoring were shared with the CRPs and they were provided guidance to conduct the group meetings as per methodology. The female CMO also monitored and validated a certain percentage of the household visits conducted by the female CRPs on monthly basis. In addition, the VHCs also provided feedback about the monthly visits of the female CRPs.

121 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Honorarium Female CRPs were taken on board for 12 months (2 month group meeting phase and 10 months household visit phase) and were paid an amount of PKR 1500 per month as honorarium. Male CRPs were only taken on board for a 2 month period of group meetings, and were paid PKR 1500 per month as honorarium.

Addressing Delays for Access to EmONC 122 in Non-LHW Areas of Pakistan

123 Addressing Delays for Access to EmONC in Non-LHW Areas of Pakistan

Rural Support Programmes Network (RSPN) House No. 7, Street 49, F-6/4, Islamabad, Pakistan Tel: 00-92-51-2829141,2829556, 2822476,2826792,2821736 Fax: +92 51 2829115 Email: info@rspn.org.pk URL: www.rspn.org