October 05, 2008	Sunday	Shawwal 05, 1429

KARACHI, Oct 4: A part of a research, case studies on maternal, newborn and child health (MNCH) carried out in Pakistan and Uganda show that community-based primary health care can make a significant difference to MNCH and mortality outcomes and substantial advances can be made even without delivering health care services through secondary-care hospitals.

The research, Interventions to address maternal, newborn and child survival: what difference can integrated primary health care strategies make? , published last month was a part of an eight-paper series in the Alma-Ata Special Issue of the British medical journal, The Lancet.

The case studies of MNCH indicators in Pakistan and Uganda show that the inclusion of evidence-based interventions in primary health care at pragmatic coverage in these two countries could prevent 20 to 30 per cent of all maternal deaths (up to 32 per cent with capability for caesarean section at first-level facilities), 20-21 per cent of newborn deaths, and 29-40 per cent of all post-neonatal deaths in children aged less than five years.

According to these studies, substantial advances can be made, even without delivering care through secondary-care hospitals, if interventions are made available through primary health care (service availability at household and community level and first-level facilities).

“The key is to implement what we know works through all available and possible channels while building robust monitoring and assessment mechanisms. Given that almost 75 per cent of 68 countries with the greatest burden of maternal, newborn, and child deaths are off target to achieve MDGs [Millennium Development Goals] 4 and 5 goals, scaling up community-based primary care on the basis of what we know, is a moral imperative.”

The report declares that an understanding of barriers to the delivery of MNCH interventions at scale in primary health care as ‘crucial’ to the development of strategies for action and identifies four main factors that have contributed to deliver effective MNCH interventions at scale.

They include lack of a universally agreed minimum set of interventions that should be delivered to all women, newborns, and children who need them; lack of attention to demand creation at community-level and strategies to promote changes in care seeking and behaviour; shortage of well-trained staff, accompanied by reservations about task shifting from more highly trained workers to those with shorter training and failure to allocate the resources needed to ensure the functionality of first-level health facilities, regular supervision of staff in these facilities, and strong links between facility-based staff and community-based workers.

While emphasising a community-based approach in the management of newborn and childhood illnesses, the research stresses that several issues must be kept in mind while developing and scaling up such approaches.

“Countries and district health services need to consider carefully the gains from developing a cadre of community health workers versus alternative approaches. In circumstances in which the primary care health system is reasonably functional and care seeking the norm, strengthening of facility-based health services and incentives and support (such as transport) to encourage use is likely to be more cost effective than the development of a new cadre of workers.”

“At the community level, all health issues are interlinked, especially for MNCH, although services within the health system do not cater equally to the needs of women, newborns, and children.”

About the lack services for instrumental deliveries and caesarean sections, the report says that though such services are key intervention for maternal survival, the case studies suggest that reasonable gains can still be made for maternal health and survival in primary health care by introducing a range of preventive interventions ranging from family planning or provision of contraceptives, through care seeking, clean delivery, pre-eclampsia prevention, and antenatal care to address maternal risk factors, such as anaemia and pregnancy-induced hypertension.

The benefit of birth spacing on reducing all-cause maternal mortality is evident and highlights the need to integrate reproductive health and family planning services within MNCH activities. These strategies should be complemented with additional therapeutic interventions to address major causes of maternal mortality such as ante-partum and post-partum haemorrhage, infections, and eclampsia.

According to the last year’s demographic and health survey, maternal mortality in Pakistan is 276 per 100,000 births, with corresponding newborn, infant, and mortality in children age younger than five years of 54, 78, and 94 per 1000 live births, respectively.

Aga Khan University (AKU), in partnership with the London School of Tropical Medicine & Hygiene, were involved in the research and development of the series funded by the Partnership for Maternal, Newborn, and Child Health, the Norwegian Agency for Development Cooperation and AKU.