Pakistan Initiative for Mothers and Newborns (PAIMAN)

Strategic Objectives

PAIMAN's strategic framework is designed to support the Pathway through five objectives. These objectives are being met by a series of interventions including training, technical assistance and continuing education to the service providers and managers as well as developing management systems. Objectives and implementation strategies are as follows:

  1. SO-1 Increase awareness and promote positive maternal and neonatal health behaviors.
  2. SO-2 Increase access (including emergency obstetric and newborn care) to and community involvement in maternal and child health services and ensure services are delivered through health and ancillary health services.
  3. SO-3 Improve service quality in both the public and private sectors, particularly related to the management of obstetrical and neonatal complications
  4. SO-4 Increase capacity of MNH managers and care providers
  5. SO-5 Improve management and integration of services at all levels

SO-1 Increase awareness and promote positive maternal and neonatal health behaviors.

Increase women's and their family's knowledge and awareness of harmful practices and for improved health seeking behavior. Encourage cultural norms and traditional beliefs that support healthful behaviors while discouraging those that are harmful. Male involvement is critical for quick decision making and support to the women and children in case of transportation to health facilities.

Outcomes:

  • Enhanced demand for maternal, newborn and child health, and family planning services by changing current patterns of health-seeking behavior at the household and community levels.
  • Increased practice of preventive MNH-related behaviors, such as seeking skilled care at delivery.
  • Institutionalized support for MNH at federal, provincial and district levels.

Implementation strategies

  • Apply an evidence-based communications strategy that is tailored to local needs, formulated in participation with all stakeholders, and established at district level.
  • Create supportive environment that promotes individual behavior change communication (BCC) interventions to put MNH on the agenda of policy makers and general public for consistent and institutionalized support for MNH at all levels.
  • Use all communication channels to ensure that messages reach the target population and generate demand for MNH and family planning services. These channels include mass and folk media, IEC packages in local languages, and good-will ambassadors.
  • Build capacity of managers & health providers to create a pool of professionals who are capable of designing communication strategies/campaigns to address local communication needs.
  • Improved interpersonal communications skills of health providers in public and private sectors including doctors, LHVs, LHWs, NGO staff, HCP's.

SO-2 Increase access (including emergency obstetric and newborn care) to and community involvement in maternal and child health services and ensure services are delivered through health and ancillary health services.

Given the social and cultural context of Pakistan, the community-based interventions are key to sustainable solutions for the maternal and newborn mortality problem. Indeed, in order to circumvent the cultural constraints limiting the mobility of pregnant women, obstetrical and neonatal service delivery needs to be brought closer to the community. PAIMAN will assist the GOP in developing a sustainable skilled birth attendants (SBA) strategy to bring a professional trained midwife to the community (see SBA concept paper developed by NCMH as annex-1). The traditional birth attendant (TBA) will remain an important community-based "obstetrical worker" and a liaison between the woman in the household and the professional health worker.

Outcomes:

  • Increased use of antenatal and postnatal care services, including births attended by SBAs, contraceptive use, tetanus toxoid coverage, enhanced basic and emergency obstetric care, and reduced case fatalities.
  • Reduced cost, time and distance to obtain basic and emergency care; the better to save newborn and maternal lives.

Implementation strategies:

  • Assist the GOP in further testing of the obstetrical support network, in which the SBA becomes the focal point of the community-based obstetrical services including prenatal, birth and post-partum care (Figure-2: Maternal and Neonatal Support Network). All efforts will be made to develop a national SBA strategy that considers aspects such as policy, regulatory mechanisms, licensing, quality of training, hands-on experience and community exposure.
  • Develop a community-based intervention package (see figure 3)
  • Prevent unwanted and mistimed pregnancy through family planning counseling and an improved service delivery and referral system.
  • Construct a continuum of skilled care during pregnancy, childbirth, and postpartum and newborn periods. To include ante-natal (ANC), birth preparedness, skilled labor & delivery care through community SBA, essential newborn care, postpartum interventions focused on mother, neonate and family planning.
  • Rapid and responsive referral in the event of an emergency through improved communication and community-organized transport.
  • Strengthen the existing service delivery system by advocating with provincial and district health departments for better deployment of existing staff (WMOs, LHVs) in BHUS/RHCs and establishing better referral linkages between BHUs/RHCs and the District/Tehsil hospitals.
  • Involve private sector providers, especially in areas where there are public sector health facilities but no female doctor or LHVs. Also engage private practitioners in such areas into contractual agreements with EDO(H). Gynecologists can be called to perform cesarean sections or manage complications of pregnancy.
  • Employ innovative solutions to resolve transport problems between homes and health facilities, Community-managed transport, as determined by location, can reduce delay and costs.
  • Increased community involvement and awareness to ensure safe motherhood and appropriate newborn care. Wide-spread education about complications associated with pregnancy and child birth is possible only through the full participation of community members in program planning and implementation. PAIMAN works with LHWs, local NGOs and CBOs to build community leadership and involvement.
  • Reduce the geographic, cultural and religious barriers that prevent women from seeking both preventive and emergency care.
  • PAIMAN prioritizes the involvement of women and men in all aspects of the program implementation.

Maternal and Neonatal Support Network

Maternal and Neonatal Support Network

Community-Based Essential Maternal and Newborn Care

Antenatal Care Labor & Delivery Care Postnatal Care  
Basic Care for all mothers & newborns Provider Contacts/Visits/
BCC/community mobilization
  • Tetanus Toxoid
  • Adequate nutrition
  • Iron, folate (iodine*)
  • Intermittent presumptive treatment and bednets for malaria*
  • Breastfeeding counseling
  • Birth Preparedness
Skilled Attendance/BCC/ community mobilization
  • Identification of danger signs in mother and baby and referral/appropriate care-seeking
  • Clean delivery
  • Safe delivery (partogram)
  • Active management of the third stage of labor
  • Prevention of hypothermia
  • Immediate breastfeeding
  • Prophylactic eye care*
Provider Contacts/Visits
BCC/community mobilization
  • Immediate and exclusive breastfeeding
  • Identification of danger signs in mother and baby and referral/appropriate care-seeking
  • Thermal protection
  • Hygienic maternal/newborn care including cord care
  • Immunization
  • Maternal nutrition
  • Birth spacing counseling and provision of contraceptives/referral

CB Material Maternal and fetal complications Maternal complications, birth asphyxia, low birth weight Hemmorhage, eclampsia infection, malformation, other problems

SO-3 Improve service quality in both the public and private sectors, particularly related to the management of obstetrical and neonatal complications

In order to provide the full "continuum of care" the community-based obstetrical and newborn care system must be backed by a strong and quality referral system at tehsil and district levels to ensure management of life-threatening obstetrical complications.

Outcomes:

  • Increased utilization of services to improved maternal and newborn health outcomes.
  • Decreased case-fatality rates for hospitalized women and neonates.

Implementation strategies:

  • Introduce client-focused services through a client-centered approach to service delivery and quality improvement, focusing on the ability of providers to identify and meet client needs. Interpersonal communication between providers and clients is of particular focus.
  • PAIMAN and MNH unit in the MOH establish MNH norms, standards of care, protocols, prevailing supervision, and provider practices for consistency with the latest best practices.
  • PAIMAN is establishing quality improvement mechanisms: to ensure appropriate oversight and improvement, through both self-regulation (i.e., professional associations, service provider associations, etc.), and the appropriate government body.
  • PAIMAN is upgrading ten referral health facilities in ten districts and is providing support for minor renovation of other health facilities in these districts including RHCs and BHUs. PAIMAN is also supplying some essential equipment.

SO-4 Increase capacity of MNH managers and care providers

The capacity of community-based (LHVs, LHWs, TBAs, and CMWs) as well as facility-based providers (MOs, WMOs, LHVs, midwives, obstetricians), needs to be strengthened to implement a continuum of care, from normal deliveries at home to the management of emergency obstetrical and neonatal complications at the hospital.

Outcomes:

  • Increased skilled attendance of deliveries in the target districts.
  • Decreased case-fatality rates for hospitalized women and neonates.

Implementation strategies:

  • Based on results of a training needs assessment, employ a comprehensive capacity building, hands-on training approach involving but surpassing individual training activities, to include follow-up of trainees and strengthening of individual performance monitoring and supervisory systems.
  • In order to institutionalize capacity building for all individual capacity building activities, PAIMAN is working closely with the Health Development Centers at provincial (PHDCs)/Provincial Health Services Academy (PHSA) and at district (DHDC) levels, as well as with the nursing and midwifery schools in the target districts. Districts with DHDCs will be allocated rooms at either DHQH or THQH for training.

SO-5 Improve management and integration of services at all levels

Work closely with government of Pakistan at all levels for Integration of MNH services within the devolved environment with particular focus on district health system.

Outcomes

  • Successfully integrated district Health Plan, leading to achievement of MNH targets.
  • HMIS data used guide MNH decisions strengthened service delivery.
  • Successfully developed and implemented district models for collaboration with CBOs, NGOs and private sector.
  • Assist the GOP in adopting a national "Maternal, Newborn and Child Survival strategy," working in close collaboration with the established "Maternal and Child Health Cell" at the Federal level,functioning as an oversight body for all programs, projects and initiatives for MNH.
  • Work closely with District Health Management Team to plan and prioritize MNH programs involving the community.
  • Build capacity of districts to use the information generated at the district level for planning and budgetary allocations based on realistic needs, as well as for ensuring quality service delivery at the facility level.
  • Introduce an improved Logistic Management Information System (LMIS) to the MOH/MOPW to ensure a continuous supply of contraceptives and medicines.
  • Develop action-oriented protocols and checklists and promote supportive supervision techniques.
  • Assist the government in developing regulatory framework for private sector including hospitals, maternity homes, general practitioners, hakeems, homeopaths, and TBAs.
  • Development of sustainable public/private partnerships by studying existing projects. Propose innovative models for outsourcing service delivery to the private sector, establish partnerships between the DHMT and local NGOs/CBOs.
  • Strengthen links with other community health and social programs (e.g. adult literacy, water and hygiene, school health).