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1.  Addressing disparities in maternal health care in Pakistan: gender, class and exclusion 
After more than two decades of the Safe Motherhood Initiative and Millennium Development Goals aimed at reducing maternal mortality, women continue to die in childbirth at unacceptably high rates in Pakistan. While an extensive literature describes various programmatic strategies, it neglects the rigorous analysis of the reasons these strategies have been unsuccessful, especially for women living at the economic and social margins of society. A critical gap in current knowledge is a detailed understanding of the root causes of disparities in maternal health care, and in particular, how gender and class influence policy formulation and the design and delivery of maternal health care services. Taking Pakistan as a case study, this research builds upon two distinct yet interlinked conceptual approaches to understanding the phenomenon of inequity in access to maternal health care: social exclusion and health systems as social institutions.
This four year project consists of two interrelated modules that focus on two distinct groups of participants: (1) poor, disadvantaged women and men and (2) policy makers, program managers and health service providers. Module one will employ critical ethnography to understand the key axes of social exclusion as related to gender, class and zaat and how they affect women’s experiences of using maternal health care. Through health care setting observations, interviews and document review, Module two will assess policy design and delivery of maternal health services.
This research will provide theoretical advances to enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems in Pakistan. It will also provide empirical evidence to support formulation of maternal health care policies and health care system practices aimed at reducing disparities in maternal health care in Pakistan. Lastly, it will enhance inter-disciplinary research capacity in the emerging field of social exclusion and maternal health and help reduce social inequities and achieve the Millennium Development Goal No. 5.
PMCID: PMC3490894  PMID: 22871056
Social exclusion; Maternal health; Gender; Caste system; Pakistan; Health care system; Class; Health policy; Pregnancy and childbirth; Antenatal care
2.  HIV, STI prevalence and risk behaviours among women selling sex in Lahore, Pakistan 
BMC Infectious Diseases  2011;11:119.
More than 340 million cases of curable sexually transmitted infections (STIs) were estimated to have occurred worldwide in 1995. Previous studies have shown that the presence of other concomitant STIs increases the likelihood of HIV transmission. The first national study of STIs conducted in Pakistan in 2004 revealed a high burden of STIs among women selling sex. The HIV epidemic in Pakistan has thus far followed the "Asian epidemic model". Earlier studies among women selling sex have shown a low prevalence of HIV coupled with a low level of knowledge about AIDS. The aim of our study was to estimate the prevalence of HIV and STIs, and assess knowledge and risk behaviours related to HIV/STI, among women selling sex in Lahore, Pakistan.
A total of 730 participants were recruited through respondent-driven sampling. The participants were women selling sex in three areas (referred to as "A", "B", and "C") of Lahore. A structured questionnaire addressing demographic information, sexual life history, sexual contacts, and knowledge and practices related to HIV/STI prevention was administered by face-to-face interview. Biological samples were obtained from all participants and tested for HIV, Treponema pallidum, Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. Pearson's chi-square and multivariable logistic regression analysis were performed to test associations between potential risk factors and specified diagnosed infections.
The prevalence of HIV infection was 0.7%, T pallidum 4.5%, N gonorrhoeae 7.5%, C trachomatis 7.7% and T vaginalis 5.1%. The participants had been selling sex for a median period of seven years and had a median of three clients per day. Sixty five percent of the participants reported that they "Always use condom". The median fee per sexual contact was Rs. 250 (3 Euro). Compared to Areas A and C, women selling sex in Area B had a significantly higher risk of chlamydial infection, gonorrhoea and trichomoniasis. Among the participants, 37% had correct knowledge about HIV/AIDS transmission and its prevention.
The prevalence of HIV was <1%, and of any other STI 18.5% among participating women selling sex in Lahore, Pakistan. A reasonably high condom use, a relatively low number of sexual partners, and a relatively low prevalence of STIs might have contributed to the low HIV prevalence.
PMCID: PMC3114735  PMID: 21569319
3.  Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan 
Public hospitals in developing countries, rather than the preventive and primary healthcare sectors, are the major consumers of healthcare resources. Imbalances in rational, equitable and efficient allocation of scarce resources lie in the scarcity of research & information on economic aspects of health care. The objective of this study was to determine the average cost of a spontaneous vaginal delivery and Caesarean section in a tertiary level government hospital in Islamabad, Pakistan and to estimate the out of pocket expenditures to households using these services.
This hospital based cost accounting cross sectional study determines the average cost of vaginal delivery and Caesarean section from two perspectives, the patient's and the hospital. From the patient's perspective direct and indirect expenditures of 133 post-partum mothers (65 delivered by Caesarean section & 68 by spontaneous vaginal delivery) admitted in the maternity general ward were determined. From the hospital perspective the step down methodology was adopted, capital and recurrent costs were determined from inputs and cost centers.
The average cost for a spontaneous vaginal delivery from the hospital's side was 40 US$ (2688 rupees) and from the patient's perspective was 79 US$ (5278 rupees). The average cost for a Caesarean section from the hospital side was 162 US$ (10868 rupees) and 204 US$ (13678 rupees) from the patient's side. Average monthly household income was 141 ± 87 US$ for spontaneous vaginal delivery and 168 ± 97 US$ for Caesarean section. Three fourth (74%) of households had a monthly income of less than 149 US$ (10000 rupees).
The apparently "free" maternity care at government hospitals involves substantial hidden and unpredicted costs. The anticipated fear of these unpredicted costs may be major factor for many poor households to seek cheaper alternate maternity healthcare.
PMCID: PMC2826286  PMID: 20085662
4.  Training in Complementary Feeding Counselling of Healthcare Workers and Its Influence on Maternal Behaviours and Child Growth: A Cluster-randomized Controlled Trial in Lahore, Pakistan 
Malnutrition is common among children aged 6–24 months in developing countries. It increases the risk of mortality. Interventions to improve infant-feeding hold the promise of reducing malnutrition among these children. A study in Brazil has shown the success of training in communication and counselling skills among health workers in improving the nutritional status of young children. Questions were raised whether the method used in the study in Brazil would also be effective when applied in other countries. The aim of the present study was to reduce growth faltering in young children through proper nutrition-promotion techniques. The objective of the study was to determine the efficacy of training health workers in nutrition counselling in enhancing their communication skills and performance, improving feeding practices, and reducing growth faltering in children aged 6–24 months. A cluster-randomized controlled trial was carried out. The method used in this study was a replica of the method in a similar study in Pelotas, Brazil. Forty health centres were paired, and one centre of each pair was randomly allocated to the intervention group, and the other to the control group. The Integrated Management of Childhood Illness (IMCI) module—‘Counsel the mother'—was used for training health workers in the health centres in the intervention group. Data from 36 paired health centres and 375 mothers and their children aged 6–24 months recruited from these health centres following consultation with health workers were included in analysis. Independent observers, masked to the intervention status, examined the performance of health workers within the first month after training. Mother-child pairs were visited at home within two weeks, 45 days, and 180 days after recruitment. Information was recorded on the feeding practices, recall of the recommendations of health workers, and sociodemographic variables at these home-visits. Weight and length of the child were measured at each contact. The communication skills and consultation performance of health workers were significantly better in the intervention group than in the control group. The mothers' recall of the recommendation of health workers and reported infant-feeding practices were also significantly better in the intervention group than in the control group, even 180 days after the recruitment consultation. Growth faltering was less in the intervention group, with the largest effect observed among children in the age-group of 12 + months. These results indicate that training in IMCI feeding counselling can enhance the communication skills and performance of health workers. Improved feeding practices of counselled mothers can, in turn, reduce growth faltering in their children.
PMCID: PMC2740673  PMID: 18686554
Child; Child-feeding practices; Child growth; Child nutrition disorders; IMCI; Impact studies; Infant; Infant growth; Infant nutrition disorders; Nutrition counselling; Randomized controlled trials; Training; Pakistan
5.  Early-life Risk Factors for Adult Chronic Disease: Follow-up of a Cohort Born During 1964–1978 in an Urban Slum of Lahore, Pakistan 
Evidence suggests that risk of chronic diseases may be programmed during the foetal and early life of the infant. With high rates of low birthweight coupled with a rapid nutritional transition, low-income countries are facing an epidemic of chronic diseases. Follow-up of a cohort of adults born during 1964–1978 in an urban slum in Lahore, Pakistan, is presented in this paper. In 695 of these adults (mean age=29.0 years, males=56%), blood pressure, fasting blood glucose, and body mass index (BMI) were measured to assess early-life predictors of risk of chronic diseases. Sixteen percent of the study population was born with a low birthweight (<2,500 g). A significant positive association (p=0.007) was observed between birthweight and BMI; additionally, adjusting for age and gender, the association with BMI was highly significant (p=0.000). Conversely, a significant negative association (p=0.016) was observed between birthweight and adult levels of fasting plasma glucose; after adjustment for age and gender, the association was more significant (p=0.005) No association was observed between birthweight and adult blood pressure. The results suggest that low birthweight may increase later risk of impaired glucose tolerance in urban Pakistani adults. Further research in this area is warranted.
PMCID: PMC2740683  PMID: 18637524
Birthweight; Chronic disease; Follow-up studies; Risk factors; Slums; Pakistan

Results 1-5 (5)