The Pakistan Lady Health Worker (LHW) program provides door-step reproductive health services in a context where patriarchal norms of seclusion constrain women's access to health care facilities. The program has not achieved optimal functioning, particularly in relation to raising levels of contraceptive use. One reason may be that the LHWs face the same mobility constraints that necessitated their appointment. Past research has documented the influence of gendered norms and extended family (biradari) relationships on rural women's mobility patterns. This study explores whether and how these socio-cultural factors also impact LHWs' home-visit rates. A mixed-method study was conducted across 21 villages in one district of Punjab in 2009-2010. Social mapping exercises with 21 LHWs were used to identify and survey 803 women of reproductive age. The survey data and maps were linked to visually delineate the LHWs' visitation patterns. In-depth interviews were conducted with 21 LHWs and 27 community members. Members of a LHW's biradari had two times higher odds of reporting a visit by their LHW and were twice as likely to be satisfied with their supply of contraceptives. Qualitative data showed that LHWs mobility led to a loss of status of women performing this role. Movement into space occupied by unrelated males was particularly shameful. Caste-based village hierarchies further discouraged visits beyond biradari boundaries. In response to these normative proscriptions, LHWs adopted strategies to reduce the amount of home visiting undertaken and to avoid visits to non-biradari homes. The findings suggest that LHW performance is constrained by both gender and biradari/caste-based hierarchies. Further, since LHWs tended to be poor and low caste, and at the same time preferentially visited co-members of their extended family who are likely to share similar socioeconomic circumstances, the program may be differentially providing health care services to poorer households, albeit through an unintended route.
Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May 2010-February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan.
ObjectiveTo understand why skilled birth attendance—an acknowledged strategy for reducing maternal deaths—has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.DesignImplementation research was conducted using an institutional ethnographic approach.Setting and populationNational programme and local community levels in Pakistan.MethodsObservations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.Main outcomesAlignment of programme theory with real-world practice.ResultsData revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public–private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography.ConclusionsGreater attention to programme theory and the ‘real-world’ setting during design of maternal health strategies is needed to achieve consistent results in different contexts.
Introduction: Despite the growing attention to the relationship between menstruation and girls schooling, there remain many challenges to addressing the issue. Current interventions, which mostly focus on developing WASH infrastructure and sanitary hygiene management products, while necessary, may not be sufficient. This paper aimed to identify the root causes of poorly maintained WASH infrastructure, and understand the deeply embedded socio-cultural values around menstrual hygiene management that need to be addressed in order to provide truly supportive school environments for menstruating girls. Methods: Qualitative data were collected in rural and urban sites in three provinces in Pakistan using participatory activities with 312 girls aged 16-19 years, observations of 7 School WASH facilities, 42 key informant interviews and a document review. Results: Three key themes emerged from our data: (1) a poorly maintained, girls-unfriendly School WASH infrastructure was a result of gender-insensitive design, a cultural devaluation of toilet cleaners and inadequate governing practices; (2) the design of WASH facilities did not align with traditionally-determined modes of disposal of rag-pads, the most common used absorbents;(3) traditional menstrual management practices situate girls in an 'alternate space' characterised by withdrawal from many daily routines. These three socio-culturally determined practices interacted in a complex manner, often leading to interrupted class engagement and attendance. Conclusions: To be truly effective, current menstrual hygiene management strategies need to address the root causes of poor WASH infrastructure and ensure facility design is sensitive to the gendered and deeply embedded local socio-cultural values and beliefs around menstrual hygiene management.
BackgroundPakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay.Methods/DesignData will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW’s in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan.DiscussionThe findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.
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