Challenges and Expectations of Women regarding Maternal Healthcare Services in Pakistan
Maternal Health Care Situation in Pakistan
Access to maternal healthcare services is an essential pre-requisite for improving women’s health. However, due to poor access and underutilization of resources, women in Pakistan remain vulnerable to various complications. Maternal mortality ratio (MMR) in Pakistan as per Pakistan Demographic and Health Survey is 186 per 100,000 live births in 2017, which is highest in the South Asian region.
Only 65% of the pregnant women in Pakistan seek routine antenatal care, half of the deliveries occur in the absence of a skilled maternal care provider and less than 50% seek post-partum healthcare services. Government has established Maternal and Child Health Integrated Program in the country, which is striving to improve access of the women to healthcare system but the health seeking behavior for maternal services is also poor among women.
Need for Inclusion of Women Opinion to Ensure Improved Access to Maternal Healthcare
Evaluation of quality maternal healthcare services in any country must include the opinions of the women as a key stakeholder utilizing maternal healthcare services. In order to design interventions to improve the access and utilization of such services, it is necessary to evaluate the opinions, experiences and expectations of key stakeholders which include clinicians as well as mothers. Limited data are available regarding expectations and experiences of pregnant mothers and post-partum women in seeking maternal healthcare services in Pakistan. There is a need to evaluate the experiences, perceptions and expectations of pre-birth and post-birth women regarding utilization and delivery of maternal healthcare services in Pakistan.
Recommendations for Improving Women Access to Maternal Healthcare
A qualitative study was designed to evaluate the experiences, perceptions and expectations of pre-birth and post-birth women regarding utilization and delivery of maternal healthcare services in Pakistan. The data from the selected respondents was taken through interviews. Most of the respondents were from the urban settings, and were either first time pregnant or were having experience of one pregnancy and there was a high c-section rate among all respondents. Nearly half of the respondents among both groups were working women.
The results of the study suggested that the overall quality of the maternal care services provided in Pakistan was not up to the mark. High rate of caesarian section was prevalent. Majority of the women faced difficulty in finding the right doctor and were not prepared for the birth. They were not involved in the decision-making process or provided with any birth plan or counselling regarding birth signs, family planning and danger signs. They had to seek information from google followed by other social media and online platforms.
The cost of maternal care was quite high and not affordable for all. All the pre-birth as well as post-birth respondents highlighted the need for reducing cost of maternal care in order to make it easily affordable and accessible for all. The role of digital health for improving maternal care was acknowledged by most of the women. Mobile app was the most recommended option for seeking digital assistance. It was suggested by the respondents to improve the maternal care services by establishing a database of gynecologists, providing birth plan and appropriate guidance/counselling to the new mothers regarding danger signs, miscarriage, life style modification, lactation, post-partum depression, birth signs and complications associated with pregnancy as well as delivery. Adequate support system should be in place at healthcare facilities to provide prenatal and post-natal support to all mothers to reduce maternal complications and promote early initiation of breastfeeding in Pakistan.
Pharmacy Practice in Pakistan
In the last one decade pharmacy profession has seen vibrant changes in policy and education in Pakistan. Introduction of Pharm.D program and now recognition of pharmacy practice as fifth pillar in pharmacy education and practice has increased the acceptability of pharmacy graduates in Pakistan and abroad. There is a need of collaborative model of pharmacy practice in Pakistan which is evidence based and has a local context in its conceptualization and implementation. The area being new to Pakistan, needs more deliberation to set future direction most suited to local conditions and environment. The Action Plan for Pharmacy Practice is a long-term collaborative initiative for managing the changes required in pharmacy practice to meet the health care needs of Pakistani population.
Initiative for Pharmacy Practice Action Plan
In an effort to address this issue, all Pharmacy stakeholders need to work together to achieve a common vision and implement a coordinated plan of action. Higher education institutions have to invest in research capacity building initiatives to support successful implementation of effective pharmacy practice models in Pakistan. Hamdard Institute of Pharmaceutical Sciences, Hamdard University took a new initiative for collaborative concept mapping that embodies effective capacity building processes by enabling exploration, articulation and negotiation of shared motives and opportunities to formulate strategy and action plan for effective pharmacy practice in Pakistan. The authors commenced this journey by first conceptualizing different pharmacy practice models as a working paper in developed and developing world as it appears in the literature and then moved to capacity building process as there is chronic shortage of pharmacy practice experts in Pakistan. There are few professionals holding PhD in pharmacy practice in Pakistan till date. Hamdard Institute of Pharmaceutical Sciences is fortunate to have two of them as faculty members. Hamdard Institute of Pharmaceutical Sciences has this privilege to be the pioneer in commencement of Masters Program in Pharmacy Practice in Pakistan to develop a task force of Pharmacy Practice in Pakistan. A focus group discussion was held on the theme “Need for Action Plan for Pharmacy Practice in Pakistan” as the first step towards translating this action plan into practice. Approximately fifteen stakeholders all pharmacists from Drug Regulatory Authority, Academia, Hospitals and Community pharmacies participated in the discussion.
Proposed Model for Effective Pharmacy Practice in Pakistan
The Focus group discussion was planned in two rounds. The authors acted as moderators for the discussion. The discussion started with the introduction of all the participants. After the introduction, the moderators formally started the discussion by sharing the main themes of their working paper conceptualizing different pharmacy practice models as reference for initiation of action plan for Pharmacy Practice in Pakistan. They highlighted, structure and requisite engagement at community level as critical areas for promoting healthcare delivery services rather just merely quantifying health GDP ratio. In other words access to health is through access to pharmacy. Three very important things were emphasized to be taken into account to persuade policy makers for any kind of reforms i.e. timing, relevance and cost benefit analysis. Another challenge to be addressed is building professional competence through continuous education to advance pharmacy practices in Pakistan. Government and policy makers must realize that role of pharmacist is critical in enhancing healthcare services delivery in Pakistan and minimizing economic burden on the patient. Unfortunately, pharmacists are not in the main stream of policy making. This valuable component is vital to participate in the main stream of policy development. The participants from Drug Regulatory Authority and academia emphasized that there is need to strengthen the current curriculum and promote research to meet the challenges of changing realties in health care services particularly in pharmacy. Pharmacoeconomic and research experts need to be involved in policy development. Accelerative legislative and regulatory changes are required to expand scope of pharmacy practice in Pakistan.
Participants from development sector enlightened that as a result of devolution of 18th amendment the role of provincial government is more important whereas the role of the federation is to facilitate provinces. It is important that this kind of focal group discussions should also be conducted at provincial levels and representatives of provincial level participating in these discussions should act as advocate to further advance this idea at the grass root level. On the other hand hospital pharmacists signified the role of pharmacist in improving health related quality of life in chronic disease management. They accentuated on building strong relationships with patients and caregivers which can enhance overall quality of life. They highlighted the need of e-prescribing and drug information systems, enhanced experiential education in hospitals and primary care and promotion of collaborative working of pharmacists & other healthcare professionals. Beside this, community pharmacists highlighted on the need of a national public relations campaign for awareness regarding pharmacy practice. They also emphasized on tracking and forecasting pharmacy human resources requirements, integration of regulated pharmacy technicians and designing & implementing Pharmacy Services business models.
In the second round of discussion, the moderators concluded the discussion after taking into consideration the themes from the working paper and comments from all the participants. They cogently articulated the outline of the action plan need to be considered for incorporation to reinforce the current healthcare system which is currently quite disjointed. For this the changing role of pharmacist in this paradigm shift by embracing six key areas was underscored: (i) changing scope of practice of pharmacist through effective legislation and regulation; (ii) addressing shortage of human resources; (iii) capacity building of health professionals through requisite education and training; (iv) delivering good value of money through effective pharmacoeconomics (v) adopting information and communication technology (vi) redefining framework of patient care services. Finally after the mutual consensus of all the participants, patient centric model which aptly defined the aims and means of the action plan for successful implementation of pharmacy practice was proposed to be implemented in Pakistan.