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Background: There is strong evidence on the potential of the Community Based Health Insurance (CBHI) schemes to facilitate access to healthcare and offer financial protection against the cost of illness for people excluded from formal insurance systems. However, enrollment in the Family Health Insurance scheme has remained low and there has been substantial dropout from the initial enrollment of the scheme’s insured members. Aim:This research aimed at exploring factors influencing enrollment of community members in a CBHI scheme. Methods:A mixed methods case studycomprisingqualitative phase of 10 Key Informant Interviews and 18 In-depth Interviews, and quantitative phase of 190 households: 96 insured and 94 uninsured were involved. Qualitative analysis was done using open coding while descriptive analysis was done for quantitative data. Results:Lack of awareness regarding insurance, lack of trust in management, unaffordability of insurance premiums, limited coverage of services in insurance plans, ambiguity regarding pre-existing conditions, negative marketing by drop-outs, and exclusion of vulnerable groups were some of the common reasons among uninsured group. Insured members of the scheme also had little knowledge about the scheme. Conclusions:The major reason for enrollment was the influence of community leader’s guidance. Stakeholders believed in modification of marketing strategies and innovations in increasing community awareness. Bangladesh Journal of Medical Science Vol.20(2) 2021 p.293-301

Objective: To explore the experiences and perceptions of midwives practising the midwifery-led care model at two private facilities of women and children hospital in Karachi, Pakistan. Methods: The descriptive qualitative data was collected through semi-structured questionnaires with 10 midwives. Results: The findings of the study revealed one theme and four related categories. The theme of the study emerged as ‘struggling to be a professional midwife’ and the related four categories were: (i) asking to perform within the full scope of practice, (ii) obstetricians’ reliance and trust in midwives' expertise, (iii) raising concerns about expensive midwifery services, and (iv) encountering barriers to practise midwifery as independent practitioners. Conclusion: Midwives face some challenges practising the midwifery-led care model such as lack of visibility in society, low salaries and increased workload due to the shortage of staff. Lack of higher education was also highlighted by the midwives as they have no opportunities for career growth. This study will increase midwives' autonomous role and decision-making in the clinical setting.

To assess the incremental value of blood oxygen saturation (SpO(2)) as a predictor in the miniPIERS model, a risk prediction model for adverse outcomes among women with a diagnosis of hypertensive disorder of pregnancy (HDP) in low-resourced settings.Using data from a prospective cohort including 852 women admitted to hospital for a HDP, the association between SpO(2) and adverse maternal outcome was assessed using logistic regression. The miniPIERS model was recalibrated and extended to include SpO(2). The incremental value of adding SpO(2) to the model was measured using a net reclassification index (NRI), sensitivity, specificity, positive and negative predictive values, and likelihood ratios.SpO(2) of93% was associated with a 30-fold increase in risk (95% CI 14 to 68) of adverse maternal outcome compared to women with SpO(2)97%. After recalibration and extension, the miniPIERS model including SpO(2) (vs. not including SpO(2)) had improved sensitivity (32.8% vs. 49.6%) at the cost of minimally decreased specificity (91.5% vs. 96.2%) with a NRI of 0.122.SpO(2) is a significant independent predictor of risk in women with a HDP. Adding SpO(2) to the miniPIERS model improved the model's ability to correctly identify high-risk patients who would benefit most from interventions.

To analyse referral pattern of high-risk obstetric cases from secondary to tertiary care hospitals and to assess their maternal and neonatal outcomes.This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised all referred obstetric cases from secondary-level hospitals to tertiary-level care within and outside the Hospital between January 2011 and December 2014. Day and time of referral, reason for referral as well as maternal and neonatal outcomes were collected. SPSS 19 was used for data analysis.Of the 634 obstetric referrals, 279(44%) patients were referred to the study site, while 355(56%) sought care in other hospitals. Of those patients who were referred to the AKUH, medical records of 195(69.9%) were available for review. The mean age of the participants was 28±4.7 years. Obstetric complications led to 122(61%) referrals. The top three reasons among these were pregnancy-induced hypertension, preterm labour and foetal causes. Medical causes such as viral infections were the cause of 50(27%) referrals. Moreover, 177(91%) patients were pregnant at the time of referral and the remaining 18(9%) were referred after delivery. Of the pregnant women, 133(75%) delivered at the study site. Caesarean section was the mode in 92(69%) deliveries. There was 1(0.75%) maternal death due to puerperal sepsis while 9(7%) neonatal deaths were recorded.The most common reason for referrals was obstetric indications. Moreover, a quarter of referrals were initiated due to medical conditions, most of which were due to infections.

To improve health outcomes through the implementation of national early warning sign tool for babies delivered through emergency caesarean section in off-work hours.This comparative clinical study was conducted at the Aga Khan Hospital for Women and Children, Karachi, from April to August 2014, and comprised women who had an emergency caesarean section. Maternal and perinatal outcomes were compared of patients in Group A and Group B which represented individuals before and after the implementation of the national early warning score respectively.Of the 200 participants, there were 100(50%) in each group. The overall mean age was 26.79±5.10 years. The mean age was 26.3±5 years in Group A, and 27.2±5 years in Group B (p=0.25). The two groups were also comparable in terms of parity (p=0.77) and co-morbidities (p =0.51). There was no stillbirth or maternal death, but decline in complications due to post-partum haemorrhage (p=0.00) was observed due to early recognition and timely management. None of the women required referral to higher facility.National early warning score was found to be a practical early warning tool for obstetric population.

To determine the reasons underlying the refusals to participate and drop outs from a follow up study involving primigravidae.A descriptive study.Aga Khan University and Aga Khan Hospital for Women, Karachi, jointly initiated a nested case-control study on primigravidae for determining the predictability of preeclampsia using various biochemical markers in blood. The protocol-eligible study subjects were counseled along with their accompanying family members to participate in the study. All women recruited in this study were followed up throughout their pregnancy till delivery.One thousand six hundred and sixty-five primigravidae were identified as the potential study subjects. Out of which, 1,307 (78.5%) consented and 358 (21.5%) refused to participate in the study. The most common reason underlying the refusal was inability to get permission from the family members (n=84; 34.4%) followed by fear of prick (n=51; 20.9%). For 114 refusals, either the reason was not mentioned by the counseled women (n=60) or the data was missing (n=54). Out of 1,307 women recruited in the research, only 611 (46.7%) women completed the study according to the prescribed protocol. Among the rest, 102 (7.8%) subsequently withdrew from the research, 503 (38.5%) were dropped out, and 91 (7.0%) were lost to follow up.Refusal to participate and drop out from the research program are two significant factors hindering the smooth flow of a study. In Pakistan, the major reason for the refusal by the protocol-eligible pregnant women for participating in a research program is the unwillingness of the family members.

Background Pre-eclampsia is one of the leading causes of maternal death and morbidity in low-resourced countries due to delays in case identification and a shortage of health workers trained to manage the disorder. The objective of the PIERS on the Move (POM) project was to provide mid-level health workers with an evidence-based and low-cost decision aid to improve diagnosis and management of pre-eclampsia, to improve outcomes.

To determine the prevalence of Group B Streptococcus genital tract infection in pregnant women and to determine the risk factors for its colonisation.The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi and Sobhraj Hospital, Karachi, from May to August 2007. Pregnant women at 35-37 weeks gestation attending antenatal clinic at these hospitals constituted the study population. Based on stratified sampling, 405 patients were recruited. High vaginal swabs of these patients were taken in order to calculate the prevalence of infection at each hospital. Logistic regression was used to evaluate the risk factor association. SPSS 11.5 was used for statistical analysis.The overall prevalence of colonisation was 17% (n = 69) (95% CI: 13.4-20.7). Of the 155 (38.27%) women at the Aga Khan Hospital, 35 (22.6%) were positive, while among the 250 (61.72%) women at Sobhraj Hospital, the prevalence was 13.6% (n = 34). The colonisation was found to be significantly associated inversely with the body mass index of the patient (OR 0.91; 95% CI: 0.08-1.0).Group B Streptococcus screening should be an integral part of antenatal care and should be offered to all pregnant women.

Restless legs syndrome (RLS) is more common in pregnant women. The objective of our study was to determine frequency of RLS in pregnant women and predictors of RLS in pregnancy in Pakistan. All pregnant women admitted at The Aga Khan University Hospital for delivery from June to July 2005 were enrolled. Eighty-one of 271 (30%) interviewed women fulfilled the diagnostic criteria of RLS. One hundred seventeen (43%) of the subjects dropped their haemoglobin during the pregnancy. No significant difference in haemoglobin drop was noted between the RLS group and healthy group. On multivariate analysis family history of RLS (OR: 8.43, CI: 2.32-30.57, p value

Sirenomelia, the Mermaid Syndrome is a rare and lethal congenital anomaly with an incidence of one in 60,000 to 70,000 pregnancies. Sirenomelia is characterized by complete fusion of the lower limbs, commonly associated with renal agenesis, absent external genitalia and other gastrointestinal defects. Another pathognomonic finding is the presence of single umbilical, persistent vitelline artery which is the chief distinguishing anatomic finding from Caudal Regression Syndrome. We report a case of termination of pregnancy done on the basis of ultrasound diagnosis of bilateral renal agenesis with no liquor volume. The foetus was identified to have characteristic features of Sirenomelia at the time of termination.

To determine the success rate of intrauterine insemination (IUI), following controlled ovarian hyperstimulation (COH) and to identify the prognostic factors associated with successful outcome in couples undergoing this form of assisted reproduction.Case series.Concept Fertility Centre, Karachi, Pakistan from January - December 2004.A total of 290 IUI procedures carried out for the treatment of unexplained and male factor subfertility were included. The age of women ranged from 20 to 44 years and the duration of subfertility were variable. All women had tubal patency confirmed before undergoing COH with one of the three regimens. IUI was performed at follicular maturity of16 mm and endometrial thickness of7 mm. Main outcome measures analyzed were pregnancy rate per cycle of IUI, miscarriage rate and ongoing pregnancy rate. Other variables observed were the various prognostic factors associated with successful outcome in IUI, such as maternal age, effect of different regimen of COH, motile sperm count and numbers of pre-ovulatory mature follicles16 mm. Data was collected and entered in SPSS version 10. Chi- square test of significance was applied and p-value determined.The cycle pregnancy rate (CPR), miscarriage rate and ongoing pregnancy rate was 10%, 13.8% and 8.6% respectively. CPR was 12% in women35 years compared to 3% in35 years (p-value 0.03). Significant difference was not observed in the CPR with three different COH regimes. CPR increased dramatically with motile sperm count of10 millions/ml compared with10 millions/ml (12.3% vs. 2.8%, p-value 0.02). Significantly higher pregnancy rate was observed with increasing number of mature follicles16 mm (6.2%, 12.9% and 30% with one, two and three follicles, p-value 0.0019). There was no case of OHSS and only one case of twin gestation.The overall CPR in patients undergoing IUI following COH at our clinic is comparable to the pregnancy rates as shown in different studies. Younger age, motile sperm count of10 millions/ml and two or three mature follicles16 mm are good prognostic factors for successful outcome. However, no significant difference was observed in CPR with different COH regimes.