Scaling up the "24/7 BHU" strategy to provide round-the-clock maternity care in Punjab, Pakistan: a theory-driven, coproduced implementation study.

Background: Pakistan's maternal mortality rate remains persistently high at 186/100,000 live births. The country's government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm.

Caste in Muslim Pakistan: a structural determinant of inequities in the uptake of maternal health services.

The failure to reduce maternal mortality rates in high-burden countries has led to calls for a greater understanding of structural determinants of inequities in access to maternal health services. Caste is a socially constructed identity that imposes structural disadvantages on subordinate groups. Although a South Asian construct, the existence of caste as a structural social stratifier is actively rejected in Muslim Pakistan as a regressive symbol of Hinduism.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah.

"How can we leave the traditions of our Baab Daada" socio-cultural structures and values driving menstrual hygiene management challenges in schools in Pakistan.

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.

Coverage of private sector community midwife services in rural Punjab, Pakistan: development and demand.

Background: In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates.

Successful Community Midwives in Pakistan: An Asset-Based Approach.

In response to the low levels of skilled birth attendance in rural Pakistan, the government introduced a new cadre of community midwives (CMWs) in 2006. Assessments to-date have found that these CMWs have yet to emerge as significant providers for a number of sociocultural, geographic and financial reasons. However, a small number of CMWs have managed to establish functional practices in the private sector in conservative, infrastructure-challenged rural contexts.

Saving mothers and newborns in communities: strengthening community midwives to provide high quality essential newborn and maternal care in Baluchistan, Pakistan in a financially sustainable manner.

Background: To address it's persistently high maternal mortality rate of 276/100,000 live births, the government of Pakistan created a new cadre of community based midwives (CMW). One expectation is that CMWs will improve access to maternal health services for underserved women. Recent research shows the CMWs have largely failed to establish midwifery practices, because CMW's lack of skills, both clinical and entrepreneurial and funds necessary to develop their practice infrastructure and logistics.

Improving maternal health in Pakistan: toward a deeper understanding of the social determinants of poor women's access to maternal health services.

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.

The role of social geography on Lady Health Workers' mobility and effectiveness in Pakistan.

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.

Signalling, status and inequities in maternal healthcare use in Punjab, Pakistan.

Despite rising uptake of maternal healthcare in Pakistan, inequities persist. To-date, attempts to explain and address these differentials have focused predominantly on increasing awareness, geographic and financial accessibility. However, in a context where 70% of healthcare is private sector provided, it becomes pertinent to consider the value associated with this good.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion.

Background: Pakistan 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.

Maternal deaths in Pakistan: intersection of gender, caste, and social exclusion.

Background: A key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available.