BACKGROUND:The role of clinical breast examination (CBE) for early detection of breast cancer is extremely important in lower-middle-income countries (LMICs) where access to breast imaging is limited. Our study aimed to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan.METHODS:Eight health care workers (HCW) and a gynecologist were educated on basic breast cancer knowledge and trained to create breast cancer awareness and conduct CBE in the community. They were then deployed in the Dadu district of Pakistan where they carried out home visits to perform CBE in the community. Breast cancer awareness was assessed in the community using a standardized questionnaire and standard educational intervention was performed. Clinically detectable breast lesions were identified during home CBE and women were referred to the study gynecologist to confirm the presence of clinical abnormalities. Those confirmed to have clinical abnormalities were referred for imaging. Follow-up home visits were carried out to assess reasons for non-compliance in patients who did not follow-through with the gynecologist appointment or prescribed imaging and re-enforce the need for follow-up.RESULTS:Basic breast cancer knowledge of HCWs and study gynecologist improved post-intervention. HCWs conducted home CBE in 8757 women. Of these, 149 were warranted a CBE by a physician (to avoid missing an abnormality), while 20 were found to have a definitive lump by HCWs, all were referred to the study gynecologist (CBE checkpoint). Only 50% (10/20) of those with a suspected lump complied with the referral to the gynecologist, where 90% concordance was found between their CBEs. Follow-up home visits were conducted in 119/169 non-compliant patients. Major reasons for non-compliance were a lack of understanding of the risks and financial constraints. A significant improvement was observed in the community's breast cancer knowledge at the follow-up visits using the standardized post-test.CONCLUSIONS:Basic and focused education of HCWs can increase their knowledge and dispel myths. Hand-on structured training can enable HCWs to perform CBE. Community awareness is essential for patient compliance and for early-detection, diagnosis, and treatment.

Objective To describe presenting diagnoses and rates and causes of death by age category and sex among children with acute illness brought to a district headquarter hospital in Pakistan.Design Prospective cohort study.Setting Sanghar district headquarter hospital, Sindh, Pakistan between December 2019 and April 2020 and August 2020 and December 2020.Participants 3850 children 0–14 years presenting with acute illness to the emergency and outpatient departments and 1286 children admitted to the inpatient department.Outcome measures The primary outcome was Global Burden of Disease diagnosis category. Secondary outcomes were 28-day mortality rate, cause of death and healthcare delays, defined as delay in care-seeking, delay in reaching the healthcare facility and delay in appropriate treatment.Results Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients aged 1 month to 9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. Few children presented with injuries. Newborn period (age <28 days) was associated with increased odds of death (OR 4.34 [95% CI 2.38 to 8.18], p<0.001, reference age 28 days–14 years) and there was no significant difference in odds of death between female vs male children (OR 1.12, 95% CI 0.6 to 2.04, p=0.72). 47 children died in the hospital (3.6%) and three (0.2%) died within 28 days of admission. Most children who died were <28 days old (n=32/50, 64%); leading diagnoses included neonatal sepsis/meningitis (n=13/50, 26%), neonatal encephalopathy (n=7/50, 14%) and lower respiratory tract infections (n=6/50, 12%). Delays in care-seeking (n=15) and in receiving appropriate treatment (n=12) were common.Conclusion This study adds to sparse literature surrounding the epidemiology of disease and hospital outcomes for children with acute illness seeking healthcare in rural Pakistan and, in particular, among children aged 5–14 years. Further studies should include public and private hospitals within a single region to comprehensively describe patterns of care-seeking and interfacility transfer in district health systems.

The use of modern contraceptive methods (MCMs) has been stagnant for the last decade in Pakistan. The second most populous province, Sindh reports 25% of MCMs use. Various factors including demographics and health services utilization are associated with the uptake of family planning services. This research aimed to identify and assess specific predictors of MCMs among women aged 15-49 in two districts of Sindh-Matiari and Badin. A cross-sectional household survey was conducted from October 2020- December 2020. In total, 1684 Married Women of Reproductive Age (MWRA) 15-49 years were interviewed. For the selection of eligible respondents, a two-stage stratified cluster sampling strategy was used. Univariate and multivariable logistic regression was used to determine the predictors for the use of MCM. Use of modern methods of contraceptive was 26.1% (n = 441). Statistically significant socio demographic predictors of MCM included: number of children 4 or more (AOR: 5.23; 95%CI: 2.78-9.84), mother having primary education (AOR: 1.73; 95% CI: 1.26-2.36), and husband having middle education (AOR: 1.69; 95% CI: 1.03-2.76). Maternal health services indicators included: postnatal care of mother (AOR: 1.46; 95% CI: 1.09-2.05); women who were visited by Lady Health Workers in their postnatal period and were counselled on family planning (AOR: 1.83; 95% CI: 1.38-2.42). Since the primary purpose of using modern contraceptive methods is for limiting pregnancies, there is a potential to promote awareness about the benefits of birth spacing as part of implementing a more integrated approach to family planning. The integration of family planning services within maternal and newborn child healthcare services effectively promote the voluntary adoption of modern contraceptive methods. The role of Lady Health Workers in family planning counseling and service provision and uptake is important in the context of Sindh and should be fostered further by opportunities for capacity building and their empowerment.

Background Adopted in 2015, the sustainable development goals (SDGs) have set specific targets (SDG 3.2) for countries to reduce their neonatal mortality rate (NMR) to below 12 deaths per 1000 live births and under 5 mortality rate (U5MR) to below 25 deaths per 1000 live births by 2030. For Pakistan to achieve these targets, there is a need to measure these rates and understand the predictors of child mortality at sub-national level. Launched in 2016, the Umeed-e-Nau (UeN) or New Hope project is based on scaling up proven and effective Maternal and Newborn Child Health (MNCH) interventions in 8 of the highest burden districts of the country, using existing public sector platforms in Pakistan at both the community and facility level. The primary aim of the project is to reduce perinatal mortality in these districts by 20% from baseline.Methods We report overall neonatal and post neonatal mortality rates for the two years preceding the UeN baseline household survey. Rates were calculated using the synthetic cohort probability method and predictors of neonatal and post neonatal mortality examined using Cox regression. To investigate spatial variations in the mortality rates, we calculated Moran's I at the district level using predicted probabilities of mortality. Finally, we create district level maps of predicted under 5 child mortality using a stochastic partial differentiation approach.Findings A total of 26,258 children contributed to the analysis of mortality with 838 deaths in the neonatal period and 2236 under-5 deaths during the observation period from March 1, 2015 to March 17, 2017. Overall, we estimated the NMR to be 29.2 per 1000 live births (95% CI: 26.9-31.4) and the U5MR to be 86.1 per 1000 live births (95% CI: 85.5- 86.8). We found evidence of within-district geospatial clustering of under 5 mortality (P < 0.0001) and that social factors (poverty, illiteracy, multiparity), poor coverage of community health workers and distance from health facilities were strongly associated with child mortality.Interpretation Important factors associated with neonatal and post-neonatal mortality in our study population included maternal education, parity, household size and gender. Additionally, antenatal care coverage (at least 4 visits) was specifically associated with neonatal mortality only, whereas, LHW coverage and distance to health facility were strongly associated with post-neonatal mortality. These findings emphasise the need for comprehensive, multisectoral strategies to be implemented for future maternal and child health programs and outreach services in rural areas.

Introduction The use of modern contraceptive methods (MCMs) in Pakistan has been stagnant for the last decade. In Sindh, current contraceptive use is at 28.9%, of which 25% is MCMs use. Such a low uptake translates into high unmet need 17% amongst married women. To bridge the gap between the health system and beneficiaries, there is a need to assess predictors that influence voluntary uptake of MCMs among women, at the health services and individual levels.Methods A cross-sectional household survey was conducted in two districts of Sindh, Pakistan namely Matiari and Badin. In total, 1684 Married Women of Reproductive Age (MWRA) 15-49 years were interviewed. For the selection of eligible respondents, a two-stage stratified cluster sampling strategy was used. Univariate and multivariable logistic regression was used to determine the predictive factors for the increase in the use of MCM.Results Mean age was 32.3 ±SD 7.1 years. Average number of children per woman was 4.0 ± 2.0. Use of modern methods of contraceptive was 26.1% [n=441).Statistically significant socio demographic predictors of MCM included: Number of children 4 or more (AOR 5.234 95%CI 2.78-9.84), Mother having primary education (AOR 1.730 95% CI 1.26-2.36), and Husband having middle education [AOR 1.69 95% CI 1.03 – 2.76).Maternal health services indicators included postnatal checkup of mother (AOR 1.46 95% CI 1.09 – 2.05); women who were visited by Lady Health Workers in their postnatal period and were counseled on family planning (AOR 1.83 95% CI 1.386 - 2.424).Conclusion Voluntary uptake of modern contraceptive methods is higher in women having 2 or more children, having primary education and husband having middle education. Significantly, receiving post-natal checkup at facility, and Lady Health Worker visit after delivery have more likelihood to opt for contraception. Additionally, young couple counseling on family planning is imperative to bridge the gap between knowledge and its translation into practice. There is also a need to focus on the provision of integrated family planning and maternal, newborn, and child health services through facility-based and community engagement platforms.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementFunder played no role in the production of this paper.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Ethical Review Committee, Aga Khan UniversityI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesThe data will be made avaibale with reasonable request to the corresponding author.

BackgroundMaternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. ObjectiveThis study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. MethodsThe implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers’ registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members’ sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. ResultsThe study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. ConclusionsThis study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. International Registered Report Identifier (IRRID)DERR1-10.2196/49578

NCT04184544; Pre-results.

Zulfiqar Bhutta and colleagues (Jan 29, p 403)1Bhutta ZA Soofi S Cousens S et al.Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial.Lancet. 2011; 377: 403-412Summary Full Text Full Text PDF PubMed Scopus (201) Google Scholar describe a decline in neonatal deaths from 49·1 per 1000 births in a control population to 43·0 per 1000 in an intervention population in rural Pakistan. This modest decline was accomplished through retraining of low-level government health workers and brief training of volunteer traditional birth attendants. Since 2007, we have achieved a two-thirds reduction in neonatal mortality in the slums of major cities in Bangladesh from 37 to 11 per 1000 births as part of a slum-wide project run by unpaid volunteers. The project aimed to register all pregnancies (in fact nearly 100% of estimated pregnancies were registered), provide convenient antenatal care (91% of women attended one visit, 72% attended four or more visits), and provide clean birthing rooms in each slum serving a population of 10 000–15 000. Birthing rooms were staffed by two local women (urban birth attendants) trained to assist normal deliveries and to detect and refer any abnormal deliveries at the first sign of problems.2Afsana K Scaling up of BRAC's maternal, neonatal and child health interventions in Bangladesh.in: Cash R Chowdhury AMR Smith GB Ahmed F From one to many: scaling health programs in low income countries. University Press, Dhaka2010Google Scholar The total cost per delivery, for this community-based system is US$13.3Islam Z Khan J Alam K Sarker S Costs of Manoshi delivery centres: normal delivery, ANC and PNC. Working paper. ICDDRB/BRAC, Dhaka2010Google Scholar A baseline survey in 2007 reported 86% home delivery and 14% hospital delivery. In 2010, home deliveries had declined to 24%, hospital delivery increased to 45%, and delivery in clean birthing centres reached 31%. Referral delays are reduced when women are referred to hospitals from birthing centres.4Nahar S Banu M Nasreen H Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: a cross-sectional study.BMC Pregnancy Childbirth. 2011; 11: 11Crossref PubMed Scopus (48) Google Scholar All women who delivered at birthing centres and 90% of the others initiated breastfeeding within 1 h of birth. In poor urban settings, a striking reduction in neonatal mortality can be accomplished by a high-coverage system based on community volunteers and low-level health workers. The Manoshi Project implemented by BRAC is funded by the Bill & Melinda Gates Foundation. KA is the Manoshi Project Director responsible for project implementation and oversight. JR is an adviser to the project, a member of the project Technical Advisory Group, and Senior Health Adviser to BRAC Health Programs. We declare that we have no conflicts of interest. Decline in neonatal mortality in large poor populations – Authors' replyK Afsana and J E Rohde raise several important issues of relevance to perinatal and newborn care in developing countries. Full-Text PDF

Despite the efforts of the international community diarrheal diseases still pose a major threat to children in children less than five years of age. Bacterial diarrhea has also emerged as a public health concern due to the proliferation of drug resistant species in many parts of the world. There is a paucity of population-based data about the incidence of shigellosis and Campylobacter infections in Pakistan. We report country specific results for Shigella diarrhea that were derived from a multicenter study conducted in six Asian countries. Disease surveillance was conducted over a 24 month period in urban slums of Karachi, Pakistan, a city with a population of 59,584. Cases were detected through passive detection in study treatment centers. Stool specimens or rectal swabs were collected from all consenting patients. Between January 2002 and December 2003 10,540 enteric infection cases were detected. The incidence rate of treated diarrhea in children under 5 was 488/1000/year. In children, 5 years and older, the diarrhea rate was 22/1000/year. 576 (7%) Campylobacter isolates were detected. The pre-dominant Campylobacter species was C. jenuni with an increase of 29/1000 year in children under 5 years. Shigella species were isolated from 394 of 8032 children under 5 years of age. Shigella flexneri was the dominant species (10/1000/year in children under 5 years) followed by Shigella sonnei (3.9/1000/year), Shigella boydii (2.0/1000/year) and Shigella dysenteriae (1.3/1000/year). Shigellosis and Campylobacter infection rates peaked during the second year of life. The incidence rate of shigellosis increased in old age but such a trend was not observed in Campylobacter infections. Of 394 shigellosis patients 123 (31%) presented with dysentery in contrast to only 54 (9%) of 576 patients with Campylobacter infections (p<0.001). Both Campylobacter infections and shigellosis are common in community settings of Pakistan but shigellosis presented more frequently with abdominal pain and dysentery than Campylobacter infections indicating that shigellosis may be a more severe illness than Campylobacter infections. Due to the increased and disease severity, drug resistant shigella have become a significant health problem; moreover it is a disease of poor and impoverished people who do not have the access to standard water and sanitary conditions, health care services or optimal treatment. In the face of these facts it is empirically important to develop a low cost effective vaccine that can protect these populations for a longer duration.