Service Delivery Redesign for Maternal and Newborn Health in Sindh, Pakistan: A feasibility study

Background

Pakistan has reduced maternal and neonatal mortality, yet Sindh faces high preventable risk, with maternal mortality at 224 per 100,000 live births and neonatal mortality around 41 per 1,000 live births. Rising institutional delivery has not ensured effective coverage where EmONC is inaccessible, poorly functional, or mistrusted. This study assessed the feasibility of service delivery redesign for maternal and newborn health in two Sindh districts.

Methods

A convergent multi-methods feasibility assessment was conducted from May to October 2024 in Thatta and Qambar Shahdadkot. Guided by the High Quality Health Systems framework and human-centred design, it integrated PDHS, MICS, PMMS, and DHIS analysis, 17 key informant interviews, AccessMod geospatial modelling, assessment of 71 facilities, surveys with 158 providers, 343 client exit interviews, 48 in-depth interviews, and 12 focus group discussions.

Results

Facility births were 46% in Thatta and 61% in Qambar Shahdadkot; caesarean rates were 5% and 15%. Although 63 of 71 facilities operated 24/7, only 8 of 35 public BEmONC facilities performed all seven signal functions, all in Thatta. Among six public CEmONC facilities, only one, in Thatta, performed all nine signal functions; none in Qambar Shahdadkot met CEmONC criteria. Geospatial modelling showed no women in Qambar Shahdadkot could reach a fully functional CEmONC facility within two hours, compared with 95% in Thatta under motorized travel. Under walking-only conditions, access fell to 13% in Thatta and 33% in Qambar Shahdadkot. Communities reported transport barriers, costs, stockouts, disrespectful care, and limited night services, contributing to delayed care seeking and home births.

Conclusions

Institutional delivery gains mask gaps in functional EmONC, referral, access, and care experience. Redesign should prioritize 24/7 CEmONC hubs, BEmONC referral networks, emergency transport, respectful maternity care, and community accountability.

Key messages

• Rising facility births in Sindh hide major gaps in functional EmONC, referral, access, and respectful care, limiting real survival gains for mothers and newborns.

• Service delivery redesign can improve maternal and newborn outcomes by linking 24/7 CEmONC hubs, BEmONC networks, emergency transport, and community trust.