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Research on Removing the Three Delays in Access to Emergency Obstetric and Neonatal Care (EmONC) in Non-LHW Covered Areas of Pakistan

Pakistan, with its current population of more than 180 million is the sixth most populous country in the world and fourth in Asia. Approximately two-thirds (65%) of the population is located in rural areas. The Maternal Mortality Ratio (MMR) is 276 per 100,000 live births. The under 5 mortality rate is 89 per thousand live births, infant mortality rate is 72 per thousand live births and neonatal mortality rate is 55 per thousand live births. These figures are far higher in rural than in urban locations. Despite the deployment of a very large work force of Lady Health Workers (LHWs), 35% of the rural areas across the country remain un-served. The non-availability of LHWs in these areas is compounded by extreme poverty which further limits the access to essential health services.

In January 2012, RSPN partnered with the Thardeep Rural Development Programme (TRDP) and the Health and Nutrition Development Society (HANDS), to conduct research on how to reduce pregnancy related mortality in areas of rural Pakistan which are not served by the government-run LHW programme.

Funded by the Research and Advocacy Fund, the research aimed to develop locally driven mechanisms to remove the three major delays women face in accessing emergency obstetric and neonatal care. These delays occur in:

  1. Deciding to seek medical help for an obstetric emergency
  2. Reaching an appropriate health facility for medical care
  3. Receiving medical treatment once a health facility is reached

Using a quasi-experimental study design, specific community based interventions were developed and implemented to address each delay. The interventions were tested in the non-LHW covered Union Council (UC) of Khudabad in district Dadu, Sindh. The acitivites in Khudabad were then compared with the control UC of Kamal Khan, located in Taluka Johi of district Dadu, where no interventions took place, to see if the interventions would increase skilled birth attendance or institutional deliveries, and improve accessibility and uptake of EmONC services. The interventions in Khudabad included:

  1. Mobilisation of communities using trained Community Resource Persons (CRPs) to address the first delay
  2. Developing community support mechanisms through Village Health Committees to ensure transport in emergency cases to address the second delay
  3. Strengthening the healthcare system for delivery of quality EmONC services to address the third delay


  • To develop and demonstrate a community based intervention model to remove the three delays for improving access to EmONC in areas not covered by LHWs.
  • To generate robust evidence to push for scaling up of proven, community based cost effective interventions with focus on improving EmONC services and access for the poor and marginalized communities in non-LHW covered Areas.


A baseline survey was conducted in both Union Councils to assess the existing knowledge, attitudes and practices surrounding maternal and child health related issues. Key findings from the survey were shared with researchers, government officials and other civil society organisations working for maternal and child health across Pakistan in October 2012. For a summary of the base line findings, please visit the publications section.

TO ADDRESS DELAY 1: The people of Khudabad were asked to select 40 male and 40 female Community Resource Persons (CRPs) from within their community through a process of introductory dialogues. After being trained, the CRPs conducted group meetings with local men, women and their families to create awareness for maternal and neonatal health. The CRPs are also responsible for motivating families to seek healthcare. The female CRPs visited women regularly to educate them on the importance of institutional healthcare, and referred pregnant women to medical facilities for antenatal checkups, deliveries, postnatal care and neonatal care.

TO ADDRESS DELAY 2: 40 Village Health Committees (VHCs) were formed at the locations of the CRPs. Each committee comprised of at least twenty members (10 women, 2 CRPs, and 6 men). The VHCs were responsible for supervising CRPs and arranging transport to hospitals for women in emergency cases. They also developed various fundraising mechanisms such as collecting donations from locals or affluent members of society, to pay for transporting women to hospitals, or for covering healthcare costs for very poor women.

TO ADDRESS DELAY 3: As part of the project’s efforts to strengthen the quality of EmONC services, healthcare providers at the District Health Quarter, BHU and Mother and Child Health (MCH) centre of Khudabad were trained on the provision of the basic and comprehensive EmONC services. The healthcare providers were given regular updates and coaching by a Women Medical Officer who visited the health facilities on a frequent basis. The health facilities were also provided some essential healthcare equipment to supplement their current supplies.


The research emphasised that community-based health financing mechanisms are vital for ensuring that women can access institutional healthcare for obstetric emergencies and neonatal care. RSPN’s Community Resource Person model was also demonstrated to be an effective solution to reach women and children in Pakistan’s far-flung rural areas, particularly for the 42% of rural areas which are not covered by the government’s Lady Health Worker program. According to the research, Community Resource Persons can effectively educate communities on health issues and refer women to health facilities for pre and post pregnancy healthcare and to give birth. Community Resource Persons can be supported by other community-based groups such as Village Health Committees, who act as a mechanism for combating any resistance to institutional healthcare from communities.

The research also highlighted the fact that even today; Pakistan has the world’s third highest burden of maternal deaths, and the country’s neonatal mortality rate is 55 deaths for every 1000 live births. In this context, properly equipped and functional health facilities play an instrumental role in meeting the demand for healthcare services. In addition, rural women and their families need to be informed and referred to these facilities for check-ups and to give birth, which is possible through Community Resource Persons. The research, which lasted one year, showed a 13% increase in health facility based deliveries as opposed to home-based deliveries as a result of the work of Community Resource Persons.

For the full research report, please visit the publications section on this page.