School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, AB, T6G 1C9S, Canada.
BMC Health Serv Res. 2012 Sep 19;12:326. doi: 10.1186/1472-6963-12-326.
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. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay.
METHODS/DESIGN: Data will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW's in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan.
The findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.
巴基斯坦是全球产妇死亡人数超过一半的六个国家之一。为了解决其居高不下的产妇死亡率问题，特别是改善贫困和弱势群体获得产妇保健服务的机会不平等问题，巴基斯坦政府建立了一个新的社区助产士（CMW）队伍。一个关键的期望是，CMW 将改善贫困和弱势群体获得熟练产前和分娩期护理的机会。我们知识上的一个关键差距是，在私营医疗保健背景下运作的这一干部队伍是否能够满足为最贫困和最边缘化的妇女提供护理的期望。收费服务的概念与为最贫困者增加获得医疗保健的机会之间存在固有矛盾，而这些最贫困者从定义上讲是无法支付费用的。
方法/设计：数据将通过三个相互关联的模块收集。模块 1 将包括在旁遮普省杰赫勒姆和拉伊亚地区 CMW 服务范围内的基于人群的调查。将评估由 CMW 服务的被社会排斥的妇女的比例及其对其产妇保健提供者的满意度。模块 2 将使用机构民族志方法探索 CMW 在为贫困和社会边缘化妇女提供护理方面面临的挑战（组织、社会、财务）。模块 3 将确定社会、财务、地理和其他障碍，以揭示塑造贫困和边缘化妇女获取 CMW 服务的选择和机会的隐藏力量和权力关系。广泛的知识传播计划将促进研究结果的采用，以告知巴基斯坦产妇保健政策、服务设计和护理提供的积极发展。
这项研究的结果将增强对性别和阶级权力动态的理解，这些动态可能是贫困妇女被边缘化出医疗保健系统的原因，包括社区助产士护理。一个关键结果将是提高对社会排斥妇女这一特殊群体的特殊需求的认识。另一个期望是为贫困和社会排斥的妇女提供产妇保健。这项研究将支持巴基斯坦实现第五个千年发展目标。
