Training for Lady Health Workers clarified

ABulletin of the World Health Organization | December 2008, 86 (12) Letters Caesarean birth as a component of surgical services in low- and middle-income countries We were very pleased to see further at- tention drawn to the issue of surgery as a global public health issue in low- and middle-income countries by Ozgediz et al. in the August 2008 edition of the Bulletin.1 We write to draw attention to one component of surgical services, Caesarean birth, which has been well documented relative to other types of surgery. Nationally representative data on Caesarean birth are available for ap- proximately 90% of births in develop- ing countries. Similar results from two separate compilation exercises have been published2,3 for the years around 2000 and efforts are underway to compile data for 2005. Many but not all of these data come from Demographic and Health Surveys, which also allow disag- gregation by socioeconomic status.4 Moreover, substantial efforts have gone into determining the unmet need for Caesarean birth by defining indica- tions for Caesarean that are “abso- lutely” life-threatening.5 Women who experience these problems are unlikely to survive if they do not receive a Cae- sarean. Absolute maternal indications include severe antepartum haemor- rhage due to placenta praevia or abrup- tio placentae, major cephalopelvic disproportion, transverse lie and brow presentation. Several studies have now a Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, United States of America. b London School of Hygiene and Tropical Medicine, London, England. Correspondence to Cynthia Stanton (e-mail: cstanton@jhsph.edu). estimated the met need for Caesarean section in urban areas with good access to emergency obstetric care,6 and the population-based incidence for the conditions suggested above range be- tween 1–2% of births. Caesarean birth rates falling below 1% are thought to reflect a real deficit in access to life- saving Caesarean section. Data on indications for Caesarean exist at the facility level but are rarely reported in routine health information systems and virtually never reviewed at higher levels. A standard categoriza- tion of indications for Caesarean is now available, separating absolutely life-threatening indications from other indications.7 Given the rapidly increas- ing trends in Caesarean birth in many developing countries, and the occur- rence of non-medically indicated Cae- sarean, we recommend the inclusion of Caesarean deliveries broken down by absolute and non-absolute indications into routine reporting systems, even where national rates are high. Thus, we write this letter to draw attention to the fact that progress has been made regarding the mortality component of the “numerator” of disease burden avertable by Caesarean. We encourage researchers to explore adaptation of the approach used by the Unmet Obstetric Need Network for other surgical services and we welcome their ideas for expanding the met need concept to encompass morbidity. ■ Cynthia Stanton a & Carine Ronsmansb References Ozgediz D, Jamison D, Cherian M, McQueen K. 1. The burden of surgical conditions and access to surgical care in low- and middle- income countries. Bull World Health Organ 2008;86:646-7. PMID:18797625 doi:10.2471/ BLT.07.050435 Betran2. AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007;21:98-113. PMID:17302638 doi:10.1111/j.1365-3016.2007.00786.x Stanton3. CK, Holtz SA. Levels and trends in cesarean birth in the developing world. Stud Fam Plann 2006;37:41-8. PMID:16570729 doi:10.1111/j.1728-4465.2006.00082.x Ronsmans4. C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006;368:1516-23. PMID:17071285 doi:10.1016/S0140-6736(06)69639-6 Unmet5. Obstetric Need Network. Guide 1: Tackling unmet obstetric needs. Part 1: Concepts, general principles and international network. Antwerp: Institute of Tropical Medicine; 2008. Available from: http://www.itg.be/uonn/ eng/home1.html [accessed 10 November 2008]. Ronsmans C, De Brouwere V, Dubourg D, 6. Dieltiens G. Measuring the need for life-saving obstetric surgery in developing countries [commentary]. BJOG 2004;111:1027-30. PMID:15383102 doi:10.1111/j.1471- 0528.2004.00247.x Stanton C, Ronsmans C, Baltimore Group 7. on Cesarean. Recommendations for routine reporting on indications for cesarean delivery in developing countries. Birth 2008;35:204-11. doi:10.1111/j.1523-536X.2008.00241.x Letters B Bulletin of the World Health Organization | December 2008, 86 (12) Training for Lady Health Workers clarified We thank Yasir Bin Nisar for his interest in our pilot study1,2 as well as the comments on various aspects of the Pakistan National Programme for Family Planning and Primary Health Care, commonly called the Lady Health Worker (LHW) programme. Indeed the LHW programme has undergone many modifications since its incep- tion in 19943 and, in particular, the last few years have seen an exponential growth in the number of LHWs as well as a streamlining of their activities and interventions. Our department has worked with the LHW programme for many years in several collaborative proj- ects and has been closely involved with curriculum revisions, training aspects and pilot innovations. Our paper represented the programme characteristics in relation to the preparatory and pilot phase (2000–2004) and the stipend for the LHWs for the time period specified was indeed 1800 Pakistani rupees (Rs). The travel costs mentioned relate to the allowances admissible for training and refresher courses. As Yasir points out, the stipend has recently been increased to Rs 2990 but, with the cur- rent exchange rate, this still translates to a mere US$ 37 per month. a Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan. Correspondence to Zulfiqar A Bhutta (e-mail: zulfiqar.bhutta@aku.edu). Yasir is right in stating that the official “initial” training period for LHWs is 15 months, inclusive of the 3 month didactic period. However, we had estimated the standard training period to include the 15 months and didactic teaching as well as the regular monthly training sessions and refresher courses. Given the mean duration of service and experience of the LHWs in the Hala region, the average training period per individual is quite close to the stated average of 18 months in most cases. This point should have been stated with greater clarity in the LHW programme description. ■ Zulfiqar A Bhutta,a Sajid Soofi a & Zahid Memon a References Bin Nisar Y. Corrections needed to Pakistani 1. programme details. Bull World Health Organ 2008;86:907. Bhutta ZA, Memon ZA, Soofi S, Salat MS, 2. Cousens S, Martines J. Implementing community-based perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ 2008;86:452-9. PMID:18568274 doi:10.2471/BLT.07.045849 National Programme for Family Planning and 3. Primary Health Care. Islamabad: Ministry of Health, Government of Pakistan; 2008. Available from: http://www.phc.gov.pk [accessed on 10 November 2008].