Assessing the effectiveness of the maternal, newborn and child health program's place-based continum of care for maternal and neonatal services from the community to the district level in district Thatto Sindh, Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


The maternal mortality ratio (MMR) in Pakistan stands at 178 deaths per 100000 live births (Pakistan Maternal mortality ratio, 1960-2017. (I) Early estimates suggest that Pakistan is failing to achieve the necessary growth required to meet the SDG target of less than 70/100,000 by 2030. (3). In addition, child mortality continues to be a national concern. Pakistan has the world's highest newborn mortality rate, with one in every 22 babies born dying within a month (4). The Pakistan Demographic Health Survey 2017-2018 showed that the antenatal coverage for at least one visit was 86%, while the antenatal care coverage for 4 visits was only 51% (5). The World Health Organization's (WHO) Continuum of Care framework emphasizes how poor communication and weak referral links between communities and facilities contribute to poor MNCH outcomes. This study aims to assess the implementation of the program and find out whether the proposed policies and actions taken are effective in achieving impact. Moreover, the study also aims to identify strengths and gaps of the program, and suggests ways in which the program can be further improved to positively impact the health of women and children in the district of Thatto. Methodology: A mixed method approach was adopted for the study to increase the scope of the study. Quantitative data was obtained using checklists from all facilities, and qualitative data was obtained by conducting in-depth interviews, focus group discussions. The sampled facilities included 3 CMW workstations, 5 BHUs, 1 RHC, 1 THQ, DHQ. Results: The results show that there are major gaps in the implementation of the policy for continuum of care. Major gaps were identified at the communication and referral linkages at all levels from LHWs to CMWs. At the BHU level, there were no referral review meetings in spite of written protocols. On monitoring, there was no strict protocol to give feedback or referral instructions to care providers. CMWs were not supported with adequate supplies and compensation. There was no communication between stakeholders of different levels of facilities such as MERF, PPM. and MNCH especially on quality and continuity of care. Conclusion: The study results on triangulation analysis showing that the resources available are not properly distributed. The main back bone of community care providers is not well supported. There appears an immense need of strategy to strengthen deployment and sustain the trained CMWs by regular job-assurance salaries. There is a need to implement existing referral and communication policy at all levels uniformly with the collaboration of organizations such as PPHI, MERF, MNCH with the support of Sindh Government. Policy makers and implementers should also develop a monitoring and supervision joint cell with a representative at district level and involvement of all stakeholders to monitor the implications of referral and communication linkages at all levels.

This document is available in the relevant AKU library