Background According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan. Methods Data for this study were taken from The Global Network’s Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018–2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m2 (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]). Conclusions More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers' health-seeking behavior and helps them make informed decisions about their health and well-being.

Background: Cotton dust is generated during various textile manufacturing processes. Only a few studies from Pakistan assessed cotton dust exposure and explored the relationship of duration of work in the textile industry with respiratory health outcomes. We aimed to assess cotton dust exposure and its association with lung function and respiratory symptoms among textile workers in Pakistan. Methods: We report findings from the baseline cross- sectional survey of the larger study, MultiTex, among 498 adult male textile workers from six mills conducted between Oct 2015-March 2016 in Karachi, Pakistan. Data collection included the use of standardized questionnaires; spirometry, and area dust measurements through UCB-PATS. Multivariable logistic and linear regression models were developed to assess the association of risk factors with respiratory symptoms and illnesses. Results: We found the mean age of workers to be 32.5 (±10) years; around 25% were illiterate. The prevalence of COPD, asthma, and byssinosis in our study was 10%, 17%, and 2%, respectively. The median cotton dust exposure was 0.33 mg/m3 (IQR;0.12-0.76). Increased duration of work among non-smokers was associated with a decline in lung function, FVC (-245 ml; 95% CI -385.71, -104.89) and FEV1 (-200 ml; 95 % CI -328.71, -84.11). Workers with certain job titles (machine operators, helpers, and jobbers), those with greater duration of work, and higher dust exposure, were more likely to report respiratory symptoms and illnesses. Conclusion: We report a high prevalence of asthma and COPD and a low prevalence of byssinosis. Cotton dust exposure and duration of employment were associated with respiratory health outcomes. Our findings highlight the need for preventive interventions in the textile industry in Pakistan.

BACKGROUND An mHealth app was developed for front line health workers, to strengthen maternal, neonatal and child health services through increased transparency, accountability, and improved governance by collecting and disseminating real-time data. Key features included tracking frontline health workers through Global Positioning System during outreach visits, registration of clients; and recording data. OBJECTIVE In this paper we report the end user experiences of the captured during the qualitative end line study of the Hayat app. This includes perceptions and experience of the using the digital app with a focus on usability, validity of data, and community response. This paper aims to identify barriers and enablers to integration of mhealth and inform how digital technology can be utilized for strengthening the district health systems in LMICs. METHODS Qualitative assessment was carried out in select rural districts of Khyber Pakhtunkhwa and Gilgit-Baltistan in Pakistan and select catchments of Bamyan and in Badakshan Province in Afghanistan. Methods used for assessment included 17 focus group discussions with LHWs and 28 key informant interviews with health workers and key stakeholders. Thematic content analysis was undertaken based on an adapted framework derived from the World Health Organization guide for “Monitoring and Evaluating Digital Health Interventions” and technology acceptance model. RESULTS The study revealed high usability of the app both by the stakeholders. Overall, the app improved quality and timeliness of data, improved immunization coverage and maternal care through supportive supervision and monitoring of frontline health workers. Data validity improved and health managers were confident of the reliability of data collected through the app. However, connectivity issues, difficulty in access to remote sites, security issues, lack of incentives and increased workload were some of the perceived barriers identified by the end users. CONCLUSIONS The use of smart phone-based application has high acceptability among the HCPs, and has benefitted the existing health system functioning but providing reliable data, and better monitoring. However, successful integration of app in the health system will require inter sectorial collaboration to address the challenges identified in implementation. CLINICALTRIAL N/A

IntroductionIn the wake of the unprecedented public health challenge of the COVID-19 pandemic, it is highly significant to recognise the mental health impact of this mounting threat on healthcare providers (HCPs) working in the obstetrics and gynaecology department. Experience from epidemics and emerging literature around COVID-19 show that the unparalleled amount of stress that HCPs are dealing with is linked with the increased burden of mental health conditions. We aim to conduct an exploratory qualitative descriptive study to assess HCPs’ perceptions of mental health amid the COVID-19 pandemic in the obstetrics and gynaecology department of a public sector tertiary care hospital of Karachi, Pakistan.Methods and analysisThis study will use a qualitative descriptive approach where approximately 20–25 HCPs from the obstetrics and gynaecology department will be recruited using a purposive sampling approach. Data will be collected through semistructured interviews and it will be analysed thematically using NVivo V.12 Plus software.Ethics and disseminationEthical approval for this study has been obtained from the Institutional Review Board Committee of Jinnah Postgraduate Medical Center hospital. The study results will be disseminated to the scientific community and the HCPs participating in the study. The findings will help us to explore the doctor’s perceptions of mental health during the current pandemic of COVID-19 and its impact on their daily lives and mental well-being.