title: Access to comprehensive emergency obstetric and newborn care facilities in three rural districts of Sindh province, Pakistan.
abstract: BACKGROUND
  Pakistan's maternal and child health indicators remain unacceptably high, with a maternal mortality ratio of 276 per 100,000 live births and a neonatal mortality rate of 55 per 1,000 live births. Provision of basic and comprehensive emergency obstetric and newborn care is mandated by the government; however, coverage, access, and utilisation levels remain unsatisfactory, with the situation in Sindh province being amongst the worst in the country. This study attempted to assess access to comprehensive emergency obstetric and newborn care (C-EmONC) facilities and barriers hampering access in Sindh.
  
  
  METHODS
  One public sector hospital in each of three districts in Sindh province providing C-EmONC services were selected for a facility exit survey. A cross-sectional household survey and focus group discussions were conducted in the catchment population of these hospitals.
  
  
  RESULTS
  Overall, 82% and 96% of those who utilised a public or private C-EmONC facility, respectively, incurred out-of-pocket expenditure. As expected, those living more than 5 km from the facility reported higher mean expenditure than those living within 5 km of the facility. More than half of the respondents (55%) among public sector users and the majority (71%) of private sector users could not afford travel costs. More than one third (35%) of public sector users and about two thirds (64%) of private sector users who could not afford travel costs took loans. The proportion of respondents who took loans was higher among those living more than 5 km of the health facility compared to those living within a 5 km distance. The majority of respondents (70%) in the community survey chose to go to a private sector C-EmONC facility. In addition to poverty, in terms of sociocultural access, religious and ethnic discrimination and the poor attitude of facility staff were amongst the most important barriers to accessing a C-EmONC facility.
  
  
  CONCLUSIONS
  C-EmONC facilities in both the public and private sectors may simply not be accessible and affordable for the vast majority of poor and marginalised women in targeted districts.
authors.affiliation: Provincial Health Development Centre (PHDC) Sindh, Jamshoro, Pakistan. shahid.ansaribt@gmail.com.
authors.forename: Muhammad Shahid
authors.initials: MS
authors.lastname: Ansari
authors.affiliation: Provincial Health Development Centre (PHDC) Sindh, Jamshoro, Pakistan. rabiamanzoor97@gmail.com.
authors.forename: Rabia
authors.initials: R
authors.lastname: Manzoor
authors.affiliation: Provincial Health Development Centre (PHDC) Sindh, Jamshoro, Pakistan. nasim.sidiki@hotmail.com.
authors.forename: Nasim
authors.initials: N
authors.lastname: Siddiqui
authors.affiliation: Development Strategies, Islamabad, Pakistan. drahsen@yahoo.com.
authors.forename: Ahsan Maqbool
authors.initials: AM
authors.lastname: Ahmed
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric; D004632:Emergency Medical Services; D005260:Female; D005102:Health Expenditures; D006268:Health Facilities; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D000068101:Maternal-Child Health Services; D010154:Pakistan; D011203:Poverty; D011247:Pregnancy; D011248:Pregnancy Complications; D019035:Rural Health Services; D012424:Rural Population; D063508:Social Discrimination; D011795:Surveys and Questionnaires; D014186:Transportation