A woman leaves her husband’s home to protect her unwanted daughter. A husband, preoccupied in his work, is unaware of the danger signs in his pregnant wife. A new husband experiences a transformation after the death of his young wife and infant from lack of pregnancy planning and medical care.These stories and many others in a Pakistan television drama series are changing the lives of women and families. Produced by the Pakistan Initiative for Mothers and Newborns (PAIMAN), the television series is part of an ambitious program designed to improve home-based practices and increase health service utilization for mothers, newborns and children. Impact data for the TV series shows that even in the face of difficult barriers, women can and do act to improve their health and that of their children if they are informed and motivated to do so.

Background

Pakistan has one of the world’s highest rates of maternal,infant, and child mortality. Of the 4.5 million women who give birth each year, 15,000 to 20,000 die as a result of pregnancy or birth-related complications. This is a leading cause of death among women in their reproductive years, accounting for one-fifth of deaths to women of childbearing age in Pakistan (PDHS, 2006-7). Contributing to these alarming rates, more than two-thirds of women deliver their babies at home, and of those, an estimated 20% are delivered by skilled birth attendants. One of the most important underlying causes of maternal mortality is the low societal status of women, all but ensuring high morbidity and mortality in women and children for generations to come unless perceptions, attitudes and behaviors are motivated to change.

Pakistan Initiative for Mothers and Newborns

With funding from the US Agency for InternationalDevelopment (USAID), PAIMAN works with the Government of Pakistan to implement a multi-channeled approach that includes mass and traditional media, community mobilization, advocacy, and innovative interventions through Lady Health Workers, schools and mosques. Interventions are designed to ensure that all members of society – especially men – commit to improving maternal, newborn and child health.

Using Stories to Motivate Change

PAIMAN’s television drama, seen by nearly 13 million men and women (ages 15 to 49 years) across Pakistan, was broadcasted on the national television channel PTV every Sunday evening between August and December 2008. Using an enter-educate approach, the drama series aimed to involve husbands in pregnancy and birth-related decision-making – typically the domain of women; and present pregnancy as a special time in a woman’s life requiring special care and attention. Each episode examines real-life issues faced by mothers and families in Pakistan including male child preference, birth spacing, gender roles, social and cultural influences on healthcare access, family decision-making, and traditional birth practices.

Measuring Effectiveness

Both qualitative and quantitative studies were conducted in Rawalpindi, Sukkur, and Jafferabad districts to evaluate reach and impact of the TV drama. A local research agency held focus groups with women of reproductive age to understand the appeal of the drama and messages, and willingness to change behavior based on viewership. In 2009, a household survey was conducted with 1,894 women of reproductive age, and 630 husbands and a similar number of mothers in law. When compared to married women who did not see the TV series, married women exposed to the TV drama were significantly more likely to report on the importance of prenatal and postpartum care; and state health care facilities and trained providers were their preferred source for antenatal care, delivery, and postpartum care. Those not exposed were more likely to state that home was their preferred place for delivery.

Taking Action

More than 70 percent of married women who were exposed to the program said that the series would motivate people to take a positive health action. Two in five married women said that they had already changed a health behavior or intended to take action as the result of watching the drama series for seeking heath care for themselves or spacing births.

TV Drama Changes Behavior Exposure and Likeability:

A total of 35% women respondents who were married and in their reproductive years reported seeing the TV drama. More than 93% of viewers stated they liked the TV drama. Repeated mention was made of the fact that the series reflected reality. Participants were particularly appreciative that the dramas used local language, and nearly 90% of viewers reported liking the series more than other shows on TV.

Interpersonal Communication:

Respondents exposed to the TV drama were asked to reflect on the extent to which they had initiated discussions on key topics related to pregnancy and childbirth, and also the extent to which others in their social networks had initiated discussions with them. One out of every three respondents reported they had discussed the drama with someone, and one out of every four indicated that someone else had discussed the drama with them.

Take Away Messages

Several common messages emerged from the evaluation as the most memorable among women who watched the TV drama series. ‘Pregnancy is a special period in a woman’s life and nothing to hide or be ashamed of’ ‘Girls deserve the same love and attention as boys’ ‘Ensuring the health of their family is a husband’s responsibility’ ‘Maternal complications can be fatal; it is important to be proactive in treating danger signs.’ ‘Couples should space their children by 3-5 years to ensure positive health outcomes for both mothers and children’.

Barriers to Behavior Change:

Through viewer group discussions, the evaluation also assessed the most common barriers to behavior change among women of reproductive age. Perceptions were consistent cross districts. The most common barriers included poverty, lack of family upport/family dynamics, and the present societal status of women. Other frequently cited barriers included patriarchal traditions and norms, and a strong dependence on men. Many women also cited the negative attitudes of in-laws.

Conclusion

The results of the evaluation indicate that the PAIMAN television series was popular, memorable, and life-changing. Women who participated in the evaluation said that the drama helped them to consider or initiate positive healthy actions to ensure better outcomes for themselves and their children. The PAIMAN television series demonstrates the effectiveness of mass media and the enter-educate approach for changing attitudes and involving men and families in pregnancy and childbirth-related decision-making. This approach provides the vehicle needed to explore the complexities of health problems in ways that are culturally acceptable, and allow the audience to examine their own choices in the context of informed decision making and empowerment. “We have learnt new things after watching these dramas. I have decided that whether I am in pain or not I will go for checkups and opt for birth spacing and arrange money for delivery in advance.”
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Age 28, Jafferabad

Funded by the US Agency for International Development, the Pakistan Initiative for Mothers and Newborns is led by JSI Research & Training Institute, Inc. in collaboration with a consortium of partners including the Johns Hopkins Center for Communication Programs. More information about PAIMAN’s media products and evaluation reports can be found at http://www.paiman.org.pk