Applying an Equity Lens to Maternal Health Care Practices in Pakistan (original) (raw)
Related papers
2018
Background: Nationally representative surveys are vital for gauging progress in health and planning health services. However, often marred with inadequate analysis to provide any guidance to health policy and planning. Most recent Pakistan Demographic and Health Survey (PDHS) 2012-2013 is an inclusive nationally representative investigation. Nonetheless, its published report offers limited evidence regarding antenatal care (ANC). Furthermore, after 18th constitutional amendment, policies are principally made at provincial level in Pakistan; therefore, it is imperative to have contextual evidence at sub-national level to feed programs and policies. Methods: We analysed 7142 women with a recent birth, to assess the individual and environmental determinants of ANC, adapting Andersen's model of healthcare utilization, by multilevel analysis. Separate models of determinants were developed for the national level and five provinces using survey command in Stata version 12.1. Results: Besides that the recommended ANC coverage (≥4 visits) is low in Pakistan (36%), gross inequities exist predominantly across provinces (12% to 82%). Small differences exist between urban and rural localities. Education, health literacy and socioeconomic status of women were strong predictors, while communities with high concentration of literate women very strongly predict ANC use (odds ratio [OR] = 12). Determinants of ANC vary at national and at sub-national level. For example, women's education had no influence on ANC utilization in Khyber Pakhtunkhwa (KPK) and Baluchistan (BC) provinces. Notably, husband's education was significantly associated with ANC utilization in KPK only. Significant positive interaction exists between urban areas and larger provinces (Punjab, Sindh, and KPK). Also, very strong positive interaction occurs when women have secondary or particularly higher level of education and living in urban areas or larger provinces. Conclusion: This study highlights conspicuous contextual differences which determine maternal care at national and sub-national level. It identified contextual factors which are important for planning maternal health services between and within provinces. High positive interaction for ANC utilization between women education, urban areas and larger provinces highlights the inequities which need to be addressed. It also identified factors at the community level (cluster) which relates to overall context and influence individual behavior and highlights the diminishing urban-rural gap in service utilization in Pakistan. Citation: Sahito A, Fatmi Z. Inequities in antenatal care, and individual and environmental determinants of utilization at national and sub-national level in Pakistan: a multilevel analysis.
International Journal for Equity in Health, 2016
Background: Poor maternal and infant health indicators are mostly concentrated among low income households in Pakistan and health care expendituresespecially on medical emergenciesare the most common income shocks experienced by the poor. Public investments in health are therefore considered as pro-poor interventions by the government of Pakistan. This study employs nationally representative household data for Pakistan for 2007-08 and 2010-11 to investigate whether benefits from publicly financed services on Mother and Newborn Child Health (MNCH) are effectively captured by the poor in terms of service utilization. Methods: The study conducts a Utilization Incidence Analysis of the use of public health services for MNCH in Pakistan. For this purpose, the utilization shares of households, ranked by economic status, are computed. The concentration curves are plotted and their dominance is tested against an equal distribution and Lorenz curves to determine whether the distribution is pro-poor and progressive. Results: Although the shares of bottom income groups in the utilization of most services for MNCH have increased between 2007 and 2011, the utilization of some services such as post-natal consultation; institutional maternal delivery; and Tetanus Toxoid injections for pregnant women remains pro-rich in 2011. The utilization of pre-natal consultation, especially through lady health workers and visitors; the use of Family Panning Units; and immunization services is somewhat evenly distributed. The use of Basic Health Units (BHUs) is found to be pro-poor. The provincial analysis reveals that the province of Baluchistan depicts an unusually high level of inequity in the distribution of utilization benefits from almost all public health services. Finally, in terms of progressivity, public spending on all health services analyzed in the study is found to be progressive at the national level implying that investment in MNCH has the potential to redistribute income from rich to the poor. Conclusion: To target the poor effectively, the study recommends expanding the network of BHUs as well as basic reproductive and child health care services. The outreach of health facilities in Baluchistan need to be expanded while targeting the poor effectively by mitigating various access costs that prevent them from using public health services.
Public Health, 2020
The aim of the study was to measure the impact of maternal education on inequalities in child health care and to explore the contribution of different factors to the observed inequality. Study design: The study is based on secondary data from the Pakistan Demographic and Health Survey 2017e18. Methods: Concentration curves and indices were used to identify and quantify the inequality in child health care. Moreover, contributions of different factors to the observed inequality were investigated using decomposition analysis. Results: The concentration indices for health care provided were 0.078 (P < 0.001) when a child was experiencing diarrhoea and 0.088 (P < 0.001) for fever/cough. The results of this study indicate that healthcare practices are more common among children of educated mothers. The main contributors resulting in the observed inequalities in child health care were improved sanitation (about 6% for diarrhoea and 15% for fever/cough treatment), rural residence (about 4% and 23% for diarrhoea and fever/ cough treatment, respectively), wealth status (49% and 28% for diarrhoea and fever/cough treatment, respectively) and maternal education (26% for diarrhoea and 28% for fever/cough treatment). Conclusion: The findings suggested that child health care is more frequently provided among educated mothers; therefore, steps should be taken to improve maternal education. Moreover, policies should seek to increase/improve the roles of women in society, as well as job opportunities to overcome the financial barriers of healthcare provision.
Addressing disparities in maternal health care in Pakistan: gender, class and exclusion
BMC Pregnancy and Childbirth, 2012
A key aim of countries with high maternal mortality rates is to increase availability of competent maternal health care during pregnancy and childbirth. Yet, despite significant investment, countries with the highest burdens have not reduced their rates to the expected levels. We argue, taking Pakistan as a case study, that improving physical availability of services is necessary but not sufficient for reducing maternal mortality because gender inequities interact with caste and poverty to socially exclude certain groups of women from health services that are otherwise physically available. Methods: Using a critical ethnographic approach, two case studies of women who died during childbirth were pieced together from information gathered during the first six months of fieldwork in a village in Northern Punjab, Pakistan.
Journal of Obstetrics and Gynaecology, 2016
Background: Pakistan is amongst the countries with high rates of maternal and neonatal mortality. Most of the deaths occur at the time of childbirth or immediately in the period after birth due to low utilization of routine postnatal care (PNC). There is scarcity of literature on determinants and impeding factors of PNC services utilization in Pakistan. This paper provides a holistic view and investigates the association of PNC services utilization with socio-demographic and delivery assistance related characteristics. Methods: The study used data from 2006-07 Pakistan Demographic and Heath Survey (PDHS), a nationally representative sample of 10,023 women aged 15-49 years. Our analysis was limited to the last birth during five years preceding the survey, total of 5,724 women. For measuring the PNC utilization, four variables i.e., utilization of PNC services, newborn PNC within 2 months, timing for PNC checkups and obstetric complications faced during PNC were combined. To check the association among the determinants of PNC, socio-demographic and other assisting variables certain momentous statistical techniques like Univariate, Bivariate and Multivariate logistic regression analysis were applied. Results: The analysis of data showed that about 64% women received some ANC for their last born child and among them about half received ANC in the first trimester. About 42% received health professionals' assistance during delivery; only 36.9% delivered in a health care facility. The findings revealed that women's place of residence like urban or rural played significant role in the whole problem of the research mainly due to its relationship with education and socioeconomic status.. The results also shown that women's level of education i.e., more than ten years of schooling versus no schooling (AOR 5.16, 95%CI 3.18-9.98), high socioeconomic status than low status (AOR 5.69, 95%CI 4.27-7.58), economically developed regions than less developed ones (AOR 2.89, 95%CI 2.25-3.71), having two or less children than five or more children (AOR 2.08, 95%CI 1.83-2.38) and having a history of abortion than no abortion (AOR 1.51, 95%CI 1.25-1.82) were significantly associated with ANC utilization. Similarly, all these variables were significantly associated with ANC utilization in the first trimester, delivery assistance by health professionals and delivery in a medical facility. Conclusions: The research found that women live in developed provincial settings with higher education, living in urban and prosperous areas, having fewer children and have more access to health services were more likely to use PNC services. The results may be useful for policymakers to develop efficient strategies to improve the health care services utilization in Pakistan.
Signalling, status and inequities in maternal healthcare use in Punjab, Pakistan
Despite rising uptake of maternal healthcare in Pakistan, inequities persist. To-date, attempts to explain and address these differentials have focused predominantly on increasing awareness, geographic and financial accessibility. However, in a context where 70% of healthcare is private sector provided, it becomes pertinent to consider the value associated with this good. This study examined patterns of maternal healthcare use across socioeconomic groups within a rural community, and the meanings and values attached to this behaviour, to provide new insight into the causes of persistent inequity. A 10-month qualitative study was conducted in rural Punjab, Pakistan in 2010/11. Data were generated using 94 in-depth interviews, 11 focus group discussions and 134 observational sessions. Twenty-one pregnant women were followed longitudinally as case studies. The village was comprised of distinct social groups organised within a caste-based hierarchy. Complex patterns of maternal healthcare use were found, linked not only to material resources but also to the apparent social status associated with particular consumption patterns. The highest social group primarily used free public sector services; their social position ensuring receipt of acceptable care. The richer members of the middle social group used a local private midwife and actively constructed this behaviour as a symbol of wealth and status. Poorer members of this group felt pressure to use the afore-mentioned midwife despite the associated financial burden. The lowest social group lacked financial resources to use private sector services and opted instead to avoid use altogether and, in cases of complications, use public services. Han, Nunes, and Dreze's (2010) model of status consumption offers insight into these unexpected usage patterns. Privatization of healthcare within highly hierarchical societies may be susceptible to status consumption, resulting in unforeseen patterns of use and persistent inequities. To-date these influences have not been widely recognised, but they deserve greater scrutiny by researchers and policy-makers given the persistence of the private sector.
Maternal Health Care Expenditure among Women in Rural Areas of Pakistan
Annals of King Edward Medical University
Background: With Pakistan failing to achieve Millennium Development Goals we have now entered into a new era of Sustainable Development Goals. Decreasing child mortality, improving maternal health and increasing the proportion of births by trained birth attendants, are the areas with unmet goals. As 29.5% of population of Pakistan is below the poverty line, expenditure on maternal health care services is of great importance as it determines the utilization of health care services to a large extent.Objective: To assess maternal health care expenditure and its sociodemographic predictors in rural Khanewal, Punjab, Pakistan.Methodology: In this cross sectional study average cost on delivery (both SVD and Cesarean section) was assessed in both public and private sector of ruralKhanewal. Total 257 women who had delivered in the last one year were included.Results: Results revealed that 69.3% of mothers were illiterate.56.8% sought antenatal care in public health unit and 43.2% in a p...
Asian Biomedicine, 2020
Background High-quality prenatal care has a significant positive impact on maternal and infant health as it helps timely diagnosis and treatment of pregnancy complications. Objective To examine factors associated with the utilization of maternal health care using the optimal count regression model. Methods A sample of 16,314 women of reproductive ages (15–49) was used. Andersen and Newman's behavioral model of health services utilization was employed for the selection of covariates. Poisson, negative binomial, zero-inflated Poisson, zero-inflated negative binomial (ZINB), Poisson hurdle, and negative binomial hurdle models were fitted and compared to identify the best model. Maternal health care utilization is found associated with maternal age and education, area of residence, domestic violence, the income level of family, access to media, knowledge about AIDS, parity, birth order, and having a child who later died. Results ZINB model is found to be best fitted for the observed...