Rising trends and inequalities in cesarean section rates in Pakistan: Evidence from Pakistan Demographic and Health Surveys, 1990-2013 (original) (raw)
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The Factors Influencing Cesarean - Section Rates - A Narrative Review from Pakistan
The Journal of medical research, 2021
The significant increase in the rate of cesarean section is a major public health issue. The World Health Organization recommends C-section rates not to be greater than 10% and not lower than 5% as both the indicated limits can adversely affect maternal and newborn health. The rate of C-section deliveries is 22% according to recent Pakistan demographics and Health Survey of 2017-2018. This study contributes to the existing literature by examining the factors influencing high C-section rates in Pakistan. A narrative review of published literature between 2000 to 2020, on "factors influencing C-section rates in Pakistan" was done. The findings highlighted five factors that primarily influence utilization of C-section which include: 1. Accessibility to utilize C-section, 2. Association of C-section rates with socioeconomic profile, 3. Elective C-section, 4. Medical conditions as a cause of C-section, 5. C-section as a source of business. Pakistan like other Low middle income countries (LMICs) is facing the increased disease burden on its week and fragile health system. The over utilization of C-section rates has imposed additional burden on the health care system of Pakistan as well as increased economic and health resource liability on maternal care.
Trends of cesarian section , 2018
Background: Pakistan is among those countries where the number of caesarean section births has increased unusually in the past two decades. Therefore, the aim of the present study is to analyse the trend of caesarean section deliveries among child-bearing women (aged 15-49 years) in Pakistan and to identify maternal sociodemographic factors and pregnancy-related variables associated with the change in caesarean deliveries from 1990 to 2018. Methods: Secondary data from Pakistan Demographic and Health Surveys (1990-2018) were analysed. The analysis of data was confined to child-bearing mothers. Sample sizes were 4029, 5721, 7461 and 8287 for the time periods of 1990-91, 2006-07, 2012-13 and 2017-18, respectively. Socio-demographic information of the mothers and pregnancy-related variables were taken as independent variables for the present study. The association between independent variables and caesarean deliveries was measured in terms of unadjusted odds ratios (OR) and adjusted OR (AOR). Results: The percentages of the mothers who had at least one delivery during the 5 years prior to each survey who had caesarean deliveries increased continuously from 3.2% in 1990-91 to 19.6% in 2017-18. Results indicate that mothers over 24 years of age, located in Punjab, from the richest socioeconomic class and living in urban areas were more likely to have delivered by caesarean section. Mothers with a first child in birth order and who had five and more children, as well as mothers who had more antenatal care visits and delivered babies in private hospitals showed a higher probability of caesarean section births.
Prevalence and determinants of Caesarean delivery in Punjab, Pakistan
Eastern Mediterranean Health Journal, 2018
especially in developing countries (5). As a reference, the World Health Organization, in its 1985 report, suggested an optimal range for C-section rates of 5-15% (6). Many studies have found that the likelihood of delivery through C-section depends on a number of institutional, demographic and socioeconomic factors. The availability of facilities, obstetricians and the place of birth, that is, private or public sector institutions, is associated with C-section rate (7,8). C-section is significantly associated with multiple conception, maternal age at birth, rise in institutional deliveries, number of previous deliveries, site of prenatal care (private or public), socioeconomic status of household and access to antenatal care (9-11). Some maternal characteristics such as education and access to antenatal care are also strongly associated with the likelihood of C-section (4,10,12). In view of the recent understanding about the factors associated with C-section, this study identified a set of socioeconomic, demographic, spatial and institutional indicators associated with C-section delivery. We used data from the Multiple Indicator Cluster Survey (MICS)
Public Health, 2018
Objective: This study examined the inequality in cesarean section (CS) utilization and its socioeconomic contributors. Study design: Retrospective two-stage stratified sample design. Methods: Data were extracted from two rounds of the Bangladesh Demographic and Health Survey conducted in 2004 and 2014. Concentration Index of CS utilization was calculated using the wealth quintile. Regression-based decomposition method was applied to assess the socioeconomic contributors of inequality in CS utilization. Results: The rate of CS utilization increased from 4.98% in 2004 to 24.21% in 2014. The utilization of CS was highly concentrated among the women of higher socioeconomic status (SES) in both rounds of the survey. Results of the decomposition models revealed wealth quintile, higher education, higher number of antenatal visits, and being overweight or obese as the critical factors contributing to the inequalities of CS utilization. Conclusion: Bangladesh is now observing a rapid rise in CS utilization and women with higher SES are the main client group of this life saving procedure. There may have inadequate access for those who are relatively less advantaged, even when CS is necessary.
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.
The Journal of medical research, 2021
Background: Caesarean section was one of the major issues in worldwide both in developed and developing countries. In Punjab, high prevalence of C-section had been perceived. Objective: To assess the prevalence, socio-demographic and socioeconomic factors of caesarean section in the Punjab. Methodology: The study was based on the data of Multiple Indicators Cluster Survey 2017-18 (MICS Punjab). Two-stage, stratified cluster sampling technique was adopted. Almost 53,840 households were selected to obtain the data from Punjab. Target population was currently and ever married women (15,656) who have given birth in last two years. From these women, a question was asked whether the delivery was normal or by C-section. We gave value 1 if delivered by C-section and 2 otherwise by using the Statistical Package for Social Sciences (SPSS) version 23. Results: The prevalence of C-section was 28.9% in the Punjab with 95% C.I (28.9%, 29.7%) and odds ratio (OR) 3.13. Out of ten, three women delivered baby by C-section. Area of residence, number of antenatal care visits, mother's age at time of marriage, education, wealth index quintile, and tetanus toxoid injection during last pregnancy were highly associated with the C-section. Educated and rich women were more attracted to deliver by C-section as compare to a women who were uneducated and belonged to poor socioeconomic group. In Central Punjab higher cases were found as compare to the South Punjab and Northern Punjab. Conclusion: The prevalence of C-sections is very high in Punjab when compared with WHO standard. The contributing factors to this rising trend of increased rate of C-section, higher education, improvement of socioeconomic status and easy accessibility of C-section facilities.
Journal of Biosocial Science
Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan – Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient–provider power differentials and financial constraints. They considered C-section an expensive and risky procedure,...
BMC pregnancy and childbirth, 2018
The increasing rate of caesarean deliveries has become a serious concern for public health experts globally. Various medical and non-medical factors, such as maternal socio-demographics, are found to be responsible for this upsurge. Like in other countries, the rate of caesarean sections has increased in Pakistan as well. Therefore, there is a need to investigate the factors behind this increase. This study aims to assess the determinants associated with caesarean deliveries among child-bearing women aged 15-49 years in Pakistan. Secondary data analysis was conducted on nationally representative cross-sectional survey data from the Pakistan Demographic and Health Survey, 2012-2013. The analysis was limited to mothers aged 15-49 years, who had given birth to at least one child during the 5 years immediately preceding the survey (n = 7461). Maternal socio-demographic characteristics and pregnancy-related variables, including antenatal care utilisation, place of delivery and pregnancy ...
Applying an Equity Lens to Maternal Health Care Practices in Pakistan
2012
The focus of this study is to see how equitable the access and utilisation of health services are among married women in Pakistan. It examines the changes in the pattern of maternal health care practices and the extent to which inequities in access to those services have changed over the past two decades. Using two datasets—the Pakistan Demographic and Health Surveys (PDHS) of 1990-91 and 2006-07, the overall findings indicate that there is an improvement in inequity patterns of health care among married women beginning in the urban areas and more recently spreading to rural areas. Among the factors explaining the health care differentials, the effect of wealth and socio-economic status are significant, especially when examined for use of private and public health facilities. It is further noted that increased educational attainment level of women improves utilisation of maternal health care services. The inequity pattern disfavouring the poor and the large majority of uneducated wo...
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.