International Journal of Health Policy and Management

International Journal of Health Policy and Management

Inequities in Antenatal Care, and Individual and Environmental Determinants of Utilization at National and Sub-national Level in Pakistan: A Multilevel Analysis

Document Type : Original Article

Authors
Ambreen Sahito 1, 2
Zafar Fatmi 1, 2
1 Department of Community Medicine, Isra University, Hyderabad, Pakistan
2 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
10.15171/ijhpm.2017.148
Abstract
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 socio-economic 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 contex and influence individual behavior and highlights the diminishing urban-rural gap in service utilization in Pakistan.

Highlights

Supplementary File 1 (Download)

 

Keywords
Inequity
Antenatal Care Utilization
Determinants
Multilevel Analysis
Pakistan
Subjects

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  1. Contraceptives performance report, 2014-2015. Government of Pakistan: Pakistan bureau of statistics; 2015.
  2. Pakistan Demographic and Health Survey 2006-2007. Islamabad: Pakistan; National Institute of Population Studies; 20018.
  3. Wagstaff A. The Millennium Development Goals for heath: rising to the challenges. World Bank Publications. 2004.
  4. Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity?  An overview of the evidence. Paediatr Perinat Epideiol. 2001;15 Suppl 1:1-42.
  5. Alexander GR, Kotelchuck M. Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research. Public Health Rep. 2001;116(4):306-316.
  6. UNDP. The millennium development goals report 2015. United Nations Publications; 2015.
  7. Pakistan Demographic and Heath Survey 2012-2013. Islamabad: Pakistan; National Institute of Population Studies.
  8. Government of Pakistan, Constitution (Eighteenth Amendment) Act, 2010. The Gazette of Pakistan.
  9. Simkhada B, Teijingen ER, Porter, M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systemic review of the literature. J Adv Nurs. 2008;61(3):244-260.
  10. Berer M. Maternal mortality or women’s health: time for action. Reprod Health Matters. 2012;20(39):5-10.
  11. Osorio AM, Tovar LM, Rathmann K. Individual and local level factors and antenatal care use in Colombia: a multilevel analysis. Cad Saude Publica. 2014;30(5),1079-1092.
  12. Tarekegn SM, Lieberman LS, Giedraitis V. Determinants of maternal health service utilization in Ethiopia: analysis of 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy Childbirth. 2014;14:161. doi:  10.1186/1471-2393-14-161
  13. Fatmi Z, Avan BI. Demographic, socio-economic and environmental determinants of utilization of antenatal care in a rural setting of Sindh, Pakistan. J Pak Med Assoc 2002;52(4):138-142.
  14. Nisar N, White F. Factors affecting utilization of antenatal care among reproductive age group women (15-49 years) in an urban squatter settlement of Karachi. J Pak Med Assoc. 2003;53(2):47-53.
  15. Alam AY, Qureshi AA, Adil MM, Ali H. Factors affecting utilization of antenatal care among women in urban slum areas of Islamabad. Rawal Med J. 2004;29(2):71-75.
  16. Yousuf F, Haider G, Shaikh RB. Factors for inaccessibility of antenatal care by women in Sindh. J Ayub Med Coll Abbottabad. 2010;22(4):187-189.
  17. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
  18. Ronald A, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51(1):95-124.
  19. Steele F. Module 5: Introduction to multilevel modeling concepts. LEMMA (Learning Environment for Multilevel Methodology and Applications), Center for Multilevel Modelling, University of Bristol;2008.
  20. Tom A, Bosker TA, Bosker RJ. Multilevel analysis: An Introduction to Basic and Advanced Multilevel Modeling. Thousand Oaks: Sage; 1999.
  21. Goldstein H, Browne WJ, Rasbash J. Partitioning variation in multilevel models. Understanding Statistic. 2002;1(4):223-232.  
  22. Pfeffermann D, Skinner CJ, Holmes DJ, Goldstein H,  Rasbash J. Weighting for unequal selection probabilities in multilevel models. J R Stat Soc Series B Stat Methodol. 1998;60(1):23-40.
  23. Rabe-Hesketh S, Skrondal A. Multilevel modeling of complex survey data. J R stat Soc Ser A Stat Soc. 2006;169(4):805-827.
  24. Joshi C, Torvaldsen S, Hodgson R, Hayen A. Factors associated with the use and quality of antenatal care in Nepal: a population- based study using the demographic and heath survey data. BMC Pregnancy and Childbirth 2014;14:94. doi: 10.1186/1471-2393-14-94
  25. Sagna ML, Sunil TS. Effects of individual and neighborhood factors on maternal care in Cambodia. Health Place. 2012;18(2):415-423. doi:10.1016/j.healthplace.2011.12.006
  26. Zaidi S,  Riaz A, Rabbani F, Azam SI, Imran SN, Pradhan NA, Khan GN. Can contracted out health facilities improve access, equity, and quality of maternal and newborn health services? Evidence from Pakistan. Health Res Policy Syst. 2015; 13(suppl 1):54.
  27. Gage AJ. Barriers to the utilization of maternal health in rural Mali. Soc Sci Med 2007;65(8):1666-1682. doi: 10.1016/j.socscimed.2007.06.001
  28. Janjua NZ, Khan MI, Usman HR, Azam I, Khalil M, Ahmad K. Pattern of health care utilization and determinants of care-seeking from GPs in two districts of Pakistan. Southeast Asian J Trop Med Public Health 2006; 37(6):1242-1253.
  29. Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190. doi: 10.1371/journal.pone.0011190
  30. Addai I. Determinants of use of maternal child health services in rural Ghana. J Biosoc Sci. 2000;32(1):1-15.
  31. Magadi MA, Madise NJ, Rodrigues RN. Frequency and timing of antenatal care in  Kenya: explaining the variations between women of different communities. Soc Sci Med. 2000;51(4), 511-561.
  32. Government of Baluchistan website. http://www.balochistan.gov.pk/index.php?option=com. Updated October 14, 2016. Accessed January 14, 2017.
  33. Green A, Ali B, Naeem A, Ross D. Resource allocation and budgetary mechanisms for decentralized health systems: experiences from Baluchistan, Pakistan. Bull World Health Organ. 2000;78(8):1024-1035.
  34. Ritcher K, Hasnain Z, Ikram K, Noshab F, Ahmaf M. Baluchistan Economic Report, From Periphery to Core. Washington, DC: World Bank; 2008.
  35. Thomas CJ. Does community participation make a difference? Girls’ Schooling Outcomes and Community Participation in Baluchistan. Stanford University;1996.   
  36. Jamal A. Men’s perception of women’s role and girl’s education among Pashtun tribes of Pakistan: a qualitative Delphi study. Cultural and Pedagogical Inquiry 2014; 6(2):17-34
  37. Khan S. Impact of father education on female education in Pashtun society of district Charsadda, Pakistan. Imperial Journal of Interdisciplinary Research.  2016;2(4):1013-1019.
  38. Ahmed T, Shahzad M, Shahzad MN, et al. Male outmigration and changing role of women in Saidu Sharif district Swat, KPK Pakistan. The Explorer Islamabad: Journal of Social Sciences. 2015;1(11):413-415.
International Journal of Health Policy and Management
Volume 7, Issue 8
2018
Pages 699-710

  • Received Date 14 January 2017
  • Revised Date 14 August 2017
  • Accepted Date 30 December 2017
  • First Published Date 01 August 2018
  • Published Date 01 August 2018