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

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 context and influence individual behavior and highlights the diminishing urban-rural gap in service utilization in Pakistan.

Regional disparities in antenatal care utilization in Indonesia

“…The analysis shows that there is no difference between urban and rural areas in ANC utilization in Indonesia. This condition is different from the findings in Nigeria [26], Ethiopia [9], Pakistan [27] and several other countries [28], which found disparities between urban and rural areas.…”

Antenatal Care Service Utilization Among Adolescent Pregnant Women–Evidence From Swabhimaan Programme in India

“…Several studies exploring factors associated with utilization and coverage of ANC services have been conducted (22,23); however, these research efforts have focused on women of all reproductive age groups, with inadequate attention given to understanding factors associated with ANC utilization among adolescent pregnant women. According to the NFHS-4 survey, the proportion of ANC coverage among women aged 15-49 years has increased by 7% during 2005-2006 to 2015-2016 (4,24).…”

Educational Empowerment and Use of Antenatal Services

“…The antenatal care, delivery by skilled birth attendant and care during postnatal period are included in essential maternal healthcare services. During pregnancy the care which is received by pregnant women from trained healthcare professionals that include 4-5 visits if women have no other medical problems as recommended by World Health Organization [6,7,8] (WHO) is termed antenatal care . This study aimed to determine the utilization of antenatal services by the reproductive age women of urban slum areas and association of women's education with antenatal care use.…”