Noreen Akhtar M.Sc
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FACTORS AFFECTING UTILIZATION OF ANTENATAL AND POSTNATAL SERVICES IN PUNJAB, PAKISTAN By Noreen Akhtar M.Sc. Rural Sociology A thesis submitted in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY IN RURAL SOCIOLOGY DEPARTMENT OF RURAL SOCIOLOGY UNIVERSITY OF AGRICULTURE, FAISALABAD (PAKISTAN) 2014 The Controller of Examinations, University of Agriculture, Faisalabad. We, the members of the Supervisory Committee, certify that the contents and format of the thesis submitted by Ms. Noreen Akhtar, Regd. No. 2001-ag-2157 have been found satisfactory and recommend that it be processed for the evaluation by the External Examiner (s) for the award of the degree. SUPERVISORY COMMITTEE Chairperson: __________________________ (Dr. Saira Akhtar) Member: __________________________ (Prof. Dr. M. Iqbal Zafar) Member: __________________________ (Prof. Dr. Tanvir Ali) DEDICATION THIS INSATIATE PIECE OF WORK IS DEDICATED TO My Worthy Mother Whose hands always raised in prayers for me I ACKNOWLEDGEMENTS I am immeasurably indebted to ALMIGHTY ALLAH, Who gives and forgives, the propitious, the benevolent and sovereign whose blessing and glory flourished my thoughts and thrived my ambitions to have the desired fruit of my modest effort in the form of this manuscript, giving me talented teachers, affectionate parents, sweet sisters, caring brother and unique friends. Trembling lips and wet eyes praise for HOLY PROPHET ((Peace be Upon Him)) for enlightening our conscience with the essence of faith in ALLAH, converging all His kindness and mercy upon him. My each and every breath, my each and every gesture throughout my transient life has ever been grateful to the Holy Prophet (Peace be Upon Him) who is the only paragon of guidance and knowledge for all humanity. My research work was accomplished under enthusiastic guidance, inexhaustible inspiration and enlightened supervision of Dr. Saira Akhtar, Associate Professor, Department of Rural Sociology, University of Agriculture, Faisalabad. I offer my heartiest gratitude to my benefactor for his untiring help, sagacious suggestions, step to step guidance and close supervision during the conduct of these investigations and in preparation of this manuscript. I deem it my utmost pleasure in expressing my cordial gratitude with the profound benedictions to Dr. Muhammad Iqbal Zafar, Professor and Dean, Faculty of Social Sciences, University of Agriculture, Faisalabad, for providing me with strategic command at every step. His inculcation towards the spirit of hard work and maintenance of professional integrity besides other valuable suggestions will always serve as a beacon of light throughout the course of my life. I extend deep emotions of appreciations, gratitude and indebtedness for his valuable guidance. Earnest and sincerest appreciation to Dr. Tanvir Ali, Director, Institute of Agri. Extension and Rural Development, University of Agriculture, Faisalabad, who, since my first year in the University of Agriculture, Faisalabad has always taken good care of me, both as regards academic and personal spheres. II My deepest thanks and gratitude to my brother-in-law Chaudhary Muhammad Hussain, Registrar, University of Agriculture, Faisalabad, who has always been a great brother teacher and friend to me. He has broadened my professional horizon, and supported me throughout the course of study and professional carrier. I will never forget all my friends specially Ms. Asma and Ms. Shagufta who were shoulder to shoulder with me in data collection and who not only provide their immediate company but also support and encourage me to complete this manuscript well in time. No acknowledgement could ever adequately express my obligations to my affectionate mother for her all inspirations and guidance which always motivated me to carry myself through the noblest ideas of life and solving all troubles and boosted my moral to fly high to accomplish my goals. My Husband, Mr. Sarfraz Ahmad, deserves deepest and heartily gratitude, who took all responsibilities of mine in the whole laborious span of my research activities. I simply want to pay my innocent apology to Tabeer and Maheer for all the time that should have spared for them but I snatched from them. Noreen Akhtar III ABSTRACT Antenatal and Postnatal services are one of the most important maternal healthcare services for the prevention of impairments and disabilities resulting from childbirth. The present study has been designed to probe into the factors and believes behind utilization of antenatal and postnatal services. The study was conducted In the Punjab, the largest and most populated, province of Pakistan. The study was intended to gain immediate knowledge and information on attitudes and trends regarding utilization of antenatal and postnatal services in the Punjab Province. Three districts i.e. Rawalpindi, Faisalabad and Multan were selected through simple random sampling techniques. Out of the selected three districts two tehsils were selected from each district through random sampling technique. From each tehsil two union councils were selected and from each union council two villages were selected through random selection method. From each selected village 25 respondents were selected through purposive sampling technique; who fall under the specific criteria i.e. the mothers aged from 15-49 years having their last baby more than 6 months and less than five years old. Size of sample (600) was fixed using equal allocation method. A well-structured interview schedule about antenatal and postnatal services was designed for this purpose. The data thus, collected were fed to computer for analysis. Univeriate, bivariate and multivariate statistical methods were used for data analysis. It was found that a huge majority of the respondents had knowledge about the antenatal (97.3 percent) and postnatal (97 percent) care services and their source of information were LHWs and TBAs. A huge majority of the respondents (87.2 percent) reported that medical health facilities were available in their area. A substantial proportion of the respondents went to antenatal services due to illness, to check the well being of the fetus and immunization of themselves. More than a half of them visited antenatal care center because of complications during child birth. A majority of the respondents (72.5 percent) reported that they called a midwife at home for any service, 48.3 percent of the respondents delivered their baby at home, while 45.0 percent of them delivered their baby at a hospital in the sampled area. Education level of mothers and their husbands, family income, awareness and availability of antenatal services have positive and significant association with the utilization of antenatal services, whereas, influence of culture, cost of antenatal services, distance from health facility, age of the respondents and total live births had negative association with the utilization of antenatal services. Similarly education level of the respondents and their husbands, family income and availability of postnatal services have positive and significant association with the utilization of postnatal services. Influence of culture, distance of health care facilities and cost of postnatal services have negative and significant association with the utilization of postnatal services. A comprehensive training program should be designed at government level to train LHWs and TBAs to improve their knowledge and practice because a huge majority of rural women rely on them for information about antenatal and postnatal services. IV Abbreviations used ANC: Antenatal Care BC: Before Christ BCG: Bacille Calmette-Guérin (Vaccine) BEOC: Basic Obstetric Care BHU: Basic Health Unit CDGF: City District Government Faisalabad CEOC: Comprehensive Obstetric Care CIA: Central Investigation Agency DHQ: District Head Quarter EPDS: Edinburgh Postnatal Depression Scale EPI: Expanded Program on Immunization ICPD: International Conference on Population and Development IMR: Infant Mortality Ratio IUCD: Intra Uterine Contraceptive Device LHW: Lady Health Workers MMR: Maternal Mortality Ratio MNT: Maternal and Neonatal Tetanus NFHS: National Family Health Survey NGO: Non Government Organization NRSP: National Rural Support Program PDHS: Pakistan Demographic and Health Survey PNC: Postnatal Care RHC: Rural Health Center SPSS: Statistical Package for Social Sciences TBA: Traditional Birth Attendant THQ: Tehsil Head Quarter TV: Television UC: Union Council UN: United Nation UNESCO: United Nation Education Scientific and Cultural Organization UNFPA: United Nation Fund for Population WHO: World Health Organization WHS: World Health Statistics V TABLE OF CONTENTS Page # Dedication I Acknowledgements II Abstract IV Abbreviations V Table of contents VI List of tables VIII Chapter Title Page # 1 INTRODUCTION 1 1.1 Need for the study 6 1.2 Objectives 7 1.3 Theoretical Framework 7 1.4 Conceptual Framework 8 1.5 Hypotheses 10 2 REVIEW OF LITERATURE 11 2.1: Residential distance from the hospital 11 2.2: Age of respondents 12 2.3: Income of the family 13 2.4: Husband’s occupation 14 2.5: Education level of the husband 15 2.6: Education level of the mothers 16 2.7: Live births 17 2.8: Mothers’ occupation 18 2.9: Availability of the antenatal and postnatal services 18 2.10: Awareness of antenatal and postnatal services 21 2.11: Influence of culture 22 2.12: Cost of maternal health services 23 2.13: Utilization of antenatal services 24 2.14: Utilization of postnatal services 27 VI 3 RESEARCH METHODOLOGY