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 30 3.1: Introduction 30 3.2: Research design 30 3.3: The Research Area (Overview of Punjab) 30 3.4: Study Area 32 3.5: Characteristics of the Respondents 35 3.6: The Sample Size 35 3.7: Interviews process 36 3.8: Reliability and validity of interview schedule 37 3.9: Meeting with the data collection team before field work 38 3.10: Pre-testing 38 3.11: Meeting with the key informants before data collection 38 3.12: Conducting survey 39 3.13: Editing of data 39 3.14: Method of data collection 40 3.15: Field time 40 3.16: Limitations 41 3.17: Coding 41 3.18: Statistical Techniques of Analysis 41 4 RESULTS AND DISCUSSION 46 4.1 Uni-Variate Analysis 46 4.2: Bi-variate Analysis 98 4.3: Multivariate Analysis 121 6 SUMMARY, FINDINGS, CONCLUSIONS AND 126 RECOMMENDATIONS 5.1: Key Findings 127 5.2: Conclusions 136 5.3: Suggestions/Recommendations 137 LITERATURE CITED 139 Appendix- 1: Interview Schedule 160
VII LIST OF TABLES
Table Title Page # 4.1 Distribution of the respondents according to their residence distance 46 from health facility 4.2 Distribution of the respondents according to their socioeconomic 47 characteristics 4.3 Educational level of the respondents and their husbands 51 4.4 Distribution of the respondents according to their type of family 52 4.5 Distribution of the respondents according to their family members 52 4.6 Distribution of the respondents according to their adolescent family 53 member 4.7 Distribution of the respondents according to their total number of 53 children (<12 years) 4.8 Distribution of the respondents according to their total family 54 members 4.9 Distribution of the respondents according to their total live births 54 4.1 Distribution of the respondents according to their dead children 55 4.11 Distribution of the respondents according to the working for cash 56 4.12 Distribution of the respondents according to their per month earning 56 4.13 Distribution of the respondents according to health facilities available 57 in their area 4.14 Distribution of the respondents according to the type of available 57 medical health facilities 4.15 Distribution of the respondents according to their knowledge about 58 antenatal services 4.16 Distribution of the respondents according to their awareness about 59 important antenatal services 4.17 Distribution of respondents regarding to receive antenatal services 60 4.18 Distribution of the respondents regarding reasons to receive antenatal 60 services 4.19 Distribution of the respondents according to the received antenatal 61 services 4.20 Distribution of the respondents according to where from received 61 antenatal services 4.21 Distribution of the respondents regarding reasons for not taking 62 antenatal services 4.22 Distribution of the respondents according to visit of health clinic 63 during pregnancy 4.23 Distribution of the respondents according to their no. of visit to health 64 clinic for antenatal services 4.24 Distribution of the respondents according to their source of 65 information about antenatal services 4.25 Distribution of the respondents according to the services provided 66 during pregnancy
VIII Table Title Page # 4.26 Distribution of the respondents according to their knowledge about 66 postnatal services 4.27 Distribution of the respondents according to their awareness about 67 important postnatal services 4.28 Distribution of the respondents who received postnatal services 68 4.29 Distribution of the respondents according to the types of postnatal 69 services they received 4.30 Distribution of the respondents according to the reasons to receive 70 postnatal services 4.31 Distribution of the respondents according to where from received 71 postnatal services 4.32 Distribution of the respondents according to the reasons for not 71 receiving postnatal services 4.33 Distribution of the respondents according to the visit of health clinic 72 after delivery 4.34 Distribution of the respondents according to no. of visits to the health 72 clinic for medical checkup after delivery 4.35 Distribution of the respondents according to their source of 73 information about postnatal services 4.36 Distribution of the respondents according to their choices to go to 74 hospital 4.37 Distribution of the respondents according to call TBA at home 74 4.38 Distribution of the respondents according to the method of delivery of 75 their last child 4.39 Distribution of the respondents according to the place of delivery 75 4.4 Distribution of the respondents according to the handling of their 76 delivery case 4.41 Distribution the respondents according to having still birth 77 4.42 Distribution of the respondents according to the number of still births 77 4.43 Distribution of the respondents according to have any miscarriage 77 4.44 Distribution of the respondents according to the number of 78 miscarriages 4.45 Distribution of the respondents whether they faced an abortion 78 4.46 Distribution of the respondents according to the number of abortion 79 4.47 Distribution of the respondents according to their opinion about the 79 “abortion is killing of fetus” 4.48 Distribution of the respondents according to their knowledge about the 80 family planning methods 4.49 Distribution of the respondents according to their awareness about the 80 types of family planning methods 4.5 Distribution of the respondents according to the family members who 81 had positive attitude towards family planning 4.51 Distribution of the respondents according to their opinion towards the 82 Islamic point of view about family planning
IX Table Title Page # 4.52 Distribution of the respondents according to their family likes breast 83 feeding 4.53 Distribution of the respondents according to the feeding practice for 83 their children 4.54 Distribution of the respondents according to the duration of breast 84 feeding of last child 4.55 Distribution of the respondents whether they immunized their baby 84 4.56 Distribution of the respondents according to the place of getting 85 immunization services/injection 4.57 Distribution of the respondents whether they injected for tetanus 85 texoid 4.58 Distribution of the respondents according to the number of injection of 86 tetanus texoid 4.59 Distribution of the respondents according to the place of injection of 86 tetanus texoid 4.60 Distribution of the respondents according to the most concerned about 87 their health in their family 4.61 Distribution of the respondents regarding who accompanied them 87 4.62 Distribution of the respondents regarding who supported them 88 financially for medicine 4.63 Distribution of the respondents according to prefer TBAs for these 89 services in their locality 4.64 Distribution of the respondents according to their knowledge of any 89 other mother die during delivery in their locality 4.65 Distribution of the respondents according to their opinion about the 90 some traditional believes 4.66 Distribution of the respondents according to their opinion about 91 maternal health services are costly for them to bear 4.67 Distribution of the respondents according to their opinion about the 92 following constraints 4.68 Distribution of the respondents according to their opinion about the 94 normative cost of health care services 4.69 Distribution of the respondents according to the means for reaching 96 hospital 4.70 Distribution of the respondents according to suggestions to the 97 policymakers for creating and ensuring conducive environment at the health outlets for the maximum utilization of antenatal and postnatal heath care services 4.71 Indexation of different variables 100 4.72 Association between distance of any health facility and utilization of 101 antenatal care services 4.73 Association between age of the respondents and utilization of 102 antenatal care services 4.74 Association between monthly family income of the respondents and 103 the utilization of antenatal care services
X Table Title Page # 4.75 Association between husband’s education and the utilization of 104 antenatal care services 4.76 Association between education of the respondents and the utilization 105 of antenatal care services 4.77 Association between total live births of the respondents and utilization 106 of antenatal care services 4.78 Association between availability of medical health facilities and 107 utilization of antenatal care services 4.79 Association between awareness about antenatal services and 108 utilization of antenatal care services 4.8 Association between influence of culture and utilization of antenatal 109 care services 4.81 Association between cost of maternal health services and utilization of 110 antenatal care services 4.82 Association between distance from care facility and utilization of 111 postnatal care services 4.83 Association between age of the respondents and utilization of 112 postnatal care services 4.84 Association between monthly family income of the respondents and 113 the utilization of postnatal care services 4.85 Association between husband’s education and utilization of postnatal 114 care services 4.86 Association between education of respondents and the utilization of 115 postnatal care services 4.87 Association between total live births of respondents and utilization of 116 postnatal care services 4.88 Association between availability medical health facilities and 117 utilization of postnatal care services 4.89 Association between awareness about postnatal care services and 118 utilization of postnatal care services 4.90 Association between influence of culture and utilization of postnatal 119 care services 4.91 Association between cost of maternal health service and utilization of 120 postnatal care services 4.92 Standardized regression coefficients, t values and level of significance 122 of socio-economic, cultural and demographic variables regressed on utilization of antenatal care services 4.93 Standardized regression coefficients, t values and level of significance 124 of socio-economic, cultural and demographic variables regressed on utilization of postnatal care services
XI Chapter-I INTRODUCTION Pakistan is a developing country and health status of Pakistani women is quite poor in comparison with the women of developed countries of the world. If compared the women health with neighboring countries, the health status of our women seems quite low (PDHS, 2008). In female's life span the most vulnerable period is childhood and motherhood (15-49 years); these are the periods in which maximum mortality of females takes place (Rizvi and Nishtar, 2008). Maternal mortality ratio (MMR) is an internationally accepted indicator of mother’s health status. Maternal mortality ratio of Pakistan is 260 deaths per 100,000 live births (CIA, 2013). The maternal period seems risky in a mother’s life due to lack of basic facilities in developing countries. It starts from conception to delivery and six weeks after delivery. Like other walks of life Pakistani women are behind the world in health status. Pakistan being a poor country has poor health and social status of women. This status can be seen on gender related development index, where Pakistan ranked 146th out of 183 countries just above the Angola and Myanmar (UNDP, 2013). The situation of maternal mortality and morbidity is so alarming that in every hour one woman dies and 40 women get permanent disability during child birth. (Terzieff, 2006) There is 46 percent reduction in maternal mortality ratio from 1990 to 2010 in Pakistan but still MMR is very high. In Pakistan one woman out of 110 women dies during pregnancy or delivery while in Europe on one out of 2900 women dies. The global maternal mortality ratio is 210 while MMR of Europe is 20 and of South Asia is 220 (WHO, 2012) In Pakistan due to lack of urban planning, lot of earthen/temporary housing schemes locally called kachi-abadies were developed around cities. These under privileged groups of kachi-abadies as well as scattered rural population lead to inadequate access to the health services. In these settlements maternal health care system is usually not available to a large number of mothers and along with antenatal and postnatal services other health problems like anemia and malnutrition are also very common and cause life threatening complications after birth. In Pakistan each year about 30,000 women die during pregnancy/at the time of delivery due to birth related complications. Some 300,000 women each year developed pregnancy related disabilities due to lack of prenatal and postnatal services. These facts and figures cannot be denied, as disability/the death is a tragedy not only for a family but
1 also for a society. Due to maternal problems low birth weight is a common issue in Pakistan as 25 percent of the children born with low birth weight and this is due to maternal health problems and malnutrition. This reflects the poor reproductive health status of women. High preference for son, early marriages in rural set up, closely spaced many pregnancies, poor delivery management under traditional birth attendants and poor antenatal and postnatal services are the factors associated with the poor women reproductive health status in Pakistan. (APWA, 2002) In poorer families the complications for pregnant women are more common and become severer and complicated like chronic pain and impaired mobility that causes damage to the reproductive system (Luthra, 2005). Genital prolepsis is a condition developed in women after having multiple children, which is extremely dangerous, uncomfortable and further pregnancy is affected badly. Its timely treatment is mandatory in postpartum period to cure this condition (Ashford, 2004) It is very important for the mothers to go through a high quality antenatal care during pregnancy period even if they don't feel complications. Health care services are important and must be followed during pregnancy, delivery and in postpartum period to ensure health safety of a mother and an infant (Frost, 2001; Khan et al., 2013). Postnatal health care services are made available to the mother and neonatal after delivery for six weeks period and the most important services are physical examination, physiotherapy, immunization, health tips and family planning. But these facilities and services with majority of health care outlets are not available if available then most of the mothers hesitate to avail these health care services due to different reasons (United Nation, 2002; Ejaz and Ahmad, 2013) Majority of women in developing world do not have idea about the importance of postnatal services and most of them avoid using postnatal services. Luthra, (2005) reported that 40% women developed complications after delivery out of which 15% suffered severe life threatening complications. It is also important as most of the mothers don’t use comprehensive postnatal care. Rower and Garcia (2003) found that availability, quality and cost are the prime factors associated with the utilization of the maternal health care services. Social setup, beliefs and personality are also linked with the utilization of health care services by mothers (Khan et al., 2013). Safe motherhood (1998) reported the factors which prevent the utilization of postnatal services were cost, distance, women’s autonomy, poor handling by the health care providers, traditional and dogmatic attitude of families and community towards women regarding utilization of services. 2
Although there is improvement in health condition of Pakistani women as compared to available in previous years but still lot of efforts are required to improve the overall health status of women in the country. The world has transformed into a global village and global maternal health is getting momentum. For a mother of a developed country giving birth to a child is not a life threatening experience but if it is compared with developing countries or even with least developed countries, child birth is always associated with weakness, illness, sufferings and even death. To avoid pregnancy related issues it is the recommendations of World Health Organization (WHO) that there should be at least four antenatal visits from first trimester up to delivery (Beeckman et al., 2010 and WHO, 2013). On an average about 55 percent of the world women received antenatal care as per recommendations of WHO but in low income countries only 37 percent of the women received antenatal care four or more times (WHO. 2013) If look at the developing world, the scenario is changing with different pace at different places but there is significant improvement in the availability of maternal health care services and accessibility of these services has also been improved (Mathole et al., 2004). Socio demographic factors, educational level of mothers, their husbands' interests and knowledge of importance of antenatal care are considered to be the important indicators which have direct correlation with utilization of antenatal health care services in developing countries (Matsumura and Gubhaju, 2001). The demographic factors affecting the utilization of antenatal care services in developing countries were considered to be the maternal age, number of previous pregnancies, number of live children etc. (Obermeyer and Potter, 1991). Socio demographic factors attitude of mothers has strong influence with the utilization of antenatal health care services. Negative attitude is associated with lesser utilization of prenatal health care services (Mathole et al., 2004). Attitude is a human mental response to a certain external stimuli. In developing countries along with other factors associated with the utilization of antenatal health care services attitude of mothers is directly associated with the utilization of antenatal care. The socio-economic status of mothers plays an important role in selection and utilization of maternal health care services. Like other accessories of life women with high socio economic status enjoy a high maternal health status as well (Mathole et al., 2004). Being under developing country Pakistan ranks among those countries where health status of mothers is very low (UNICEF, 2008). According to the statistics of 3
UNICEF (2008) for maternal mortality, Pakistan is among the group of ten countries of the world which account for 63% of total maternal deaths. High maternal mortality group also includes sub-continent which is a serious situation for mothers of South Asian Countries. According to World Health Statistics (WHS) and Pakistan Demographic & Health Survey (PDHS, 2008) only 65 percent of the mothers visited antenatal health care service center for the first time only and the number dropped to 26% for the mothers who took four visits for antenatal health care services. In Pakistan maternal mortality ratio varies from region to region and is very high in rural and less developed provinces of the country and comparatively better in developed provinces. Maternal mortality ratio in different Provinces of Pakistan is as in Punjab 223; KPK 275; Sindh 314 and in Balochistan 750 (PDHS, 2008). In spite of all these efforts to improve the health status of mothers and to reduce maternal mortality, about half a million mothers die each year due to the complications arise during the pregnancy period or at the time of delivery (Fosteo et al., 2009). It was also found out that mothers' autonomy was closely associated with the choice of place of delivery by the women of middle to least poor class. In Pakistan the maternal health care system in a broader way can be divided into two parts i.e. private sector and public sector (Ghaffar et al., 2000). ) Overall in health care system of Pakistan the number of qualified physicians is 127,859, nurses 62,651, and 110,000 lady health workers working in both public and private health care system (Govt. of Pakistan, 2008). In developing countries like Pakistan the poor, illiterate and unemployed people face serious hardships to avail health needs. The importance of health care system for women in developing countries has not only been recognized but also accepted as health of the mother is of great importance as far as fulfillment of the needs of the children are concerned. If a woman is healthy and well nourished before being pregnant; the dangers and diseases associated with being mother can greatly be reduced with routine check up during pregnancy. In developing countries the basic health facilities are being focused and are considered to be an important tool to the masses “health without wealth”. The twelve hours after delivery are also important for postnatal check up of the mother and after delivery up to six weeks special care is needed for better health and well being of the mother and neonatal (Shanna et al., 2004)
4
Four million neonatal die in the world each year during the first week after birth (Lawn et al., 2005 and WHO, 2005). There is declining trend in neonatal mortality globally as it has been decreased from 4.4 million in 1990 to 3.0 million in 2010 (WHO, 2013) Deliveries in low and middle income countries are carried out mostly with the assistance of a tradition birth attendant and at an improper place like home (Mrisho et al., 2007 and Bell et al., 2003). This situation is alarming if life threatening complications develop during pregnancy and/or at delivery. Care must be taken regularly to get them addressed and to avoid any human loss. Mortality rate of new born can also be reduced from 20 to 30 percent by provision of skilled birth attendants at the time of delivery (Darmstadt et al., 2005). Infant Mortality Rate (IMR) is number of neonatal deaths from birth to the age of one year expressed per 1000 live births (UNICEF, 2011) which is quite high in Pakistan as every 14th child dies before his/her first birthday. In Pakistan health care system and its utilization of male and female is differential because of the impact of different social and cultural factors which are known to be important for seeking services of health care system. Lesser availability of female qualified health care providers and limitations in the female mobility since different cultural and social barriers make it difficult for the female to utilize services of available health care system (Shaikh and Hatcher, 2005). In spite of having huge network of Lady Health Workers, large number of mothers could not be able to reach the health care facilities. In public sector's health care system especially in rural areas there is a lack of skilled health care providers to handle the complications and serious situation arising during pregnancy or delivery. Along with limitations of skilled heath providers, the health facilities in remote rural areas are at lower level with poor management and lesser supply of important medicines. In developing countries the utilization of antenatal and postnatal health care services is not at that level as it should be to control the neonatal and maternal deaths. In developing countries, the proportion of mothers visit for 1st antenatal check up is improving with the fact that in Asia 54% of the mothers made at least one antenatal visit while in Africa (Sub-Sahara) the ratio is relatively high and 69% of the mothers make at least one antenatal visit (UNICEF, 2006). Whereas in developed countries 97 percent of mothers made at least one antenatal visit and most promising is that 99 percent mothers deliver with the help of a skilled birth attendant. After delivery in developed countries of
5 the world 90 percent mothers made at least one postnatal visit (AbouZahr, 1997). Antenatal and postnatal health care services had the potential to reduce maternal and neonatal deaths if available and utilized properly (McDonagh, 1996 and Finger, 1997). The health care providers recommended four antenatal visits for a safe delivery (Koblinsky, 2006 and Urassa et al., 2002). As far as postnatal visits are concerned it is least concerned topic in the developing world but importance of postnatal care can’t be denied. In recent years the need and importance of post partum care have been emphasized because rate of maternal deaths is alarming. Most of the maternal deaths occurred during labor, delivery and 24 hours after delivery. With timely diagnosis and treatment most of the complications can be avoided (Campbell and Graham, 2006; Ronsmans and Graham, 2006) There is a close relationship between utilization of antenatal care and the utilization of services of skilled birth attendants at the time of delivery (Bloom et al., 1999 and Ejaz and Ahmad, 2013). The mothers who got high level of antenatal care during pregnancy are four times more likely to avail the services of skilled birth attendants at the time of delivery than the mothers who got low level of antenatal care (Bloom et al., 1999). The quality and availability of both antenatal and postnatal health care services are important to have maximum impact of these services. But the barriers like geographical, cultural and financial was important to be addressed as these are the hurdles which reduce the delivery of these services to the public (Winch et al., 2005; Ejaz and Ahmad, 2013). 1.1 NEED FOR THE STUDY Mother health is the indicator of child life and his or her health. One should take care of oneself for the development of a healthy nation and also for one’s own family. Mother care during pregnancy is the integral part of child care and development. In this regard the developed nations are provided marvelous facilities to the pregnant females like medication, furnished hospitals, physiotherapy and recommended diet. It is reported that a woman’s health involves her emotional, social, cultural, spiritual and physical well being (McComas and Harris, 1996). It is determined by the social, political and economic context of a woman’s life as well as her biology. Every woman should be provided with an opportunity to achieve, sustain and maintain health. The condition of antenatal and postnatal services is deteriorated in developing countries especially in Asia and Africa, whereas, the same situations have occurred in
6 most parts of Pakistan. In the rural area, the extent of maternal mortality is significantly high. However, in city hospitals there is varying degree of such services. Mothers who go for delivery along with antenatal and postnatal services at any hospital of their choice vary by age, socio-economic backgrounds and educational levels. However, there is great concern about the small number of women who actually receive the antenatal and postnatal services by which the present study was initiated. Many projects are in progress in Pakistan regarding reproductive health and mother child health. Thus the present study has been designed to determine the factors responsible for under utilization of antenatal and postnatal services and draw conclusions and to suggest measures for its improvement in the light of empirical investigations. 1.2 OBJECTIVES To study the attitude and trends regarding utilization of antenatal and postnatal services in Punjab, Pakistan. To identify mothers’ awareness, interest and adoption of modern techniques about antenatal and postnatal services. To determine the constraints in the utilization of antenatal and postnatal services. To suggest measures to the policymakers for creating and ensuring conducive environment at the health outlets for the maximum utilization of antenatal and postnatal heath care services. 1.3 THEORATICAL FRAMEWORK Theoretical framework is an application of certain scientific terminologies with a view to clearly communicate intended outcomes of the study. The need for the conceptualization and defining the general concept with specific and purified component is important. Some of the concepts used in the present study are discussed in following paragraphs. Theoretical framework is deeply embedded into three roots of the theories i.e. modernization, gender stratification theory. According to modernization theory (Billet, 1993) a nation’s industrialization and modernization enhance women’s status in general by providing more opportunities to work as laborer and to increase women’s access to, and control over, resources including health services. In response to that the maternal mortality rate decreases automatically in step with the decline of general mortality. Gender stratification theory argued that societies in which women have higher status and more autonomy the maternal mortality is lower (Boserup, 1970, Abraham and
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Abraham, 1988). Decrease in fertility reduces the risk of dying from pregnancy-related causes. With greater access to education, employment and contraception, women choose to have fewer children. Thus fertility decreases with the increase of women’s status since women have more say with respect to the number of children they have, greater respect to the number of children they have, greater access to health care and better nutrition during pregnancy. That leads to improved women reproductive health status which link to reduced maternal mortality. In societies where the status of women is low, women have too many children, start childbearing too early, and end child bearing too late and children are too close together (Royston and Armstrong, 1989). Women’s status measured by education health and reproductive autonomy has beneficial impact on reducing child mortality. In poor socio-economic conditions women are vulnerable to health risks caused by childbearing, yielding high mortality (Shen and Williamson, 1997) The economic dependency theory gives more broad spectrum and wide illustration with the special perspective of antenatal and postnatal health services for safe motherhood. In economic dependency theory a global division of labor is preserved in a capitalist world system which deteriorated the economies of the most of the less developed countries. This economic dependency decreased their economic growth rate and increased financial inequalities among masses which thus badly affected the conditions of substantial fraction of population (Wallerstein, 1974). There is a close relationship between the economic dependency and utilization of antenatal and postnatal services. Economic dependency accelerates poverty thus limits affordability of the mothers to use maternal care services. In developing countries like Pakistan due to poor economic conditions and unequal distribution of resource there is gender discrimination. Women are deprived part of the society and are unable to avail the maternal health care facilities because of certain socio-economic factors. 1.4 CONCEPTUAL FRAMEWORK A conceptual framework is a group of ideas which are broad in nature and the principles that are relevant to the field of inquiry. Conceptual framework is used to develop a subsequent presentation (Reichel and Ramey, 1987). It is also considered as a tool very practical to scaffold research. Conceptual framework is also a transitional theory that is connected with the all the aspects of the study like research analysis, research questions, methodology, literature review. The justification of the conceptual framework
8 is that it helps the researchers to know the linkages of the existing literature and their own research objectives with references. This present study was designed with an aim to identify the factors influencing the utilization of antenatal and postnatal services in Punjab, Pakistan and how demographic and socio economic and cultural variables influence the utilization of antenatal and postnatal services by mothers. How husband's occupation, education and education level of mothers, income of family, cost of antenatal and postnatal services, influence of culture, availability of antenatal and postnatal services, age of the respondents, total live births and awareness about maternal health services affect the utilization of antenatal and postnatal services. So assumptions were developed keeping in view conceptual framework, which play a vibrant role to design and investigate the realities of the situation. Here is a pictorial representation of the conceptual framework.
Conceptual Framework
Background Variables Independent Variables Dependant Variables
o Influence of culture o Residential distance from the hospital Utilization of o Availability of the Antenatal o Age of antenatal and respondents postnatal services Service o Education level o Cost of the husband o Live births o Education level o Awareness of of the mothers antenatal and Utilization of o Income of the postnatal services family Postnatal o Services
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1.5 HYPOTHESES 1. Distance from health facilities and utilization of antenatal care services are associated 2. Age of the respondents and utilization of antenatal care services are associated 3. Monthly family income of the respondents and utilization of antenatal care services are associated 4. Husbands education and utilization of antenatal care services are associated 5. Respondents’ education and utilization of antenatal care services are associated 6. Total live births and utilization of antenatal care services are associated 7. Availability of medical health facilities and utilization of antenatal care services are associated 8. Awareness level of antenatal care services and utilization of antenatal care services are associated 9. Influence of culture and utilization of antenatal care services are associated 10. Cost of maternal health services and utilization of antenatal care services are associated 11. Distance from health facilities and utilization of postnatal care services are associated 12. Age of the respondents and utilization of postnatal care services are associated 13. Monthly family income of the respondents and utilization of postnatal care services are associated 14. Husbands’ education and utilization of postnatal care services are associated 15. Respondents’ education and utilization of postnatal care services are associated 16. Total live births and utilization of postnatal care services are associated 17. Availability of medical health facilities and utilization of postnatal care services are associated 18. Awareness level of postnatal care services and utilization of postnatal care services are associated 19. Influence of culture and utilization of postnatal care services are associated 20. Cost of maternal health services and utilization of postnatal care services are associated
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Chapter-II REVIEW OF LITERATURE In this chapter various studies conducted in different parts of the world by different researchers on different times concerning the utilization of antenatal and postnatal services by the mothers and factors associated with the utilizations of these services are reviewed. 2.1: Residential distance from the hospital Residential distance from the hospital or health care center does matter in the utilization of maternal health care services especially in rural areas of developing countries. Long distance from the health care center proved to be a barrier for the utilization of maternal health service (Ghaffar et al. 2012, Bhattacherjee et al. 2013). Buor (2003) searched out that in Ghana the distance played an important role in utilization of health care services and was significantly associated with the utilization of health care services. Long distances together with unreliable means of transportation led to the delay in reaching health care units by the rural mothers, which in turn led to the high infant mortality rate and low life expectancy in rural areas (Ajala et al. 2005). According to the reports of World Bank (1994) conditions were worse and one third of women lived more than five kilometers away from the health facility. In Tanzania Bicego et al., (1997) found that due to long distances, lack of roads and lack of transport facilities more than 84percent of women who delivered their babies at home wanted to avail the health care facility for delivery. It is also a fact that in urban areas modern health facilities were available while in rural areas they were not so common and women had to cover long distances to reach a health care center or hospital. Women in urban areas had better opportunities to avail such facility that's why in urban areas most of the births took place in health care centers than in rural areas (Paul and Rumsey, 2001). Location of residence proved to be an indicator of utilization of modern health care facilities and it was confirmed in a study in Morocco, that utilization of health care by urban women was two to three times more than the rural women. (Obermeyer, 1993). Similarly it was reported in Philippines that urban women were more likely to use modern health care facilities while rural women preferred traditional practitioners. The study concluded that 38 percent rural and 59 percent urban women used modern health care facilities (Wong et al. 1987). Utilization of skilled attendants during delivery was more likely to be availed by urban women than rural women in India (Hazarika, 2010). In developing countries, the 11 utilization of maternal health care services varies with place of residence and socio- economic status with high utilization rate in urban women than rural women and high socio economic status than low socio-economic status. High utilization is also associated with better cure and treatment of maternity related diseases (Pallikadavath and Foss, 2001). Easy access to health facilities is linked with their utilization but in developing world accessibility to maternal health facilities is a major issue. Poor road infrastructure, long distances and unavailability of vehicles made it difficult for the women to reach health facility and they had to walk long distances to reach maternal health facilities even in labor pain (William et al. 1985, World Bank, 1994). Mwaniki et al. (2002) reported that in Kenya mothers living in areas less than 5km away from health facility were more likely to use health care facilities than mothers living in areas 5km or more. Availability of transport was associated with the utilization of maternal health care services (Kaufmann, 2002).Gautam (1998) reported that in Thailand mothers who utilized antenatal and postnatal care; most of them (64.9 percent) resided in a radius of 1-5 km from hospital/health center. Abosse et al. (2010) found that women living close to health care facility with less than one hour walking time were four times more likely to receive antenatal care services than women living at a distance with more than two hours walking time. 2.2: Age of respondents Age of a mother is also associated with the choice and utilization of maternal health care services. Younger mothers had more exposure to education and awareness and more like to avail modern maternal health care facilities than older mothers. As older women avoid medicine and give less importance to modern health care services (Raghupathy, 1996). In the Bangladesh the type of facilities used at the time of delivery were the same (Paul and Rumsey, 2002) regardless of the age of the mothers but in Nepal (Sharma et al. 2007) found that mother over 35 years of age got less antennal visits but utilization of delivery services and postnatal care was the same. In Philippines older mothers were less likely to avail prenatal services both in rural and urban areas (Wong et al., 1987). Daniels et al. (2013) reported that age of the mothers and utilization of health care services was associated. It was concluded that younger women used maternal health care services early and in greater proportion that older women. Also younger women preferred to deliver at health facility with the assistance of a trained attendant.
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Among different socio-demographic factors affecting the utilization of maternal health care services age and equality of women were of significant determinants affecting its repeated utilization (Adekunle et al. 1990; Celik and Hotchkiss, 2000; Leslie and Gupta, 1989, Addai, 2000). The older and experienced women with more confidence and greater degree of responsibility were less likely to avail maternal health care facilities (Kwast and Liff, 1988). In Bangladesh age did not affect the health care facility utilization (Paul & Rumsey, 2002). Gautam (1998) studied the factors affecting the antenatal and postnatal services in Thailand. It was found in the study that 31.1 percent of the mothers using postnatal services were in the age range from 20-24 years and as far as education of mothers was concerned 46.4 percent of the mothers had primary level of education and for occupation 46.4 percent of the mothers were house wives. Bari and Mariam (2000) studied that although average age of women for marriage is improving from 16.9 years to 22.5 years but still due to early marriages together with illiteracy and closely spaced pregnancies health conditions of women are adversely affected. WHO (2000) revealed the fact that poor health condition of the female adolescents in the region are because of the early marriage, sexual violence, anemia and poor educational opportunities. Meera and Julian (2003) studied health condition of women of India and Pakistan. The study concluded that in these two countries women remained under nutritional stress right from childhood to child bearing age. During reproductive age close pregnancies, short birth interval and lactation resulted in premature deaths and nutritional deficiencies like protein energy malnutrition, anemia and deficiencies of iodine and vitamin A which collectively contributed to the poor health status of women in these two countries. Bhattacherjee et al. (2013) did not found any relationship between age of respondents and utilization of prenatal, delivery care and postnatal services. 2.3: Income of the family Income of the family determines the selection and utilization of available health care services by the mothers. In India Hazarika (2010) used data from population based NFHS 3 survey 2005-06 with a sample size of 31,797 mothers who delivered within 3 months within the age group of 15-49 years. From the study it was determined that family wealth was one of the prominent factors associated with the use of skilled birth attendants. In under-developed and developing countries it is still a common practice to
13 deliver at home with or without the help of trained birth attendants (Mrisho et al. 2007 and Bell et al.2003) Nisar and White (2003) found from the studies conducted around urban slum areas of Karachi that income of women had direct linkage with the utilization of health care services. Women with high income had double tendency than the women with low income for the utilization of maternal care services. Similarly in Nepal the socio- economic status of the husband had significant association with the utilization of postnatal services. This was not the only factor but other factors like occupation, ethnicity and education were also associated (Dhakal et al. 2007). Fotso et al. 2009 conducted studies to find out relationship among women autonomy, wealth and education with the utilization of maternal health care services, among all factors family wealth had significant association with the place of delivery and utilization of maternal health care services. It was also proved that women with high social and economic status were more likely to avail maternal health care services than women with low status. (Addai, 2000, Addai, 1998, Leslie and Gupta, 1989). This was also reported by Fatmi & Avan (2002) that socio economic status of mothers is one of the key factors affecting the utilization of maternal health care services. Ovell and Abed (1988) highlighted that socio-economic status of women affects different other factors which are associated with health status of women. Women of poor socio-economic status had poor and imbalance diet, close pregnancies, high parity and lack awareness of importance of nutrition and health. Poverty and illiteracy found to be the major factors hindering the access to health facilities. Ejaz and Ahmad (2013) reported that financial problems were one of the reasons for not utilizing postpartum care by mothers. Similarly Zhao et al. (2012) also highlighted that mother having higher family income were more likely to receive antenatal care than the mothers with low household income. The study also revealed that 20.2 percent of mothers did not have money for antenatal care. Ghaffar et al. (2012) also found similar results where low family income proved to be a barrier in utilization of antenatal services. Daniels et al. (2013) reported that in Ghana 25 percent of women did not use antenatal care services and 39.3 percent did not deliver at health facility because of financial constraints. 2.4: Husband’s occupation Occupation of husband represented the level of education and wealth (Nwakoby, 1994). Wives whose husbands were having high status jobs had better opportunity to
14 avail modern health care facilities. Celik and Hotchkiss (2000) reported that in Turkey there is no relationship between occupation of husband and utilization delivery services. But when husband had health insurance facility then delivery was more likely at a facility. Daniels et al. (2013) found that there was association between occupation of husband and utilization of maternal health services, women whose husbands were farmers were more likely to utilize antenatal and institutional delivery services. Wealthy families used modern health care services more often than those having less family income (Elo, 1992). Other thing which is pertinent to the occupation of the husband is his vision about the use of health care services before and after new birth. Fathers in different occupations perceived the importance of antenatal and postnatal services differently. It was noted that in Bangladesh that husbands who were involved in farming were less responsive to the utilization of services by trained professionals for delivery than those engaged in other professions (Paul and Rumsey, 2002). Similarly Chakraborty et al. (2002) revealed that Bangladeshi mothers whose husbands were businessmen or employed in service sector used health care services more effectively than others. 2.5: Education level of the husband Education level of husbands plays an important role for the selection and utilization of health care services by the mothers. Education influences the behavior towards the preferences for selection of modern health services. Husbands with higher education levels proved to be more positive for utilization of child care services than those with lower level of education or illiterate (Cardwell, 1986). There is positive association between utilization of health care services and the education level of husband and wife (Alam et al. 2004, Bhattacherjee et al. (2013). Singh and Sharif (2002) found that matriculation level of education in India had significant impact on the utilization of health care services. The probability of utilization of prenatal service, postnatal service and trained attendant at the time of delivery was increased 10 percent, 8 percent and 7 percent respectively. Kistiana (2009) reported that among different socio economic factors affected the utilization of antenatal and delivery care, education level of husband and mother was one of the strong independent variables significantly associated with the utilization of the antenatal and delivery care services. Singh et al. (2012) in a study revealed that husband's education had profound effect on the utilization of antenatal, delivery care and postnatal services. Women whose
15 husbands had high school or higher education were more likely to avail antenatal care services than women whose husbands were illiterate. About 19.1 percent, 60.9 percent and 42.8 percent of women utilized comprehensive antenatal care, safe delivery and postnatal care whose husbands had high school or higher education. On the other hand 8.3 percent, 32.8 percent and 27.5 of the women utilized antenatal care, safe delivery care and postnatal care having illiterate husbands. 2.6: Education level of the mothers Education of mothers had strongest link with the utilization of maternal health care services. Women with low education level were less likely to avail antenatal care and skilled services at the time of delivery (Hazarika, 2010, Long et al. 2010). In Peru and Thailand it was confirmed that mother’s formal education had strong influence on the use of maternal health care services (Elo 1992, Raghupathy 1996). In Thailand it was found that the women with primary level of education were more likely to use antennal care services and skilled services at the time of delivery than the women without any formal education (Raghupathy 1996, Abosse et al. 2010). Although female education and utilization of maternal health services had a positive link but this is not the case everywhere in all social setups. In Bangladesh Dharmalingam et al. (1999) did not find any difference for utilization of maternal health care services among the women with primary level of education and women with no education. In Peru and Gutemala, primary level education played a very positive role and mothers with primary level of education used the prenatal and delivery services in a greater proportion (Elo, 1992; Goldman & Pebley, 1994). Studies conducted in Pakistan reported that there is a positive association between mother’s education and utilization of maternal health care services. Mothers with high degree of literacy were more likely to avail modern antenatal and delivery services than the illiterate mothers. This feature was more prominent with mother having middle school education than the primary school education (Khan et. al, 1994). Education made the mothers self responsible not only for themselves but also for their kids. Educated women had better opportunities to avail modern health care because of their preferences for educated/wealthier husbands and high family income (Schultz, 1984). In urban areas where modern health facilities were available and easily approachable then education did not affect their utilization (Khan et al. 1994).
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In Ethiopia, Mekonnen and Mekonnen (2002) found out that education of women had positive link with the utilization of maternal health care services but this was not the case in Uganda where Kyomuhendo (2003) proved that only education did not improve the maternal behavior to use health care services. Primary education and provision of basic health care services, the utilization of health care services was not improved because the mothers' decisions were influenced by local norms, traditions and community. Lot of researchers observed that education is one of the factors that is positively associated with the utilization of maternal health care services (Addai, 2000; Addai, 1998; Akin and Munevver, 1996; Beker et al., 1993; Celik and Hotchkiss, 2000; Ferdnandez, 1984; Stewart and Sommerfelt, 1991, Zhao et al. 2012, Bhattacherjee et al. (2013). Kogan and Leary (1990) found that higher the education level of the mother the more likely she returned for postnatal visits after delivery. Singh et al. (2012) in a study revealed that education of mother had definite impact on the utilization of antenatal, delivery care and postnatal services. They reported that 31.8 percent, 82.5 percent and 60.3 percent of women utilized full antenatal care, safe delivery and postnatal care respectively that had high school or higher education. On the other hand illiterate women utilized 6.9 percent, 31.3 percent and 24 percent of full antenatal care, safe delivery care and postnatal care respectively. Zhao et al. (2012) found the better frequency of utilization of maternal health care services by women having better education level. The educated mother had greater opportunities to seek information about healthcare. 2.7: Live births Health care utilization is influenced by the living children of mothers as reported by Mwaniki et al. (2002) who observed that in Kenya utilization of health care services is associated with number of kids she had. The mothers having more number of kids less likely she will be interested to avail health care facility. A comprehensive study (Kogan and Leary (1990) showed similar behavior, 82 percent of women with having first baby returned for postnatal visit, while visit ratio was 77 percent for second and third while 70 women returned for postnatal visits with four or more babies. Mothers having more number of babies showed more confidence and experience which affect their behavior to go for postnatal visit. Abosse et al. (2010) reported that women with three or less than three children were eight times more likely to receive antenatal health care services than mothers with
17 five or more than five children. Bhattacherjee et al. (2013) found that having a child reduced the use of antenatal care for subsequent pregnancies. But this study also revealed that having one or more children enhanced the utilization of institutional delivery and postnatal care utilization. Hollowell et al. (2011) in their study concluded that in first pregnancy perception of risk increased the utilization of maternal health services than in later pregnancies. Also having so many children led to resources depletion which had negative association with the utilization of maternal health care service. 2.8: Mothers’ occupation In developing countries men are the nucleus of financial activities for their family and women are dependent on men for economic survival which is considered as the major barrier for the reproductive health control for them. Women empowerment with more control on economic decisions at household level can increase control on reproductive health of their own. Employed women have good reproductive health status because of their economic independence and more awareness about health care services because of interaction with outside people (Sharma et al. 2007). In Kenya it was reported by Magadi et al. (2000) that women engaged with employment went for prenatal visit more frequently than others and they had updated knowledge about mother and child health because of more interaction with outside people. Employed mothers had more knowledge about the type and availability of antennal and postnatal services. Mothers employment is not always associated with the more use of maternal health services (Sharma et. al, 2007) because in developing countries women employment is mostly associated with poverty, like in Nepal with women at home were quite well off than the women at work. 2.9: Availability of the antenatal and postnatal services It is dilemma in developing countries that maternal health care facilities are not so commonly available especially in rural areas and if these are available the scope is limited. Various studies conducted on utilization of maternal health care services in developing world (Govindasamy and Ramesh, 1997; Raghupathy, 1996; Magadi et al. 2000 and Dharmalingam et al., 1999) indicated that health services differed significantly in different cultural and socio-economic set ups. Awoyemi et al. (2011) found that the type and quality of maternal health care services available was not evenhanded for everybody and poor accessibility played an imperative role in the utilization of these services.
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In developing countries traditional birth attendants (TBAs) locally called Dai in the Punjab played a key role in delivery services (UNFPA, 2004). The Child birth (56 percent) took place with the help of trained attendants (AbouZahr and Wardlaw 2001). In South Asia only 29 percent deliveries were attended by skilled birth attendants and rest took place with the help of TBAs or relatives or neighbourers (AbouZahr and Wardlaw, 2001). Kongsri et al. (2011) reported that the utilization of antenatal care and trained birth attendants were 98.9 percent and 99.7 percent respectively. In making these things available to the women their public sector played a major role where 90.9% of the total deliveries took place in public maternity homes. There is a big difference in the availability of maternal health facilities in poor and rich countries and similarly there is big difference in the health conditions of women in poor and rich countries. According to WHO (1998) maternal health includes health conditions of women during pregnancy period, during delivery and the postpartum period. In developed countries where modern health facilities are available and accessible to women, giving birth to a child is a good and satisfying thing, while in developing countries most of the times with most of the mothers this is associated with illness and even some times death. According to WHO reports, maternal mortality and utilization of maternal health care services are inversely proportional; 88-98 percent maternal mortalities during pregnancy and delivery can be avoided if women were given access to better health care services (Kunst and Houweling, 2001) Poor health conditions of women are linked with the non use of maternal health care. Antenatal care leads to proper monitoring of mother and child during pregnancy (UN, 2008) and is proactive approach to have knowledge about expected complication so that those can be managed in advance (AbouZahr and Wardlaw, 2001). So to make these health care services available is important for their utilization. During pregnancy period mothers must be realized the importance of trained birth attendants at the time of delivery. Unexpected complications were one of the key factors of maternal mortality because unexpected complications required emergency obstetric care. Skilled attendant at birth could ensure timely referral to emergency obstetric care and this could reduce 16 to 33 percent of deaths those occurred due to obstructed labor, haemorrhage, sepsis and eclampsia. A trained health worker like a doctor, nurse or a midwife can recognize complications in time and perform necessary treatment of the
19 mother and neonatal with timely referral to the next level of care if needed (UNFPA, 2004). Use of contraceptive could save the life of women by preventing unwanted and high risk pregnancies. Contraceptive is also a tool to reduce maternal mortality (Winikoff and Sullivan, 1987). Thus, ensuring access to contraception can avoid women from entering the risk of the death from pregnancy. According to UNFPA (2004), ensuring access to family planning could reduce maternal deaths. According to Govt. of Indonesia (2008) the use of contraceptive among Indonesian women was 61 percent. A professional delivery care, such as assistance by a skilled health worker (doctor, nurse or midwife) at delivery is a key to reduce maternal mortality (Lerberghe and De Brouwere 2001). In Indonesia, non use of skilled attendant at the time of delivery was a key factor associated with the maternal deaths and only seventy three percent births were attended by skilled health professional (Govt. of Indonesia, 2008). In other words, more than a quarter of the births were remained unattended by skilled health professional. There is a wide variation in the use of skilled birth attendants at the time of delivery among different provinces with 97 percent in Jakarta, 44 percent in West Sulawesi and 33 percent in Maluku (Govt. of Indonesia, 2008).The role of traditional birth attendants (TBAs) in assisting deliveries can’t be denied. As per information from IDHS (2007), 69.6 percent of the deliveries in Gorontalo were assisted by TBAs followed by Maluku 67.5 percent, Southeast Sulawesi 67.3 percent and West Sulawesi 63.3 percent. In Indonesia, 35 percent deliveries were assisted by a TBA (Govt. of Indonesia, 2008). Since the occurrence of International Conference on Population and Development (ICPD) there was an increasing importance of maternal health care services for reducing maternal and infant mortality. According to the ICPD program of action, maternal health services should include education on safe motherhood; prenatal care; maternal nutrition programs; focus on delivery assistance that avoids excessive alternative to caesarian sections and obstetric emergency; referral services to cope with emergency situation during pregnancy, delivery and abortion; post-natal care and family planning (UNFPA, 2004). The studies showed that in developing countries with the uplift of maternal health care facilities there was visible improvements in the safe transition of mother through pregnancy and child birth, and the survival and health of the child during early pregnancy (Khan, 1987). The place of delivery equipped with necessary facilities was also linked with the reduced risk of maternal mortality (Thaddeus and Maine, 1994). The conditions 20 for facilities at birth delivery to be effective were: first, delivery must be attended by a trained professional with the ability to handle the problematic situation. Second, Referral facilities must be available who can provide emergency obstetric care to avoid further complications or even death (Thaddeus and Maine 1994). Quick and emergency transport system to take mother to the health facility ensured effective use of the service provided. (Griffiths and Stephenson 2001). 2.10: Awareness of antenatal and postnatal services Awareness about antenatal and postnatal services proved to be associated with its utilization in developing countries. In Pakistan in last decade the campaign on electronic and print media about family planning services gave great awareness about use of these services in the masses. Electronic media and print media are the important tools for dissemination of information about health care services and this awareness is associated with its utilization. Shreriff and Singh (2002) found that in India women who were exposed to radio, television and newspaper for maternal care services and the rate of utilization of these services was significantly high. Studies conducted by Obermeyer (1993) in Morocco and Tunisia found that listening radio and watching television were significantly associated with the utilization of pre and postnatal care services. It was noted that frequently listening radio was associated with 5 percent increase in the probability of utilization maternal health care services and watching television once in a week increased the use of antenatal care and hospital delivery. Awareness about postnatal services is one of the barriers associated with the utilization of these services (Dhakal et al., 2007). Ejaz and Ahmad (2013) reported that awareness about pregnancy related complications increased the utilization of postnatal care 2.49 times. A study carried out in India by Kumar et al. (2008) found that there was a big difference between awareness and utilization of maternal health care services. The study findings revealed that there was a big gap in knowledge and bringing knowledge into practice by pregnant and lactating women. The percentage of awareness and utilization differed significantly, as 69.6 percent women were aware about the use of trained birth attendants at the time of delivery but utilization was only 39.1 percent similarly awareness about postnatal care was 75.4 percent but utilization of postnatal care was 51 percent. Bhattacherjee et al. (2013) found lack of awareness as one of the barriers for utilization of maternal health care services. The study revealed that women who did not
21 utilize antenatal care 81.2 percent of them reported that they were not aware about the importance of antenatal care. 2.11: Influence of culture Cultural beliefs and traditions are one of the barriers in the utilization of antennal and postnatal care services. In developing countries and especially in rural area where most of the population lives, there are certain cultural and ethnic barriers which hinder the mothers to make use of maternal health care services. A study was carried out in northern districts of Bangladesh (Rangpur and Kurigram) and a sample of pregnant that already had at least one child and lactating women was selected and the result showed that they take pregnancy just a normal thing and most of them did not received any sort of antenatal care. They used maternal health care services only in case of complications. Choudhry and Ahmad (2011) found out that women did not perform any sort of preparations prior to delivery and in case of complications due to traditional beliefs and rituals they even delayed to avail the health care services. Cultural believes and traditional practices seem to be more powerful and influential than the cost. Study was carried out on ultra poor women taking part in grant based maternal health care system. This was carried out to find out the behavior of ultra poor women towards the utilization of maternal health care services. Study findings were that these women took pregnancy such like a normal routine matter and antenatal care was just the confirmation of pregnancy. Due to traditional beliefs and ritual even during illness the seeking of health care services was delayed which led to more complications (Choudhary and Ahmad, 2011). As compared with rural women, urban women were more likely to avail antenatal care services (Raghupathy, 1996). Studies were carried out by Fikree et al. (2004) on mothers in low income areas of Karachi, Pakistan on 525 mothers with 6-8 week postpartum period to find out traditional believes and practices affecting the utilization of maternal health care services. It was proved that results were quite good and more than 75 percent mothers got antenatal care service and more than half of the mothers delivered their babies at clinic or hospital but utilization of postnatal care was rather very little as out of total deliveries at maternity home or hospital only 16 percent got advice to get postnatal care out of which only 11 mothers got postnatal care. About 53.3 percent of the mothers reported illness symptom but the first preference of the mothers was to get help from relative women or from
22 traditional healers and if the illness continued then they went to doctor or trained midwives and this practice caused delay in seeking maternal health care services. A detailed study was carried out by Das et al. (2010) in Mumbai, India to find out the reasons influencing the choice of mothers for the selection of delivery place. Study covered the population of 280,000 in six selected wards of Mumbai, over a period of two years, depicting 16 percent home deliveries and one of the most common reasons of the home delivery was their custom. Traditional Birth Attendants played a prime role and they facilitated more than 70% of home deliveries. Living pattern and approaches quite significantly differ in rural and urban communities. Similarly cultural believes and preferences also differ in rural and urban population. In Thailand urban women were more likely to avail maternal health facility than the women living in rural areas (Raghupathy, 1996). Type of family also affects the social and health status of the mothers and children. More independence in nuclear family system leads to better status and autonomy of women which ultimately results in better health condition of mothers. Berger et al. (1983) found that nuclear family had positive impact on the social and cultural well being of the family. Khan et al. (2013) found in a study at Swat (Pakistan) that traditions and cost were the key factors associated with the delivery of child at home. It was reported that 79 percent of mothers delivered at home because it was a tradition. To deliver at home was less expensive reported by 49 percent of mothers and 77 percent mothers reported that having Dai at the time of delivery was a tradition. Bhattacherjee et al. 2013 also reported family traditions as a barrier in utilization of antenatal services. 2.12: Cost of maternal health services Cost of antenatal and postnatal services is one of the prime factors associated with the utilization of antenatal and postnatal services. These costs included consultation fee, medicine, food, transportation, loss of labor etc which occurred while availing health care services (Paruzzolo et al., 2010). In developing countries fee was the major barrier because of which millions of women could not avail health facilities even when they were having complications with them. There are certain cases where hospital fees were negligible or even without fee but still there were certain costs associated with it, like cost of medicine, food and lodging of the mother or the person with her to take care in hospital so all these hindered with the utilization of maternal health care services (Gertler and van der Gaag, 1988; Gertler et al., 1988).
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Borghi et al. (2006) concluded the study in Bangladesh found out the costs associated with pregnancy, delivery and up to postpartum period separately. Out of the total cost of maternal health care major cost was of delivery, antenatal cost was only about 7 percent and postnatal cost was about 30 percent of the total cost. There was no significant difference between cost of delivery at basic obstetric care (BEOC) and delivery at home and costs of facilities at comprehensive obstetric care (CEOC) was as high as nine times as that of BEOC. A study was carried out by Harris et al. (2010) in China to find the factors affecting the utilization of maternal health care utilization by mothers in remote areas. The study concluded that cost was the key factor affecting the utilization of antenatal and postnatal care. Khan et al. (2013) in a study also found that 49 percent of the mothers delivered at home only because it was expensive to deliver at any health facility. The cost included both direct and indirect cost i.e. fee for consultation, cost of using services or facility, cost of medicine and cost of transportation and in some cases cost due to loss of wages in case of working ladies. All these costs collectively hindered women to use maternal health care services (Paruzzolo et al., 2010). Bhattacherjee et al. (2013) investigated that if health facility was free of cost even then indirect costs like bed stay, accommodation, food, medicine, transport and communication acted as barriers for the utilization of maternal health care services. Daniels et al. (2013) also reported that in Ghana the cost of transportation hindered the mothers to receive maternal health services. 2.13: Utilization of antenatal services Utilization of antenatal care services is one of the tools to reduce maternal mortality rate as reported by United Nation findings (UN, 2008). According to reports in 2005 a number of pregnant women who got antenatal care with at least one antenatal visit to health care unit was 74 percent and trained attendants assisted 61 percent of the total deliveries (UN, 2008), out of the total deliveries 40 percent took place at health care facilities (UNFPA, 2004). In developing and underdeveloped countries the rate of utilization of prenatal care was very low and because of its low utility most of the deliveries took place at home with or without the assistance of trained professionals (Mrisho et al., 2007 and Bell et al., 2003). Due to under utilization of prenatal care services maternal and newborn mortality rates high and four million new born and .524 million mothers died each year (Lawn et al., 2005 and WHO 2005, Ronsmans and
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Graham 2006). In a survey it was found by Darmstadt et al., 2005 that 20-30 percent of total mortalities could be reduced by the use of trained professionals for delivery. In Vietnam (Swenson et al., 1993) pointed out that maternal mortality rate reduced with the use of antenatal services and it was because of improvement in the nutrition of mothers and with the pre-assessment of risk during pregnancies. In Zaire utilization of antenatal care reduced the maternal mortality rate up to 17 times (Royal College of Obstetricians and Gynecologists, 1979). Essex and Everett (1977) found that in Tanzania during antenatal visits that about 81 percent of high risk deliveries could be identified and special care could be given to improve mother health. Coria-Soto et al. (1996) reported that decreased utilization of antenatal services led to 63 percent high risk of intra uterine growth retardation of babies in the uterus. Use of health care services and the deaths related to obstetric complications accounts for as much as 58 percent which could be reduced by antenatal visits (Campbell and Graham, 2006; Filipi et al., 2006 and Weiner et al., 2003). In developing countries lot of factors were associated with the utilization of maternal health care services. Liu et al. (2011) reported that 95 percent women availed prenatal care and the 52.9 percent, mothers availed more than four prenatal visits. Out of total 86.3 percent of women delivered at hospital and average number of prenatal and postnatal visits was 4.94 and 2.19 respectively. Out of total women 98 percent had at least one antenatal visit. In Vietnam the study revealed that 71 percent women had at least one antenatal visit (Trinh et al., 2007). In Cambodia in 2002 and in Tanzania in 2007 women who had one antennal visit was 43 percent and 80 percent respectively (Fujita et al., 2005 and Mrisho et al., 2009). In Kenya 64 percent mothers had at least one antenatal visit (van Eijk et al., 2006). The findings showed association between utilization of maternal health care services and social, economic and demographic factors (Ahmed et al., 2010 and Long et al., 2010) Although antenatal care is an important tool to prevent maternal mortality yet it is not sufficient to cope with all emergencies and obstetric complications. Antenatal service provider is very important in social system because information provided by him serves as basis for safe management of pregnancy, delivery and health of neonatal. The core objective of this antenatal health care system is to monitor maternal health conditions (Llewellyn and Jones, 1990). Factors like social, cultural, demographic and political affected the utilization of antenatal health care (Babar et al. 2004 and Harris et al. 2010). Alam et al., 2004 conducted a comparative study in utilization of antenatal services and non utilization of services by women and the results showed a significant difference in the 25 health condition of women utilizing antenatal care services over the women who were not utilizing antenatal care services. Daniels et al. (2013) reported that in Ghana 77.7 percent of women went for antenatal services at least four times as recommended by WHO and out of these women 98.6 percent used public health institutions. Contrary to antenatal visit the proportion of delivery at health facility was only 39.9 percent. More than 60 percent of mothers delivered at home with the assistance of neighbor (43.8 percent), TBAs (40.4 percent) and themselves (14.6 percent). The women who remained careless about prenatal visit and utilized less or no antenatal, they and their infants remained at high risk to morbidity and mortality during postnatal stage. The study confirmed that level of antenatal health care services mothers availed indicated the level of postnatal services they availed for themselves and for their infants Burtz et al. (1993) and York et al. (2000). Kistiana (2009) studied the different factors associated with the utilization of maternal health care services which had a definite impact on the health condition of mother and fetus during pregnancy, at the time of delivery and post partum period. It was proved from the study that utilization of health services both antennal and postnatal reduced maternal mortality and help to overcome potential complications. In southern India Navaneetham and Dharmalingam (2002) examined the utilization pattern of maternal health care services (in the states of Andhra Pradesh, Karnataka, Kerala and Tamil Nadu). They used data from National Family Health Survey (NFHS) 1992-93 and result showed that planning and implementation of appropriate health care services played an important role in the utilization these services. It is an established fact that life of mother and neonatal depended on the utilization of antenatal care services (McCarthy and Maine, 1992). Health status of mothers and newborn could be improved by improving accessibility and affordability of health care services to women and their families (McCarthy and Maine, 1992, Rooney, 1992). Lot of studies have proved that less or no utilization of antenatal services led to risk of maternal mortality (Melrose, 1984, Kwast and Liff, 1993, Hartfield, 1980) Tetanus is very common in the areas where equines are common especially in rural areas of developing and under developed countries. According to WHO (2008) health estimates about 59,000 neonatal died because of neonatal tetanus in year 2008. Immunization is the best technique to prevent tetanus in neonatal for this purpose women of child bearing age are vaccinated during or after pregnancy. According to UNICEF (2000) in Pakistan Maternal Neonatal Tetanus Mortality rate was 4.08 deaths per 1,000 live births. Tetanus that attacks women during pregnancy or within 6 weeks after delivery 26 is called maternal tetanus. According to UNICEF (2013) maternal and neonatal tetanus (MNT) killed 58,000 newborns in 2010. After the attack of the disease without hospital care the death rate is as high as 100 percent and with hospital care utilization the mortality could be between 10-60 percent. Ayaz and Saleem (2010) reported that in Karachi 70 percent of the women received antenatal care services during pregnancy but only 54.5 percent of the mothers went for four or more antenatal visits. About 79 percent of the women received immunization against tetanus toxoid during pregnancy and 94.3 percent of the mothers used micronutrient supplements during pregnancy. Ninty four percent mothers were examined and more than a half (56.1 percent) of the mothers delivered at health facility like hospital or clinic in the presence of a doctor or a nurse and 43.9 percent of the women delivered at home. Only five percent of the respondent had caesarean section while 95 percent of the respondents had normal vaginal delivery. Business Recorder (2013) reported that 205 million pregnancies in the world occurred annually and out of which 44 million abortions happened . Rate of unsafe abortions was around 20 million per annum and 97 percent of unsafe abortions were performed in developing countries. In Pakistan due to complications during miscarriages and abortions around 10-12 percent of maternal deaths occurred. In developing countries majority of deliveries took place at home especially in rural areas. These deliveries carried out with the help of Dai/TBAs or relatives. Fauveau (1993) pointed out that in mothers vaginal infection took place because of the using unclean hands by TBAs for vaginal examination. In rural areas the application of herbs and dung are the practices which may cause genital infection. 2.14: Utilization of postnatal services Postnatal visits help mothers not only to cover up expected complications after delivery but also growth of newborn and there are associated with contraceptive use after delivery to avoid repeated pregnancies in short time which lead to low birth weight and intra uterine growth retardation (Kogan and Leary, 1990). Postnatal care like antenatal care is equally important to reduce maternal mortality and to overcome postpartum complications. Postnatal care is least utilized by mothers in developing countries. Studies showed that only 21% of new mothers utilized postnatal care services in Nepal. Dhaka et al. (2007) found that utilization of postnatal care was not so frequent in Nepal. The quality of postnatal care was not standardized where it was available, but postnatal care is
27 essential to treat disabilities and impairments after delivery and is improve health condition of mothers and newborn. In Nepal women had limited access to postnatal health care services and were more likely to get advice from traditional healers than men (Ishikawa et al. 2001). Inandi et al. (2005) used Edinburgh Postnatal Depression Scale (EPDS) to identify risk factor of depression in mothers in postnatal period and concluded that in Turkish mothers the level of depression was high. The attitude of mothers towards pregnancy was also an important factor that affected the utilization of postnatal care. Hulsey et al. (2000) reported that women who liked to be pregnant utilized postnatal services and those who didn’t like to be pregnant did not go for postnatal visit. So feelings towards pregnancy played an important role in the utilization of health care services. In Zimbabwe a study was conducted by Hove et al. (1999) on the mothers having infants with the age ranging from six weeks to 23 weeks to highlight the factors affecting the non use of postnatal health care services. The major factors of non utilization were the religion and traditional birth attendance and the result showed 10.1 percent women were not utilizing the health care services. The recommendations were more frequent for training of the birth attendants to get them familiar with the importance of postnatal care so that they could ask their clients to use postnatal services. Sibanda et al (2001) reported that in Zimbabwe postnatal care utilization by women was 61 percent which was quite astonishing because usually it was reported to be low. Ayaz and Saleem (2010) in their studies on square settlements of Karachi, Pakistan observed that after two hours of delivery 80.3 percent of the mothers started breast feeding and total breast feeding was 94 percent of the mothers. In postnatal period immunization of 81.1 percent of children was carried out for BCG and polio. It was also reported that rate of immunization of children who delivered at health facility was 86 percent compared with the 75 percent for home delivered. According to Pakistan Demographic and Heath Survey 2006-07 there was a decline in infant mortality rate in Pakistan from 1990-91 to 2006-07 from 91 to 78 infant deaths per 1000 live births but there was low decrease in neonatal mortality rate which is from 56 to 54. Immunization of children is global topic and is mostly run by Government agencies with the help of international donors like WHO, UNICEF etc. In Pakistan Expanded Program on Immunization (EPI) stared in year 1978 with aim was control six childhood diseases i.e. tuberculosis, diphtheria, pertussis, tetanus, polio and measles (WHO, 2013). Thapa (1988) found that breast feeding was most economical and best 28 nutritional source for infants. Breast milk especially colostrums contained antibodies which were very essential for the protection of infants from gastrointestinal diseases. It was also reported that breast milk feeding was very difficult for working women.
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Chapter-III RESEARCH METHODOLOGY 3.1. Introduction The methodological techniques used for the collection, analysis and interpretation of data are guidelines for a researcher to carry out all the steps of research design. It is a "blue print" that enables the researcher to come up with the solutions of the problems encountered during the research (Nachmias and Nachmias, 1992). There are many approaches, and different study designs are used to inquire different questions. Quantitative research seeks to identify determinants or relationships in a sample that can be assumed and assessed to be true of the population from which the sample is drawn. This study empirically investigated the socio- economic and cultural factors affecting utilization of antenatal and postnatal services. For this purpose quantitative approach was employed to examine the effects. The sequence of methodology to conduct research for quantitative data collection and for estimation is described in terms of research design, the universe of study, selection of respondents, sampling procedure, sample size, development of interview schedule and data analysis techniques. 3.2. Research design It is a process of collecting, analyzing, and interpreting the data. It enables a researcher to draw logical inferences, concerning casual relationship among the variables under investigation. Research design also determines the domain of generalization (Nachmias and Nachmias, 1992). In present study correlation design was used. It is most commonly used design in social sciences especially when the data are based on survey research. In this design collected data are used for developing casual relationship among the variables (Nachmias and Nachmias, 1992). These data/information were collected through key informant interviews technique. It is a useful technique which provides more useful and in-depth knowledge in less time and in limited cost. 3.3 The Research Area (Overview of Punjab) Punjab is the biggest province of Pakistan having population 9.67 million (Government of Punjab, 2012) which is half of the population of the country. It is the largest agricultural and industrial zone of the country and is main hub of Pakistan’s economy. The word Punjab itself means land of five rivers and it has the best man made irrigation system of the world. Along with agricultural and industrial richness, it is also rich in cultural heritage and it is historically rooted back to 1500 BC by the remains of Indus Valley Civilization. Administratively it is divided into 36 districts which are further
30 subdivided into tehsils and then to union councils (Government of Punjab, 2012). The common language is Punjabi with some different vernacular in different regions. The vocabulary of the vernacular in all regions of the province is common. Following are the districts of the Punjab
1. Rawalpindi 14. Sheikhupura 26. Vehari 2. Chakwal 15. Faisalabad 27. Khanewal 3. Jehlum 16. Jhang 28. Lodhran 4. Attock 17. Sargodha 29. Muzzafarghar 5. Khoshab 18. Mandi-Baha- 30. Bhawalpur 6. Gujrat uddin 31. Rahim Yar Khan 7. Sialkot 19. Sahiwal 32. Rajanpur 8. Narowal 20. Pakpatan 33. D.G Khan 9. Gujranwala 21. Okara 34. Layyah 10. Hafizabad 22. Chiniot 35. Bhakkar 11. Lahore 23. Nankana sahib 36. Bahawalnagar 12. Kasur 24. Mianwali 13. TT Singh 25. Multan
The Province of Punjab has fertile agriculture fields, canal irrigation system and hard working people. 3.2.1 Economy, culture and health facilities The land of the Punjab is the land of five rivers and known as the granary of east and is the lifeline of the country and its share is 50 to 60% in Pakistan’s economy. Literacy rate of the province is 60% (Government of Punjab, 2013) and also famous all over the world for its strong cultural norms. Major cities of the province are Lahore, Faisalabad, Rawalpindi, Multan and Gujranwala. Punjab and its economy is mainly based on agricultural, although industry makes a substantial contribution as well, it contributes 68 percent of the food grains production in the country. Although Punjab had been the cradle of civilization since centuries yet one third population of Punjab is below the poverty line. There is only one doctor for 1590 persons and most of the villages lack basic health facilities. Culturally most of the women in rural areas are housewives and spend most of their time at home or in agricultural activities. In Punjab at rural level cultural practice, economic conditions, education and health facilities are almost similar. In every district there is government hospital called district head quarter or DHQ and Govt. hospital at tehsil level is called tehsil head quarter hospital (THQ). As far as maternal health is concerned, role of traditional birth attendants (TBAs) can’t be over looked. They are playing significant role especially in rural areas of Punjab. Still most of the women in rural areas like either to call or to go to TBAs at their home because still male don’t like
31 their ladies to go to doctor or LHW. Due to rigidity and non- awareness among the rural women for utilization of health facilities, the women do not get vaccine of Tetanus during pregnancy. Special program of Population Welfare and program of Lady Health Workers played a significant role in creating awareness for utilization of maternal health facilities among the rural women. It is because of the awareness that the death rate of mother and their infants has reduced to the great extent. Role of mass media especially electronic media can’t be denied for awareness campaign for population welfare and lady health visitors. But still there is lack of awareness and utilization of postnatal services among the rural women. The doctors should ask their patients to come after delivery for postnatal services and there is need for creating more awareness for importance and utilization of postnatal services not only among the masses but also among the TBAs, LHWs and doctors. 3.4: Study Area This study was carried out in three districts of Punjab. Three selected districts are as under: i- Rawalpindi ii- Faisalabad iii- Multan
Rawalpindi district: District Rawalpindi is situated in the north of Punjab on the Potohar Platue and lies between 330-040, 340-010 North latitude and 720-380 and 730-370 East longitude and is nearly 300 km away from Faisalabad and is neighboring city of the Capital of Pakistan (Islamabad). Rawalpindi is also military headquarter and its population is 3.3 million and half of its population (55.78%) lives in urban area. Literacy rate of the population is 79 percent (Government of Punjab, 2013). It is surrounded by Jehlum and Chakwal districts on the southern side, Kashmir on the eastern side, Attock on the western side and Province of Khyber Pakhtunkhaw on the northern side. Most of the area of Rawalpindi district is of arid agriculture with dependency on rain water but in some areas tube well irrigation is common. Rawalpindi, also known as Pindi and it has a long history spread over several millennia. Archaeologists believe that a distinct culture flourished on this plateau as far back as 3000 years. The district comprises of six tehsils namely Rawalapindi, Murree, Kotli Sattian, Kahuta, Gujar Khan, and Taxila. It has total 175 union councils among them 119 are rural
32 and remaining 56 are urban. Two tehsils Kotli Sattian and Gujjar Khan of district Rawalpindi as these were selected which are predominately rural. From Gujjar Khan tehsil two union councils namely Budhana having population of 14,502 and Kuri Dolal having population of 15,613 were selected. From UC Budhana village Bhagpur and Village Bodhana were selected and from UC Kuri Dolal village Saheeb and village Noor Dolal were selected. Two union councils namely Santh Saroola having population 8988 and Malot Sathian having population 6462 were selected from Tehsil Kotli Sathian. Villages Kuthian and Village Santhian Wali were selected from UC Santh Saroola and Village Barian Pathoara and Village Jangle Gila were selected from UC Malot Sathian. The population of Kotli Sathian and Gojar Khan were 81,000 and 494,000 respectively.
Faisalabad District: Faisalabad district has 5.4 million of population and 42 percent of its population is urban areas according to the census of 1998. The district is composed of 6 tehsils i.e. Faisalabad City, Faisalabad Saddar, Chak Jhumra, Sammundri, Jaranwala and Tandlianwala. The district consists of 289 total union councils, among these 166 union councils are rural and 123 are urban. Two tehsils i.e. Faislaabad Saddar and Samundri were selected being predominately comprising of rural union councils. The population of Faisalabad Sadar and Samundari was 0.9 million and 0.5 million respectively. Two union councils namely UC169 and UC 145 were selected from Tehsil Faisalabad Sadar and two union councils, UC 475 GB having population 16,291 and UC 142GB having population 14,499 were selected from Tehsil Samundri. Two villages Chak 2 JB Ramadwali and Chak 47 JB were selected from UC 169 and village Islam pura and village Bukhari Town were selected from UC 145. Similarly from Tehsil Samundri two villages Chak 475 Gidar Pindi and Chak 476 were selected from UC 475GB and two villaged namely 140 GB and 142 GB were selected from UC 142GB. Faisalabad, previously called Lyallpur was founded in 1880 by the governor of Punjab Sir Charles James Lyall. Faisalabad is second largest populous city of Punjab and third largest populous city of Pakistan. It is one of the rapidly grown cities of Pakistan and its rural area is famous for cotton, wheat, sugarcane, fruits and vegetables. Its urban area is also famous for its industry based on cotton, sugar ghee/oil and flour mills. It is commonly regarded as an industrial city. Out of total population of the district 42.7% live in urban area and 57.3% live in rural area (Government of Punjab, 2012). Literacy rate is 66 percent (Government of Punjab, 2013)
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Faisalabad District has a total area of 5,856 square kilometres and out of it 5,150 square kilometres is devoted to agriculture, of which no less than 96% is irrigated. The canal irrigation of the District is manly based on Lower Chenab Canal since 1892. The main agricultural crops are wheat (50% of total) and sugar cane (23% of total) and this district has significant numbers of livestock (CDGF, 2006). The four tehsil headquarters towns, Chak Jhumra, Jaranwala, Sammundri and Tandlianwala have traditionally been acting as market centers for the surrounding agricultural areas. It has 820 villages, four of which can now be considered as small towns. Multan District: Multan district lies between North latitude 29'-22' and 30'-45 and East longitude 71'-4' and 72'-4'55. It is situated in a bend created by five confluent rivers and the river Sutlej separates it from Bahawalpur District and the river Chenab and Jehlum jointly separate it from Muzaffar Garh district. District Multan is spread over an area of 3,721 square Kilometers. It comprises of tehsils Multan Cantonment, Multan Sadder, Shujjabad and Jalalpur Pirwala. It has 126 union councils among them 68 union councils are rural and 61 are urban. Multan Saddar and Shujjaabad tehsils are selected being predominantly consisted of rural union councils. The population of Multan Sadar and Shujah Abad tehsils was 0.8 million and 0.43 million respectively. In Tehsil Multan Sadar union council Qasba Maral having population 22001 and union council Bangal wala having population 23216 were selected. Village bangal wala and village Rab 147 were selected from UC Bangal wala and village Qasba Maral and village Mehnay wala were selected from UC Qasba Maral. From Shujahabad District Union Council Koltin Najabat having population 19,989 and Raja Ram having population 26037 were selected. Two village (Kotli Najabat and Man Wala Khu) were selected from UC kotli Najabad and Raja Ram and Rab 147 were selected from UC Raja Ram. District Multan is surrounded by the districts Khanewal on the North and North East, Vehari on the East and Lodhran on the South. The river Chenab and Hehlum jointly pass on its Western side and across which lies district Muzaffargarh. District Multan is spread over an area of 3,721 square Kilometres with population of 3 Million. District Multan has an extreme climate in summer (49 degree Celsius) and winter (1 degree Celsius). The land of the district is plain and very fertile and rainfall is 127 mm. However, the portions of tehsils Multan and Shujabad close to the river Chenab and Jehlum (joint) result in flood during monsoons season. The soil of Multan district is considered best for cotton but other crops like wheat, sugarcane are also grown in this
34 district. Multan is also famous for Mangoes which are very much popular round the globe. 3.5: Characteristics of the Respondents The population taken under of this study consisted of mothers aged from 15-49 years having their last baby more than 6 months and less than five years old. The aim was to select only those respondents who passed through the process of delivery and had experience of antenatal and postnatal services. Only one woman was selected from a household to capture maximum variation in social structure of the area. 3.6: The Sample Size Present study was conducted to examine the effect of socio-economic, cultural, demographic and health characteristics of the respondents on the utilization of antenatal and postnatal services. Quantitative method/approach was used to collect data. Multistage sampling technique was used for selection of districts, tehsils, union councils and villages. Out of the above mentioned, three districts were selected and 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 criteria already defined. Size of sample was fixed using equal allocation method.
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Mechanism of Study
Fig 3.2 Pathway for data collection
3.7: Interviews process Two basic principles were kept in mind while developing the interview schedule. The interview schedule was developed to obtain the information from the respondents. The interview schedule was developed keeping in view research objectives and hypothesis. The elements of language, prestige biasness, and double barreled questions, threatening question, false premises and double negatives are also taken into account in the development of interview schedule. The questions were basically designed to get demographic information from the respondents and then it was also divided into four sections based on four stages of the objective of the research study. The first stage was to study attitude and trends regarding utilization of antenatal and postnatal services in Punjab, Pakistan. In second stage mothers’ awareness and adoption of modern techniques about antenatal and postnatal services was identified. During third stage the constraints in utilization of antenatal and postnatal were identified. In forth stage the measures for
36 policy makers for creating conducive environment at the health outlets for the maximum utilization of antenatal and postnatal health care services were suggested. This instrument was designed keeping in view the specific objectives of the study, the lessons learnt through review of literature and on the basis of the outcomes of review of literature and discussion with research supervisor and personal experience of the investigators. Some questions were also collected from previous studies. 3.8: Reliability and validity of interview schedule Validity: Validity is a measure for a test, it determines the extent to which a test measures for which it was supposed to measure. Because all the study results depend on the validity of the interview schedule two tools of validity i.e. face validity and content validity were used to test the interview schedule (Cronbach and Paul, 1955; Rehman and Younis 2002). Experts of the Faculty of Social Sciences tested the instrument for its face validity and suggested some additions and deletions which were incorporated in final version of the instrument. To check the extent of a test after completion of the interviews process, the researchers measured the validity of the interview schedule, using tools of face and content validity (Rehman and Younis, 2002). A panel of eight social scientists from the discipline of rural sociology tested the instrument for its face validity. After going through the process of face validity some changes were suggested by the experts, which were incorporated in the interview schedule. After completion of the process of face validity the instrument had to pass through the process of content validity. As the name indicated it is the validation of the contents of the instrument. So it contained adequate contents for which it was designed to measure (Rusin, 1983). The same team of experts who tested the instrument for face validity also tested the content validity of the instrument to achieve the study objectives. So on each question in the instrument the experts gave their own view point and only those questions were retained in the instrument on which 80-90% of the experts agreed. Reliability: Reliability refers to the consistency in the repeatability of the instrument. A test is called a reliable test when it gives same result all the times for a specific task under same set of conditions. Reliability represents the rank of the internal steadiness of any instrument. To check the reliability of the instrument it does not need much more administration but only single administration is needed to test it (Borg and Gall, 1989).
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To check the reliability of the instrument it was tested on 30 respondents for the selected areas with 10 respondents from each selected district. In order to find out the reliability of the instrument Cronbach’s Coefficient Alpha was applied which gave result with reliability coefficient of 0.8795 for the instrument. 3.9: Meeting with the data collection team before field work A team of eight field workers who were master in rural sociology was organized and they had sufficient experience of data collection from the field. They also had passed through the process of thesis writing and had enough understanding about research methods being applied in social sciences studies. Correct data collection need experienced researchers having clear understanding about the research being conducted, so special care was given to the team formation. To have uniformity on each question, regular daily meetings of the team members twenty days before the start of data collection were held. All the team members conducted one hour daily meeting about the interview schedule to have in depth understanding of each question of the interview schedule and everybody would have same understanding and same line of action about every question. These meetings played a very positive role during data collection and nobody faced any difficulty. 3.10: Pre-testing Interview schedule was developed after through discussions and meetings with the concerned supervisor and committee members. To check the quality of the interview schedule, to overcome the difficulty faced by data collection team and make and every question understandable to the respondents, a pretesting of the interview schedule was conducted. This pretesting was conducted in all the three selected districts of the Punjab. Ten respondents were interviewed in each district namely Rawalpindi, Faisalabad and Multan and ten interview schedules were filled. After pre-testing of the interview schedule it was reviewed by the team. The questions which seemed difficult to get them understandable for the interviewee were modified to improve the quality of the interview schedule so that all the questions could convey the required meanings to the respondents in a simple and clear manner. 3.11: Meeting with the key informants before data collection As the researcher belonged to Faisalabad so she went herself to the targeted area for data collection along with the data collection team. In every village a meeting was arranged with the Nambardar of the village, who introduced the team with the local
38 community and build confidence with them so that our respondents get relaxed while providing information as nothing is bad with it and this information will not be used for misreporting. Data were collected from Rawalpindi area as researcher was not familiar with the area so help was taken from National Rural Support Program (NRSP) offices of Kotli Sathian and Gojar Khan. In Gojar Khan a meeting was made with Mr. Saeed Gill, Senior Organizer NRSP who cooperated a lot for data collection. He arranged a male and a female official of NRSP along with vehicle and driver with the team who took the team to the targeted area. They involved the ladies of the local communities so that the team can get required data easily. In Kotli Sathian area a meeting was made with Mr. Hameed Ahmad Niazi, Senior Organizer, NRSP who provided list of union councils and list of villages in the area. He also arranged a male and a female staff with the team along with vehicle and driver. They took us to their communities and team members collected data with their help. As people had trust in NRSP in that area so the researcher got good response. In Multan data were collected from Multan Sardar and Shujahabad area. The researcher took the services of Ex. Member Provincial Assembly Mr. Nawab Nadeem ud Din, Nazim Mr. Tahir Ghani and an NGO namely MAVRA society being run by a lady. In that area these people gave good response and in some areas they made announcements in loud speakers of the village mosques so that people got confidence in the team and provided information without any fear or hesitation. 3.12: Conducting survey The survey was conducted in three months. All information about the respondents and houses was collected from the office of concerned union councils, NRSP regional office and from internet. The key investigator visited the target areas one day before the data collection. The reason for early visit was to get in touch with the local people especially with Nambardar/Nazim of Union Council to gain their confidence and to select the households for data collection. In this day the researcher also selected the household. 3.13: Editing of data Every member of the team had her own file duly maintained by herself. On every evening all the members went through all the interview schedules filled on that day and filled of the missing elements which they observed during the survey. Because human mind can reproduce the most recent things and forgets the older ones so it was top priority
39 to complete the work daily. If missed something it was very difficult to find the respondents and to collect the missing elements, also it cost extra time and resources so editing was carried out on daily basis. 3.14: Method of data collection Social scientists deal with human behavior and they have very sensitive nature. It is very important that during interview schedule data quality and human nature should be taken in to account with all aspects. Data from each respondent included in the sample was gathered through an interview process by using a structured interview schedule. Information was collected on all the required indicators, which fulfilled the research objectives and gave clear answer to the research questions and helped in approving or disapproving the hypothesis 3.15: Field time Sociology is a branch of science which deals with human behavior and attitude of the people. Behavior cannot be measured in quantity and is continued to change every time. It is very important for the interviewers to keep information of the activities during interview process. At the time of interview, interviewers check and record the behavior of the respondents in the covert or overt manner. When the respondents reported the events and comments by the other family members about their standard of living, it was very important to get the confident of the respondent in order to make them relaxed and frank so that all the questions might be asked in a very respectable manner during the interview. The difficulties faced during data collection are as under: The male hesitated to give permission to their wives/ladies for interview The respondents firstly hesitated in providing information but later when satisfied with purpose of study, they gave satisfactory responses. Most of the time, the researchers had to reside in the respective area. Most of the respondents thought that socio-economic data may be used against them for enforcement of any type of tax by the government; this took more time for clarification. The interviewers removed this misconception by describing the whole purpose of this data collection. The researchers built up the confidence of respondents by telling them that this information would be used only for research purpose. In spite of these difficulties, the data collection activity was very meaningful. The interaction with the respondents and their level of co-operation during the course of the interview was a charming, pleasant and learning experience.
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3.16: Limitations The following were the study limitations: 1. The study was limited to the rural women of the three districts i.e. Rawalpindi, Faisalabad and Multan because of limited resources and time constraints. 2. Being females it was very difficult to give time to family, job and to visit remote rural area for data collection at the same time. 2. Only 600 rural mother in the age range (18-49 years) having at least one baby more than six months and less than five years old were selected. 3. Because of the communication difficulties of the study subject, the interview proceeding were translated in to Urdu language and interview was conducted in Urdu, Punjabi (local) Saraiki (local) and Pothohari (local) languages. 4. Most of the women being illiterate were reluctant to talk to outsiders as it is against their customs that is why the open ended qualitative data could not be generated. 3.17: Coding After completing the whole processing of survey, the data was fed into the computer based SPSS software (SPSS 16) for analysis. During shifting the data on SPSS the data was coded with different numbers like 1, 2, 3, 4 etc. because there were certain question which had answers in yes or no so these might be coded as 1 and 2 and also there were some questions and statements having more than two answers so that those were coded to make it convenient. 3.18: Statistical Techniques of Analysis The collected data was analyzed using univariate, bivariate and multivariate statistical techniques. In univariate analysis frequency, percentage, mean and standard deviation were used for description of data. In bivariate analysis Chi-square and gamma tests were used to describe the relationship among different variables. Multivariate analysis was carried out to describe the relative importance of independent variables to explain the dependent variable. 3.18.1: Use of SPSS One of the most popular statistical software used to analyze data of social sciences is called SPSS that stands for Statistical Package for Social Sciences. Nie, Hull and Bent (1968) developed this SPSS software to analyze the large quantities of social sciences data in a quickest way. Stanford University was the pioneer where this SPSS software was used for the first time to analyze the data.
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SPSS is the one of the most widely used software packages in the world of social sciences. While using individual as well as discrete units of analysis the usage of SPSS is very vital for the researchers (Wellman, 1988). The usage of SPSS technology has facilitated the researchers to make the things easier and easier for analysis. 3.18.2: Univariate Analysis In univariate analysis data is analyzed using single variable at a time, so single variable is explored individually and independently. It not only explores the range of values but also central tendency measures of the values. Being a social scientist it is of great value because it depicts patterns and trends of the responses to the variable. First of all values of different variables were identified for lowest and highest values and frequency distribution was done by putting them in descending order. Number of appearances of each value of the variable was counted to determine the frequency distribution of each value in a set of data. The descriptive data in frequency distribution can also be presented in a graphical as well as in text form. Frequency distribution can be presented in the form of percentage distribution or cumulative percentages. 3.18.3: Bivariate Analysis Bivariate analysis is used to determine the association between two variables. Bivariate analysis simultaneously analyses two variables (attributes). It determines the concept of relationship between two variables, whether there is any association and strength of that association and are there any differences between two variables and the significance of these differences. Bivariate analysis tests the hypothesis of association and causality. Bivariate analysis was used to find out association of socio-economic, cultural and demographic variables with the utilization of antenatal and postnatal services. Association is the extent to which it becomes easier to foresee a value for the dependent variable if the case’s value on the independent variable is known. Chi-square and gamma statistics were used to determine the association and testing hypotheses of association and causality as well. 3.18.4: Chi-Square Test Chi-square is a nonparametric statistical test commonly used to compare the observed data with the expected data. The expected data is one which is expected to be obtained according to a specific hypothesis. It also determines its degree of independence (Fisher, 1928). This test is denoted by symbol χ2 and it can only be applied on discrete data. There are many ways to apply Chi-square test but the most frequent and easiest to understand method is in tabulated form. The formula for calculating Chi-square (χ2) is: 42
χ2= (fo-fe)2/fe fo = observed frequency fe = expected frequency Assumptions of chi-square The data is a random sample of population data is based on nominal/ ordinal The expected frequency is not less than 5 in any cell 3.18.5: Gamma Statistics Gamma test measures the strength of association of the cross tabulated data when two variables are measured at an ordinal level (Sheskin, 2007). The values range from -1 means 100 percent negative association or perfect inversion to +1 means 100 percent positive association or perfect agreement, and a value of zero showed the absence of association between the variables. This test is also recognized as Goodman and Kruskal's gamma test and it is close to Somers'D and to Kendall's tau. Gamma tests of statistics showed an index of association between two variables when those are measured on an ordinal level. The value of a gamma test statistic, (γ) depends on two quantities as shown below:
Ns - Nd Gamma= ------Ns + Nd
Ns, the number of pairs of cases ranked in the same order on both variables (number of concordant pairs), Nd, the number of pairs of cases ranked differently on the variables (number of discordant pairs).
Gamma indicates the results in following way:
i) Gamma = Ns − 0 =1.0 Ns + 0 When value of Gamma is positive 1.0, it means that you can predict the value of dependent variable based on independent variable without any error. It shows positive relationship between two variables. A negative value of Gamma shows negative association between two variables as shown below:
ii) Gamma = 0 − Nd = -1.0 0 + Nd
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When the values of Ns = Nd, then the resulting gamma will be zero:
iii) Gamma = Ns − Nd = 0 = 0.0 Ns + Nd Ns + Nd This illustrates that there is no association between the two variables. So we will not be able to predict the value of dependent variable using independent variable. 3.18.6 : Multivariate Analysis- Multiple Linear Regression Multivariate analysis technique is normally used to determine the relative significance of independent variables to the dependent variable. The multivariate analysis can analyze three or more variables simultaneously and most of the times it is used to refine bivariate analysis and to ensure causality. Before applying multivariate technique it is necessary to determine the suitability of data to apply multivariate analysis because the data had to fulfill all the assumptions of multivariate analysis. In order to determine the relationship among one dependent and more than one independent variable the technique of linear regression analysis is used. In statistical analysis techniques with the involvement of more than two variables normally multiple linear regression model is used to see the significance of the independent variable to the dependent variable (Woehr and Carvell, 1993 and Maki et al., 1978). Regression is not a single technique but it is a set of techniques used for the analysis of quantitative data consist of dependent or response variables and one or more independent or explanatory variables (Richard, 2004) a. Multiple Linear Regression Model The multiple linear regression analysis term was for the first time used by Pearson, 1908. This model is indicated as follows:
Y = + b1X1 + b2X2 + b3X3... + bnXn + e Where: = it indicates the value of y when all the x values are zero. b = these regression coefficients estimate the amount of change in the dependent for a unit change in the dependent variables. X = independent variables, Y = Dependent variable, e = it denotes as an error that indicates the proportion of unexplained variance in the dependent variables.
44 b. Purpose of Regression Analysis The value of beta can be calculated by regression analysis. In regression analysis standardized regression coefficient are calculated by the multiplication of regression coefficient with the standard deviation of relative independent variables which are then used for the comparison of independent variables.
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Chapter-IV RESULTS AND DISCUSSION
Introduction The general objective of this study was to analyze the factors affecting the utilization of antenatal and postnatal services by women of Punjab, Pakistan. The study was conducted in three districts namely Rawalpindi, Faisalabad and Multan of Punjab. The data was analyzed and is presented as under.
4.1 Uni-Variate Analysis
4.1.1: Socio-Economic and Demographic Information
Table 4.1: Distribution of the respondents according to their residence distance from health facility
Distance Frequency Percentage Up to 5 km 321 53.5 More than 5 km 279 46.5 Total 600 100.0
Residential distance from health care facility has profound effect on the utilization of maternal health care services. Gautam (1998) reported that in Thailand mothers who utilized antenatal and postnatal care; most of them (64.9 percent) resided in a radius of 1- 5 km from hospital/health center. Abosse et al. (2010) found that women living close to health care facility with less than one hour walking time were four times more likely to receive antenatal care services than women living at a distance with more than two hours walking time. The information presented in Table 4.1 reveals that more than a half (53.5%) of the respondents lived closed the hospital facility with the distance less than 5 km and 46.5 percent of the respondents lived at the distance more than 5-km from the hospital facility.
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Table 4.2: Distribution of the respondents according to their socioeconomic characteristics N = 600 Age of the respondents Frequency Percentage (in years) 16-25 158 26.3 26-35 361 60.2 36-45 81 13.5 Mean age = 29.63 Std. Dev. = 5.78 Age at marriage (in years) Frequency Percentage 12-18 209 34.8 19-24 285 47.5 25-30 106 17.7 Mean age at marriage = 20.29 Std. Dev. = 4.04 Duration of marriage Frequency Percentage (in years) Up to 5 165 27.5 6-10 217 36.2 11-15 148 24.7 16 and above 70 11.7 Mean duration of marriage = 9.34 Std. Dev. = 5.32 Age difference between Frequency Percentage husband and wife (in years) Up to 5 373 62.2 6-10 171 28.5 11 and above 56 9.3 Mean age difference= 5.97 Std. Dev. = 5.54 Monthly income from all Frequency Percentage sources (in Rs.) Upto 5000 223 37.2 5001-10000 243 40.5 10001 and above 134 22.3 Mean income = 8841.67 Std. Dev. = 6805.79 Husband’s occupation Frequency Percentage Government service 110 18.3 Pvt. Job 88 14.7 Farmer 47 7.8 Labour 122 20.3 Business 115 19.2 Driver 84 14.0 Any other 34 5.7
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Age of the respondents Age of the respondent is an important determinant while considering the utilization of maternal health services. Nisar and White (2008) reported that the mean age of the respondents in their study was 29 years. Ejaz and Ahmad (2013) also reported in their study that majority of their respondents (73 percent) were below age of 24 years. The data given in Table 4.2 show that 60.2 percent of the respondents fell in the age group of 26-35 years, while little more than one forth (26.3%) of the respondents were in age of 16-25 years and small proportion (13.5%) of the respondents belong to the age group of 36-45 years. As the target group was pregnant women and mothers of young kids so most of the respondents belonged to age category of 26-35 years old which was the ideal age for women to be mother. More than quarter of the respondents was also up to 25 years. Women of these two groups were more likely to be available at homes and elderly women have to move outside their homes to perform different domestic activities. The mean age of the respondents was 29.63 years with standard deviation 5.78 years reflecting the concentration of the respondents in the middle of the reproductive age. Age at marriage Age at the time of marriage is an important factor because of its association with the maternal health and fertility. Zafar et al. (2003) reported that in Pakistan majority (72 %) of the women married at the age of 20 years. Ejaz and Ahmad (2013) reported that in their study 51 percent of the majority of the women married up to the age of 21 years. Table 4.2 also shows that less than a half i.e. 47.5 percent of the respondents were in the age group of 19-24 years at the time of marriage and about one-third (34.8 percent) of the respondents were at the age of 12-18 years at the time of marriage and remaining 17.7 percent of the respondents were in the age range of 25-30 years at the time of marriage. It showed that teen age marriages are very common in our rural areas of Punjab. In this study mean age at the time of marriage was 20.29 years with standard deviation 4.04 years. Having traditional values in Pakistani society; early marriages with closely spaced many pregnancies are the cause of poor health status of the women. Ansar Burney Trust (2007) quoted the Act "Child Marriages Restraint Act" according to this act marriages of girls below sixteen years of age are illegal. Bari and Mariam (2000) studied that although average age of women for marriage is improving from 16.9 years to 22.5 years but still due to early marriages together with illiteracy and closely spaced pregnancies health conditions of women are adversely affected. WHO (2000) revealed
48 the fact that poor health condition of the female adolescents in the region are because of the early marriage, sexual violence, anemia and poor educational opportunities. Duration of marriage Sunmola et al. (2003) in their study in Nigeria reported that 92 percent of their respondents were having marriage duration between 1 to 6 years. In our sampling criteria it was the condition that respondents must have at least one child less than five year and more than six months old. The data presented in Table 4.2 reveals that more than one third (36.2%) of the respondents belonged to the category whose duration of marriage was 6-10 years, more than one forth (27.5%) of the respondents were in the category of up to 5 years of duration of marriage and less than quarter of the respondents (24.7%) belonged to the group of 11-15 years of marriage and 11.7 percent of the respondents were in the category of duration of marriage 16 years and above. The study shows that majority of the respondents belonged to first two categories and they had up to ten years duration of marriage. The mean duration of marriage was 9.34 years with standard deviation 5.32 years. Age difference between husband and wife Age difference of the husband and the wife had impact on the stability of the family relations. In our country care is give to the age difference while making matches. Table 4.2 also reveals that a majority (62.2 percent) of respondents belonged to the category with age difference between husband and wife was up to 5 years. Data also showed that 28.5 percent of the respondents were in the group with age difference between husband and wife was 6-10 years and remaining 9.3 percent of the respondents were in the category with age difference more than 11 years. The mean age difference between husbands and wives was 5.97 years with standard deviation 5.54 years. Scholl (1994) studied that in teen age mothers especially below age of eighteen there is greater tendency of stillbirth, blood loss, premature labor and low birth weights. Monthly income Ejaz and Ahmad (2013) in their study in Pakistan reported that monthly income of the 37.6 percent of the respondents were less than 5000 rupees and 46.3 percent of the respondents had monthly income between 5001 to 10000 rupees and only 16 percent of the respondents had monthly income more than 10000. Arshad (2006) reported results similar to our current study that 67.3 percent of the families had monthly income less than
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10,000 rupees and more than half of the families had monthly income less than 5000 rupees. Table 4.2 further depicts that 40.5 percent of the respondents had monthly income from 5001-10,000 rupees and more than one-third (37.2 percent) of the respondents belonged to income group up to rupees 5,000. It is also revealed that only 22.3 percent of the respondents belonged to monthly income group more than rupees 10,000. Mehboob- ul-Haq (1997) reported that "Poverty of basic human capabilities is more terrifying than income poverty because it restricts them to utilize market opportunities. The mean monthly income of the respondents from all sources was 8841.67 rupees with standard deviation of 6805.79 rupees. Low family income is directly linked to the malnutrition, illiteracy and large family size (Robert et al., 1993) Occupation of their husbands In a study in Pakistan Ejaz and Ahmad (2013) reported that 15.1 percent of the husbands had Govt. jobs and 29.3 percent were engaged in private jobs and majority (55.6) were engaged in others occupations. Mustafa (2008) in a study reported that 45 percent of the husbands were engaged in private businesses. According to Arshad (2006) the majority of the husbands (50 %) were engaged in private businesses and 34.7 percent were engaged in private jobs. Occupation or profession is a regular activity performed by the individuals for income. Ahmad (1990) defined occupation as a specific activity being carried out by the individuals for the steady flow of income. Occupation is also linked with the social status of the individual and the family. People having high paying occupations enjoy high level of health status. In rural areas now due to changing needs of the masses there is diversity of occupations. Agriculture is not the only profession even in rural areas. The data presented in the Table 4.2 depict a wide range of variation in the occupation of the husbands of the respondents. It is evident from the table that 20.3 percent husbands were labourers, 19.2 percent had their own business, 18.3 percent husbands were Government servants, 14.0 percent were drivers, 5.7 were engaged in miscellaneous occupations, 14.7 percent were engaged in private jobs and only 7.8 percent were farmers. This data reveals that farming is not an ideal job even in rural areas. Paul and Rumsey (2002) identified that husbands who were farmers were less responsive to the utilization of services by trained professionals for delivery than those husbands who were not farmers and were engaged in other professions.
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Table- 4.3: Educational level of the respondents and their husbands
Education Husbands Respondents categories Frequency Percentage Frequency Percentage Illiterate (0) 110 18.3 196 32.7 Upto Middle (1-8) 165 27.5 202 33.7 Matric (10) 194 32.3 119 19.8 Above Matric 131 21.8 83 13.8 (10+) Total 600 100.0 600 100.0 Mean education of the respondents’ husbands = 7.87 Std. Dev. = 4.49 Mean education of the respondents = 5.82 Std. Dev. = 4.83
Education is always linked with the awareness. Highly educated women prove to be more conscious about their health than women having lesser education. Similarly husbands' education level also affects the behavior of the husbands for the well being of their wives. Studies conducted in Pakistan revealed that there is a positive association between mother’s education and utilization of maternal health care services. Mothers with high degree of literacy were more likely to avail modern antenatal and delivery services than the illiterate mothers (Khan et. al, 1994). Education makes the mothers self responsible not only for themselves but also for their kids and educated women have better opportunities to avail modern health care because of their preferences for educated/wealthier husbands and high family income (Schultz, 1984). The data given in Table 4.3 show two things, one is respondents’ education and the other is their husbands’ education. It is evident from the table that about one-third (32.3 percent) husbands were matriculate, more than quarter of the husbands (27.5%) up to middle level education, 21.8 percent were educated above matric and 18.3 percent were illiterate. The Table 4.3 also shows that about one-third (33.7 percent) of the respondents had education level up to middle, 32.7 percent were illiterate, which is a quite significant figure. 19.8 percent respondents were matric and 13.8 percent were above matric level education. The study showed that in rural areas people are still reluctant to send their females to educational institution so majority of the respondents had middle level education or illiterate. The data show that mean education of the husbands was 7.87 years with standard deviation of 4.49 years and mean education of respondents was 5.82 years with standard deviation 4.83 years. Similar results were reported by Ahmad (2008) in a study in Faisalabad district that 20.3 percent of the husbands and 35.3 percent of the
51 wives were illiterate, which shows low level of literacy of the masses in rural areas of the country in this era of modern technological developments. Table 4.4: Distribution of the respondents according to their type of family Type of family Frequency Percentage Joint 358 59.7 Nuclear 242 40.3 Total 600 100.0
Type of family also affects the social and health status of the mothers and children. More independence on nuclear family system led to better status and autonomy of women which ultimately results in better health condition of mothers. Berger et al. 1983 found that nuclear family has positive impact on the social and cultural well being of the family. Singh et al. (2012) in a study reported that 69 percent of the families were living in joint family system in rural India. Family is a group of intimate individuals emotionally involved and blood related marriage or adoption responsible for the reproduction and rearing of the children living together. Most common is nuclear and joint family system. In cities nuclear family system is most common system found and in rural areas both nuclear and joint families are found but in rural areas people prefer joint family system (Mansoor, 2008). Husband and wife are the two pillars of a family. Better understanding between husband and wife is a key to the healthy families. Keeton (2007) studied that nuclear families in comparison with joint families performed better when compared for better health, schooling and nutrition. The data given in Table 4.4 show that more than half of the respondents (59.7 percent) were living in joint family system and 40.3 percent of the respondents were living in a nuclear family system. Arshad (2006) also reported similar results that majority of the people (60 percent) were living in joint family system. Ejaz and Ahmad (2013) in a study in Pakistan reported that 62 percent of the families were living in joint family system. Table 4.5: Distribution of the respondents according to their family members
Members Male (More than 18) Female (More than 18) Freq. %age Freq. %age 1-2 405 68.5 383 63.5 3-4 128 21.3 155 25.8 5 and above 67 11.2 62 10.3 Total 600 100.0 600 100.0 Mean = 2.33 Std. Dev. = 1.66 Mean = 2.33 Std. Dev. = 1.54
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The data presented in the Table 4.5 show that 68.5 percent of the respondents had 1-2 male family members (more than 18 years age), while 21.3 percent of them had 3-4 male members and remaining 11.2 percent of the respondents had 5 and above male members who had more than 18 years of age. Mean male family members was 2.33 with standard deviation 1.66. Out of the respondents 63.5 percent had 1-2 female family members more than 18 years of age, while about one-fourth (25.8 percent) of them had 3-4 female members and remaining 10.3 percent of the respondents had 5 and above female members who had more than 18 years of age. Mean female family members was 2.33 members with standard deviation 1.54. Table 4.6: Distribution of the respondents according to their adolescent family member Adolescent family Frequency Percentage members (12-18 years of age) None 392 65.3 1-2 136 22.7 3-4 58 9.7 5 and above 14 2.3 Total 600 100.0
Table 4.6 shows that 65.3 percent of the respondents had no adolescent family members, while 22.7 percent of the respondents had 1-2 adolescent members, 9.7 percent of them had 3-4 adolescent members and only 2.3 percent of the respondents had 5 and above adolescent members. As it was the condition set for the respondents that she should had at least one child less than five years and more than six months old. Also mean age of the respondents was 29.6 years there was lesser chances of adolescent children. Table 4.7: Distribution of the respondents according to their total number of children (<12 years)
Number of children Frequency Percentage 1-2 264 44.0 3-4 217 36.2 5 and above 119 19.8 Total 600 100.0 Mean = 3.15 Std. Dev. = 1.90 Early marriages and repeated pregnancies are very common in South Asia. It is considered honor for a lady that immediately after marriage she get pregnant and become mother of baby boy. Children are considered as source of pride and power. Table 4.7
53 depicts that a substantial proportion (44.0 percent) of the respondents had 1-2 children, while more than one-third (36.2 percent) of them had 3-4 children and about one-fifth (19.8 percent) of the respondents had 5 and above children. Mean of children was 3.15 with standard deviation 1.90. Mwaniki et al. (2002) pointed out that the mothers having more number of kids showed less interest to avail health care facility. In a study in Faisalabad (Pakistan) Arshad (2006) reported that majority of the families (38.7%) had 3- 4 children and 37.3 percent had 5 and above and 24 % of the families had 1-2 children. Ahmad (2008) reported similar results that 39 percent of the mothers had 3-4 babies. Table 4.8: Distribution of the respondents according to their total family members
Total family members Frequency Percentage Up to 5 184 30.7 6-10 286 47.7 11 and above 130 21.7 Total 600 100.0 Mean = 7.69 Std. Dev. = 3.76 Joint family system is the culture of South Asia. Family size indicates that there are members in the house other than husband wife and children. Joint family system had its own advantages and disadvantages. Keeton (2007) studied that nuclear families in comparison with joint families perform better when compared for better health, schooling and nutrition. Table 4.8 reveals that a major proportion (47.7 percent) of the families were having family member in the range of 6-10 members and 30.7 percent of the families were having up to 5 family members. Only one fifth of the respondents families (21.7 percent) were in the range of family members 11 and above. Joint family system is very common in rural areas of the country; so mean family member in the study was 7.69 with standard deviation 3.76. Table 4.9: Distribution of the respondents according to their total live births
Total live births Frequency Percentage 1-2 249 41.5 3-4 216 36.0 5 and above 135 22.5 Total 600 100.0 Mean = 3.25 Std. Dev. = 1.90
In Pakistani society the basic aim of marriage is to get pregnant and have a child. This thinking is due to socio-cultural beliefs. In Pakistani society woman’s position is
54 getting stronger when she gives birth to a son. Early marriages and multiple pregnancies along with poor educational background are very common in the rural areas of the country. Vora (1998) studied that number of pregnancies and miscarriages are more in developing countries than developed countries because of mother's health issues. The data given in the Table 4.9 show that 41.5 percent of the respondents had only 1-2 live births and 36.0 percent of the respondents had 3-4 live births and 22.5 percent of the respondents had 5 or more than five live births. The means number of live births was 3.25 with standard deviation 1.90 which showed high fertility trends. High fertility is very common in developing countries especially in South Asian countries. As per the preliminary report of Pakistan Demographic and Health Survey 2012-13 the total fertility rate of Pakistan was 3.8 (PDHS, 2013) Table 4.10: Distribution of the respondents according to their dead children Children Boys Girls Total (Nos) Freq. %age Freq. %age Freq. %age None 453 75.5 514 85.7 421 70.2 One 120 20.0 64 10.7 110 18.3 Two 27 4.5 13 2.2 37 6.2 Three - - 9 1.5 23 3.8 Four - - - - 7 1.2 Five - - - - 2 .3 Total 600 100.0 600 100.0 600 100.0
At global level around four million neonatal die each year during the first week after birth (Lawn et al., 2005 and WHO, 2005). According to Pakistan Demographic and Health Survey (PDHS, 2008) the infant mortality rate was higher (78/1000) than other neighboring countries of the region. With the passage of time things are improving. The data presented in the Table 4.10 show that 70.2 percent had no died child, 18.3 percent of the respondents had only one died child, 6.2 percent of the respondents had two died children, 3.1 percent of the respondents had three died kids, 1.2 percent of the respondents had 4 died kids and only a negligible proportion of the respondents (0.3 percent) had more than 5 kids died. This data also show significant decrease in the mortality rate of the infants, this happened due to availability and usage of basic health facilities especially for pregnant and lactating women.
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Table 4.11: Distribution of the respondents according to the working for cash
Working for cash Frequency Percentage Yes 153 25.5 No 447 74.5 Total 600 100.0
In our society especially in rural areas women are considered to be the second state citizen and they always feel it difficult to go out of home to earn money. Women remain dependent on men. Most of them don’t have control over the resources and they remain on subordinate position. The data given in the Table 4.11 show that majority of the respondents (74.5 percent) did not work to earn cash, as earlier discussed that they are bound to live in homes to look after the children and care for elder family members. About one fourth of the respondents (25.5%) were working ladies who worked somewhere to earn money. This study showed that the social barriers restricted them to their homes. Maclean (2004) identified that women involved in money making are more likely to receive health care facilities and they remained at lower health risk than those women who have less income. Shields (2001) also identified that professional ladies show higher trends of consultation with the doctors or other health providers than non professional ladies. Table 4.12: Distribution of the respondents according to their per month earning
Earning (Rs.) Frequency Percentage Upto 1000 45 29.4 1001-2000 38 24.8 Above 2000 70 45.8 Total 153 100.0 *447 respondents were not working for cash see Table 4.11 Income is an indicator of social status of an individual in the society. Social status is also linked with the health status of the individual and the families. High income leads to good health status of women. Shields (2001) indicated that high income women were twice to report good health than low income women. Fatmi and Avan (2002) also studied that socio economic status of mothers was one of the major factors affecting the utilization of maternal health care services. The data give in Table 4.12 show that out of total 153 working ladies 45.8 percent of the respondents earned more than Rs. 2000/- per month, 29.4 percent of the respondents earned up to Rs. 1000/- per month and 24.8 percent of the respondents earned
56 between Rs.1001 to Rs.2000 per month. These figures indicate very poor earnings even of the working ladies. These figures indicate poor economic status of even the working ladies of rural areas of the country. 4.1.2: Health Facilities
Table 4.13: Distribution of the respondents according to health facilities available in their area
Health facilities available in Frequency Percentage their area Yes 523 87.2 No 77 12.8 Total 600 100.0
There is a big difference in the availability of maternal health facilities in poor and rich countries and similarly there is big difference in the health conditions of women in poor and rich countries. It was very unfortunate that in South Asia on 29 percent deliveries were being attended by skilled birth attendants and rest took place with the help of TBAs, relatives or neighbors (AbouZahr and Wardlaw, 2001). From last decade there is lot of improvement in the road infrastructure and health care facilities in the country. Similarly in rural and urban areas the availability of health facilities also varies. The data of Table 4.13 show that 87.2 percent of the respondents reported that the health facilities are available in their area, while only 12.8 percent of the respondents reported that they don't have health facility in their area. It means that health facilities were available in the sampled area. Table 4.14: Distribution of respondents according to the type of available medical health facilities
Medical Health facilities Yes No Total F. % F. % F. % Government Hospital 189 31.5 411 68.5 600 100.0 (THQ) Private Hospital 163 27.2 437 72.8 600 100.0 RHC 114 19.0 486 81.0 600 100.0 BHU 325 54.2 275 45.8 600 100.0 Dispensary 90 15.0 510 85.0 600 100.0 Clinics 171 28.5 429 71.5 600 100.0 T.B.A 541 90.2 59 9.8 600 100.0 Hakim 48 8.0 552 92.0 600 100.0
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Overall in health care system of Pakistan the qualified physicians were 127,859, nurses 62,651, and 110,000 lady health workers working in both public and private health care system (Govt. of Pakistan, 2008). Public sector country wide health care system comprises of 11,000 health facilities that can be divided into primary, secondary and tertiary level. Out of total 9000 of these facilities are of primary level. Table 4.14 presents the available medical health facilities. Little less than one- third (31.5 percent) of the respondents had government hospital in their locality, while 27.2 percent of them told that they had private hospitals and 19.0 percent of them had RHC health facility in their locality. A substantial proportion (54.2 percent) of the respondents had Basic Health Units (BHUs) in their locality, 15.0 percent of them had dispensaries, 28.5 percent of them had clinics and 90.2 percent of the respondents reported that they had TBAs facility and 8.0 percent of them had Hakim facility in their locality. So TBAs, BHUs and government hospitals were the major health facilities in the sampled area. 4.1.3: Awareness and Adoption of Antenatal Services
Table 4.15: Distribution of the respondents according to their knowledge about antenatal services
Knowledge about antenatal Frequency Percentage services Yes 584 97.3 No 16 2.7 Total 600 100.0
Knowledge is important for the utilization of any service Sheriff and Singh (2002) reported that; women who were exposed to radio, television and newspapers for maternal care services their rate of utilization of these services was significantly high. The data given in the Table 4.15 show that a huge majority (97.3%) of the respondents had knowledge about the antenatal services and only 2.7 percent of the respondents did not know about antenatal services. It means that majority of the respondents were well aware about antenatal services. The awareness is due to the big program of family planning and lady health visitors launched by the Government of Pakistan at grass root level.
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Table 4.16: Distribution of the respondents according to their awareness about important antenatal services n = 584* Important antenatal services To a great extent To some extent Not at all F. % F. % F. % Physical examination 480 82.2 23 3.9 81 13.9
Iron and folic acid tablets 441 75.5 18 3.1 125 21.4
Immunization of herself 506 86.6 11 1.9 67 11.5
Counseling 340 58.2 27 4.6 217 37.2
Physiotherapy 211 36.1 38 6.5 335 57.4
* 16 respondents had no knowledge about antenatal services (see Table 4.15)
In order to promote the health conditions of mother and neonatal it is very important to increase the awareness of important antenatal services. Dhakal et al. (2007) reported that awareness about postnatal services is one of the barriers associated with the utilization of these services. Antenatal care includes not only the above mentioned parameters but also it coaches the mother for handling pregnancy related issues, better nutrition management, exercise and infant caring practices. Meera and Julian (2003) studied health condition of women of India and Pakistan. It was found out that in these two countries women remained under nutritional stress right from childhood to child bearing age. During reproductive age close pregnancies, short birth interval and lactation resulted in premature births and nutritional deficiencies like protein energy malnutrition, anemia and deficiencies of iodine and vitamin A which is collectively contributed to the poor health status of women in these two countries. The data given in Table 4.16 on important antenatal care services indicate that 82.2 percent of the respondents had awareness ‘to a great extent’ and 3.9 percent of them had awareness ‘to some extent about physical examination, 75.5 percent of the respondents had awareness ‘to a great extent’ and 3.1 percent of them had awareness ‘to some extent’ about using iron and folic acid tablets. About 86.6 percent of the respondents had awareness ‘to a great extent’ and 1.9 percent of them had awareness ‘to some extent about immunization of themselves. More than a half (58.2 percent) of the respondents had awareness ‘to a great extent’ and 4.6 percent of them had awareness ‘to some extent’ about counseling. About one-third (36.1 percent) of the respondents had awareness ‘to a great extent’ and 6.5 percent of them had awareness ‘to some extent’
59 about physiotherapy and its impact on body. It means there was adequate awareness of the important antenatal care practices by mothers who know what antenatal care is. Only physiotherapy was the least one known by the respondents. Table 4.17: Distribution of the respondents regarding to receive antenatal services n = 584* Received antenatal services Frequency Percentage Yes 542 92.8 No 42 7.2 Total 584 100.0 *16 respondents had no knowledge about antennal services There is a difference in bringing knowledge into practice, but it is very important to bring knowledge into practice to get its utility. Ahmad (2008) reported that majority of the females (64 percent) received antenatal care services. Liu et al. (2011) reported that 95 percent of the women received antenatal care services. The data given in Table 4.17 show 92.8 percent of the respondents reported that they went for antenatal services, while only 7.2 percent of the respondents did not go for antenatal care. The study results are quite promising that only 7.2 percent respondents did not utilize the antenatal care services. Table 4.18: Distribution of the respondents regarding reasons to receive antenatal services n = 542* Reasons to received Yes No Total antenatal services F. % F. % F. % Due to illness 200 36.9 342 63.1 542* 100.0 Midwife suggested 45 8.3 497 91.7 542 100.0 to go To check the well 341 62.9 201 37.1 542 100.0 being of fetus Immunization of 305 56.3 237 43.7 542 100.0 herself Due to 126 23.2 416 76.8 542 100.0 complications in child birth * = 42 respondents never went for antenatal services and 16 respondents had no knowledge about antenatal services (see Table 4.17). So total (42+16=58) were NA.
Utilization of antenatal care services is one of the tools to reduce maternal mortality rate. McDonagh (1996) noted that during antenatal visits about 81 percent of high risk deliveries could be identified and special care could be given to improve mother health. Coria-Soto et al. (1996) observed that decreased utilization of antenatal services led to 63 percent high risk of intra uterine growth and retardation of babies in the uterus.
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The data given in Table 4.18 show that 36.9 percent of the respondents received antenatal services because of their illness and 63.1 percent of the respondents did not receive antenatal care because of illness. Only 8.3 percent of the respondents visited for antenatal care because of advice of midwives, 62.9 percent of the respondents went for antenatal care to check well being of the fetus and 37.1 percent of the respondents did not go to check well being of the fetus. More than a half (56.3 percent) of the respondents went for antenatal care to immunize themselves and 23.2 percent of the respondents went for antenatal care because of complications in child birth.
Table 4.19: Distribution of the respondents according to the received antenatal services n = 542* Antenatal services Yes No F. % F. % Physical examination 338 62.4 204 37.6
Iron and folic acid tablets 100 18.5 442 81.5
Counseling 118 21.8 424 78.2
Immunization of herself 515 95.0 27 5.0
Physiotherapy 216 39.9 326 60.1
* = 42 respondents never went for antenatal services and 16 respondents had no knowledge about antenatal services (see Table 4.17). So total (42+16=58) were NA.
In developing countries still traditional birth attendants (Dai) are playing major role in delivery services which was supported by the reports of UNFPA (2004) that 56% of deliveries are taken place with the help of trained attendants (AbouZahr and Wardlaw, 2001). In Table 4.19 the data show that 62.4 percent (out of 542) of the respondents received physical examination, while 37.6 percent of the respondents did not receive physical examination. The data show that only 18.5 percent (out of 542) of the mothers received iron and folic acid tablets, while 81.5 percent of the respondents did not get iron and folic acid tablets. The table also shows that 21.8 percent of the respondents had counseling with doctors, LHVs/TBAs. About 95.0 percent of the respondents reported that they get them immunized themselves, 39.9 percent of the mothers receive physiotherapy treatment and 60.1 percent of the respondents did not receive physiotherapy.
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Table 4.20: Distribution of the respondents according to where from received antenatal services n = 542* Received the antenatal care Frequency Percentage services Government postnatal 137 25.3
Pvt. Hospital 58 10.7
Lady Doctor/clinic 60 11.1
Nurse 64 11.8
TBA 174 32.1
Lady Health Workers 49 9.0
Total 542 100.0 * = 42 respondents never went for antenatal services and 16 respondents had no knowledge about antenatal services (see Table 4.17). So total (42+16=58) were NA.
Table 4.20 indicates that 25.3 percent of the respondents received the antenatal services from government hospitals, while 10.7 percent of them received the antenatal services from private hospitals and 11.1 percent of them received the antenatal services from lady doctor/clinics. About 11.8 percent of the respondents received the antenatal services from nurses, 32.1 percent of them received the antenatal services from TBAs and remaining 9.0 percent of them received the antenatal services from lady health workers (LHWs). Table 4.21: Distribution of the respondents regarding reasons for not taking antenatal services n = 42* Reasons for not taking antenatal Yes No services F. % F. % Attending the other family matters 19 45.2 23 54.8 It is expensive 33 78.6 9 21.4 Beliefs 9 21.4 33 78.6 Health worker provide services at 38 90.5 4 9.5 home It was not necessary 26 61.9 16 38.1 Due to long waiting time 34 81.0 8 19.0 Look after the children 7 16.7 35 83.3 * = 42 respondents never went for antenatal services (see Table 4.17).
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Factors like social, cultural, demographic and political affect the utilization of antenatal health care (Babar et al. 2004 and Harris et al. 2010). Alam et al. (2004) revealed a comparative study between antenatal services utilizing and non utilizing women and result showed a significant difference in the health condition, knowledge about danger signals during pregnancy and nutritional requirements of women utilizing antenatal care services over the women who were not utilizing antenatal care services. Data presented in Table 4.21 show that 19 (42.5 percent) out of 42 of the respondents who had to attend other family matters so they did not go for antenatal services and 33 (78.6 percent) out of 42 of the respondents considered that antenatal services were expensive, so they never utilized these. Nine (21.4 percent) out of 42 respondents were never belief for going to receive antenatal services. The reason of 38 (90.5 percent) out of 42 respondents for not going out for antenatal care was that the health workers team came at their homes, 26 (61.9 percent) out of 42 respondents were those who consider it not to be necessary for them. According to the data 34 (81.0 percent) out of 42 were the respondents who did not go for antenatal services because of their experience of long waiting time at the health care providers and 7 (16.7 percent) of the respondents were those who did not have any person to live with their children at home so they did not go for antenatal care. Table 4.22: Distribution of the respondents according to visit of health clinic during pregnancy
Visited health clinic during Frequency Percentage pregnancy Yes 526 87.7 No 74 12.3 Total 600 100.0
Liu et al. (2011) conducted study about the utilization of maternal health care services. According to the study 95% women availed prenatal care and the mothers who availed more than four prenatal visits was 52.9%. 86.3% women delivered at hospital and average numbers of prenatal and postnatal visits were 4.94 and 2.19 respectively. Out of total women 98% had at least one antenatal visit. Table 4.22 represents medical checkup during pregnancy and the data confirm that 87.7 percent of the respondents had regular medical checkup during pregnancy, only 12.3 percent of them had no regular medical checkup during pregnancy. Kongsri et al. (2011) studied the access to reproductive health services from Reproductive Health Surveys of
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2006 and 2009. The results were very impressive for the utilization of antenatal care and trained birth attendants at the time of delivery. According to the study the coverage of antennal care was 98.9 percent and the skilled birth attendants was 99.7 percent. Table 4.23: Distribution of the respondents according to their number of visit to health clinic for antenatal services n= 526* No. of visits of health clinic Frequency Percentage 1-3 282 53.61 4-6 176 33.46 7-9 55 10.46 10 and above 13 2.47 Total 526 100 *74 respondents never visited health clinic
Antenatal care is an important tool to prevent maternal mortality but only antenatal care does not cope with all emergencies and obstetric complications. Antenatal care is an initial point to come into the health care system. Antenatal service provider is very important in this whole system because information provided by antenatal service provider form the basis for safe management of pregnancy and delivery and health of neonatal and mother. The core objective of this antenatal health care system is to monitor maternal health conditions (Llewellyn and Jones, 1990). In developing countries more than fifty percent of women went for at least four antenatal visits (UNFPA, 2004) Table 4.23 shows that 12.3 percent of the respondents did not have medical checkup during their pregnancy. A major proportion (53.61 percent) had 1-3 visits to the health clinics during pregnancy, more than two third (33.46 percent) of them had 4-6 visits, 10.46 percent had 7-9 visits and only 2.47 percent of them had 10 or more visits to health clinics during pregnancy. The number of pregnant women who got antenatal care with at least one antenatal visit to health care unit was 74% and trained attendants assisted 61 percent of the total deliveries (UN, 2008), out of the total deliveries 40 percent took place at health care facilities (UNFPA 2004).
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Table 4.24: Distribution of the respondents according to their source of information about antenatal services *n = 584 Source of Yes No information Frequency Percentage Frequency Percentage Doctor 210 36.0 374 64.0
Midwife 65 11.1 519 88.9
Nurse 51 8.7 533 91.3
Leady Health 196 33.6 388 66.4 Worker TBAs 120 20.5 464 79.5
Friend 101 17.3 483 82.7
Relative 12 2.1 572 97.9
Neighbourer 54 9.2 530 90.8
TV 161 27.6 423 72.4
*16 respondents had no knowledge about antenatal care services (see Table 4.15)
The data given in the Table 4.24 shows that 36.0 percent of the respondents got information about antenatal services from doctors and 33.6 percent from lady health workers, 27.6 percent of the respondents got that information from TV, 11.1 percent got information from midwives, 20.5 percent got information about antenatal services from traditional birth attendants (TBAs). Friends and relatives were a source of information for antenatal services and in current data 17.3 percent of the respondents got information from friends and 2.1 percent of the respondents from relatives. Neighbourers provided information about antenatal services to 9.2 percent of the respondents and 8.7 percent got information from nurses. It means doctors, lady health workers, TBAs and TV played important role in dissemination of information of antenatal services. Shreriff and Singh (2002) found that in India women who were exposed to radio, television and newspaper for maternal care services and the rate of utilization of these services was significantly high.
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Table 4.25: Distribution of the respondents according to the services provided during pregnancy n = 600 Services provided Yes No F. % F. % Measured weight 338 56.3 262 43.7 Measure height 185 30.8 415 69.2 Measurement of blood pressure 466 77.7 134 22.3 Told them when to come next time 266 44.3 334 55.7 Advised about diet 370 61.7 230 38.3 Prescribed supporting medicine 412 68.7 188 31.3 Do the ultrasound is required 309 51.5 291 48.5
The data given in Table 4.25 show that 56.3 percent of the respondents weighed themselves during pregnancy and 43.7 percent did not weighed themselves during pregnancy. Little less than one-third (30.8 percent) of the respondents measured their height during pregnancy while 69.2 did not measure their heights during pregnancy. Blood pressure of 77.7 percent of the respondents was checked during pregnancy and blood pressure of 22.3 percent of the respondents was not checked during pregnancy. A number of respondents (44.3 percent) of the respondents were asked to repeat the visit and 55.7 percent of the respondents were not asked to repeat the visit. A number of respondents (61.7 percent) were advised about diet during pregnancy and 38.3 percent of the respondents were not advised about diet during pregnancy. 68.7 percent of the respondents were advised supporting medicine and 31.3 percent of the respondents were not advised any sort of supporting medicine during pregnancy. 51.5 percent of the respondents were gone through ultrasound diagnosis and 48.5 percent of the respondents were not gone through ultrasound therapy. 4.1.4: Awareness and Adoption of Postnatal Services Table 4.26: Distribution of the respondents according to their knowledge about postnatal services
Knowledge about postnatal Frequency Percentage services Yes 582 97.0 No 18 3.0 Total 600 100.0
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Postnatal care like antenatal care is equally important to reduce maternal mortality and to overcome postpartum complications. Ejaz and Ahmad (2013) reported that 87.3 percent of the primigravida had awareness about postnatal services. The data given in the Table 4.26 shows that a huge majority (97 percent) of the respondents had knowledge about the postnatal services and only 3.0 percent of the respondents knew nothing about postnatal services. The study showed that a high number of mothers had knowledge about postnatal services. Table 4.27: Distribution of the respondents according to their awareness about important postnatal services n = 582* Important postnatal To a great extent To some extent Not at all services. F. % F. % F. % Physical examination 330 56.7 35 6.0 217 37.3
Iron an folic acid tablets 276 47.4 29 5.0 277 47.6
Immunization of baby 464 79.7 41 7.0 77 13.2
Immunization of herself 21 3.6 19 3.3 542 93.1 (after delivery) Counseling 289 49.7 27 4.6 266 45.7
Family planning services 374 64.3 42 7.2 166 28.5
Breast feeding education 272 46.7 31 5.3 279 47.9
Physiotherapy 279 47.9 24 4.1 18 3.1
* 18 respondents had no knowledge about postnatal services (see Table 4.25)
Postnatal visits help mothers not only to cover up expected complications after delivery but also growth of newborn. Awareness about important postnatal service is important for its proper utilization. Sibley (1997) observed that out of all maternal deaths 63 percent occurred during 24 hours after delivery and during first week after delivery 80 percent of the total maternal deaths occurred. So it is very important to create awareness of the importance postnatal care services. The data given in Table 4.27 shows the tendency of use of the most common and important postnatal services. A significant number (56.7 percent) of the respondents had awareness ‘to a great extent’ and 6.0 percent of them had knowledge ‘to some extent’ about physical examination. About 47.4 percent of the respondents had awareness ‘to a great extent’ and 5.0 percent of them had knowledge ‘to some extent’ about using iron and folic acid tablets. A large majority (79.7
67 percent) of the respondents had awareness ‘to a great extent’ and 7.0 percent of them had awareness ‘to some extent’ about immunization of baby. Only 3.6 percent of the respondents had awareness ‘to a great extent’ and 3.3 percent of them had awareness ‘to some extent’ about immunization of themselves after delivery. Immunization against tetanus texoid is a complete course which starts during pregnancy and continue after delivery but small number of mothers had awareness about the vaccination after delivery. About a half (49.7 percent) of the respondents had awareness ‘to a great extent’ and 4.6 percent of them had awareness ‘to some extent’ about counseling. About 64.3 percent of them had awareness ‘to a great extent’ and 7.2 percent of them had awareness ‘to some extent’ about family planning services. Less than a half (46.7 percent) of the respondents had education ‘to a great extent’ and 5.3 percent of them had education ‘to some extent’ about the impact of breast feeding of babies. About 47.9 percent of the respondents had awareness ‘to a great extent’ and 4.1 percent of them had awareness ‘to some extent’ about physiotherapy and its impact on body. Table 4.28: Distribution of the respondents who received postnatal services n=582* Received postnatal services Frequency Percentage Yes 459 78.9 No 123 21.1 Total 582 100.0 *18 respondents had no knowledge about postnatal services
The utilization of postnatal care was not so frequent but in last two decades the awareness about the utilization of postnatal care including immunization of child, breast feeding and contraceptive use etc. increased government as well as non government organizations played vital role in creating awareness. According to Ejaz and Ahmad (2013) the rate of utilization of postpartum care among primigravidas of rural Punjab was 68.2 percent which is also close to the result of current study. The data given in Table 4.28 show that a large majority (78.9 percent) of the respondents reported that they received postnatal services, while 21.1 percent of the respondents did not receive postnatal care even they knew about postnatal services.
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Table 4.29: Distribution of the respondents according to the types of postnatal services they received n = 459 Postnatal services Yes No Frequency Percentage Frequency Percentage Physical examination 216 47.1 243 52.9
Iron and folic acid tablets 0 0.0 459 100.0
Immunization of baby 316 68.8 143 31.2 (BCG) Immunization of herself 17 3.7 442 96.3
Counseling 195 42.5 264 57.5
Family planning services 127 27.7 332 72.3
Breast feeding education 108 23.5 351 76.5
Physiotherapy 49 10.7 410 89.3
* = 123 respondents never received postnatal services and 18 respondents had no knowledge about postnatal services (see Table 4.28). So total (123+18=141) were NA
Postnatal health care services are the services given to the mother and neonatal after delivery for six weeks period. In postnatal services the most important services are physical examination, physiotherapy, immunization, counseling, breast feeding education and family planning. These health care services are very important for mothers but it is fact that most of the mothers do not avail these health care services due to different reasons. In order to avoid disabilities and life threatening complications due to child birth, postnatal care includes important maternal health care services that must be adopted (UN, 2002). In Mangolia Janes (2004) reported that hard work at farm and at home make women weak and anemic. He mentioned that women were deficient in iron, vitamin and mineral deficient and it was the predominant cause of maternal mortality. The data given in Table 4.29 show that slightly less than half (47.1 percent) respondents reported that they received physical examination when they went back to hospital after delivery, while 68.8 percent of them received immunization (BCG) of baby. Only 3.7 percent of them received immunization for themselves, whereas 42.5 percent of the respondents told that they counseled; when they went back to hospital after delivery. About one-fourth (27.7 percent) of the respondents received family planning services, 23.5 percent of them received the importance of breast feeding education. Only 10.7
69 percent of the respondents received physiotherapy services when they went back to hospital after delivery.
Table 4.30: Distribution of the respondents according to the reasons to receive postnatal services n = 459* Reasons Yes No F. % F. % Because of illness 83 18.1 376 81.9 For immunization of baby 310 67.5 149 32.5 Midwife guided me 17 3.7 442 96.3 To start family planning 148 32.2 311 67.8 Because I wanted to make sure I am back to 126 27.5 333 72.5 normal To check the well being of child 118 25.7 341 74.3 * = 123 respondents never received postnatal services and 18 respondents had no knowledge about postnatal services (see Table 4.27). So total (123+18=141) were NA
The utilization of postnatal care is dependent on different reasons Ejaz and Ahmad (2013) studied that 69.1 percent of the total 74.1 percent of the respondents who had any health problem received postnatal care while 54.7 percent of 25.9 percent of the respondents having no health problems utilized postnatal health care services. Access to contraception is important to save women’s life since family planning can prevent the women from serious health consequences by helping them is prevent unwanted pregnancies and high risk pregnancies (Winikoff and Sullivan 1987). Table 4.30 indicates that 18.1 percent (out of 459) of the respondents reported that they went for postnatal services because of illness and 67.5 percent (out of 459) of the respondents told that they went for postnatal services because their baby needed an immunization. Only 3.7 percent of the respondents reported that they went for postnatal services because the midwife recommended her for postnatal checkup. About one-third i.e. 32.2 percent (out of 459) of the respondents went to postnatal services because they wanted to start family planning, 27.5 percent of them wanted to make sure that they returned to normal and 25.7 percent (out of 459) of the respondents went for postnatal services to check well being of child. So results reflected that majority of the respondents received postnatal services because their baby needed immunization, another significant population wanted to start family planning so they received postnatal services.
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Table 4.31: Distribution of the respondents according to where from received postnatal services n = 459* Received the postnatal care Frequency Percentage services Government postnatal 125 27.2
Pvt. Hospital 49 10.7
Lady Doctor/clinic 50 10.9
Nurse 70 15.3
TBA 228 49.7
Lady Health Workers 27 5.9
Total 459 100.0 * = 123 respondents never received postnatal services and 18 respondents had no knowledge about postnatal services (see Table 4.27). So total (123+18=141) were NA
Table 4.31 indicates that 27.2 percent of the respondents received the postnatal services from government hospitals, while 10.7 percent of them received the postnatal services from private hospitals and 10.9 percent of them received the postnatal services from lady doctor/clinics. About 15.3 percent of the respondents received the postnatal services from nurses, 49.7 percent of them received the postnatal services from TBAs and remaining 5.9 percent of them received the postnatal services from lady health workers (LHWs). Table 4.32: Distribution of the respondents according to the reasons for not receiving postnatal services n = 123* Reasons Yes No F. % F. % Attending the other family matters 17 13.8 106 86.2 It is expensive 36 29.3 87 70.7 Beliefs 10 8.1 113 91.9 Health worker provide services at home 79 64.2 44 35.8 It was not necessary 57 46.3 66 53.7 Due to long waiting time 38 30.9 85 69.1 Look after the children 18 14.6 105 85.4 * = 123 respondents were never received postnatal services (see Table 4.26).
Rower and Garcia (2003) found out that availability, quality and cost are the most important factors associated with the utilization of the maternal health care services. Social setup, beliefs and personality are also linked with the utilization of health care 71 services by mothers. Safe motherhood (1998) reported the factors which prevent the utilization of postnatal services were cost, distance, women autonomy, poor handling by the health care providers. Table 4.32 reveals that 13.8 percent (out of 123) of the respondents did not receive postnatal services because they were busy in attending other family matter and 29.3 percent (out of 123) of the respondents reported that the postnatal services were expensive. Only 8.1 percent of the respondents had no belief in postnatal checkup, whereas 64.2 percent (out of 123) of the respondents were not going for postnatal checkup because health workers team came home and 46.3 percent of the respondents thinking that the these services are not necessary. A number of the respondents (30.9 percent) did not go to postnatal services center due to long waiting over there and 14.6 percent (out of 123) of them had no one to live with the children at home so they did not go for postnatal services. Table 4.33: Distribution of the respondents according to the visit of health clinic after delivery
Visit of health clinic after Frequency Percentage delivery Yes 322 53.7 No 278 46.3 Total 600 100.0
Table 4.33 shows that a majority i.e., 53.7 percent of the respondents reported that they visited health clinic after delivery in postpartum period, while 46.3 percent of them told that they had never medical checkup during postpartum. Table 4.34: Distribution of the respondents according to no. of visits to the health clinic for medical checkup after delivery n=322* Visited health clinic for Frequency Percentage medical checkup after delivery (how many times) One 96 29.8 Two 135 41.9 Three 40 12.4 Four 28 8.7 Five or above 23 7.1 Total 322 100.0 *278 respondents never visited health clinic after delivery (see table 4.32)
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As far as postnatal visits are concerned it is least concerned topic in the developing world but importance of postnatal care can’t be denied. In recent years the need and importance of post partum care have very much emphasized because of the maternal deaths. To have a child the most of the deaths occur during labour, delivery and 24 hours after post partum. If diagnosis and care taken timely most of the complications can be avoided (Campbell & Graham, 2006 and Ronsmans & Graham, 2006) Table 4.34 indicates that 29.8 percent of them had one, 41.9 percent of them had two and 12.4 percent had three visits of health clinic for medical checkup after delivering the child, while 8.77 percent of the respondents had four visits and 7.1 percent of them had five or above visits of health clinics for medical checkup after delivering the child.
Table 4.35: Distribution of the respondents according to their source of information about postnatal services n = 582* Source of Yes No information Frequency Percentage Frequency Percentage Doctor 98 16.8 484 83.2
Midwife 70 12.0 512 88.0
Nurse 41 7.0 541 93.0
Leady Health 210 36.1 372 63.9 Worker TBAs 165 28.4 417 71.6
Friend 147 25.3 435 74.7
Relative 127 21.8 455 78.2
Neighbourer 59 10.1 523 89.9
TV 112 19.2 470 80.8
*18 respondents had no knowledge about postnatal services (see table 4.26)
Ejaz and Ahmad (2013) reported that doctors and lady health workers were the main source of information for the postpartum care. According to their findings of this 39.0 percent of the respondents got information for postpartum care from doctors and 60.5 percent from lady health workers. The data given in the Table 4.35 shows that 36.1 percent of the respondents got information about postnatal services from lady health workers, 28.4 percent of the
73 respondents got information from TBAs, 12.0 percent got information from midwives, Friends and relatives were also a big source of information for postnatal services and in current data 25.3 percent of the respondents got information from friend and 21.8 percent of the respondents from their relative. Neighbourer provided information about postnatal services to 10.1 percent of the respondents and 7.0 percent got information from nurses. It means that lady health workers, TBAs and friends played significant role in dissemination of information of postnatal services.
Table 4.36: Distribution of the respondents according to their choices to go to hospital
Like to go to hospital Frequency Percentage Yes 494 82.3 No 106 17.7 Total 600 100.0
Fosteo et al. (2009) revealed that efforts are being carried out at international level to uplift the health status of mothers and to reduce maternal mortality. About half a million mothers died each year due the complications arising during the pregnancy or at the time of delivery. Mothers' autonomy was closely associated with the choice of place of delivery by the women of middle to least poor class. The data given in the Table 4.36 show that a huge majority (82.3 percent) of the respondents liked to go to hospital and 17.7 percent of the respondents did not like to go to hospital. It means that awareness was there to go to hospital and get health services.
Table 4.37: Distribution of the respondents according to call TBA at home
Called TBA at home Frequency Percentage Yes 435 72.5 No 165 27.5 Total 600 100.0
Table 4.37 depicts that a majority of the respondents (72.5 percent) reported that they called a TBA at home for any service, while 27.5 percent of them told that they did not do so.
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Table 4.38: Distribution of the respondents according to the method of delivery of their last child
Method of delivery Frequency Percentage Normal vaginal delivery 396 66.0 Caesarean section 101 16.8 Assisted vaginal delivery 103 17.2 Total 600 100.0
Shamsa et al. (2013) conducted a study in New South Wales Australia and reported that there were 62.9 percent normal vaginal deliveries, 25.9 percent were through caesarean section and 10.4 percent were operative vaginal deliveries. The results of the current study also supported these results. Table 4.38 reflects that 66.0 percent of the respondents had normal vaginal delivery, 16.8 percent of them faced caesarean section and 17.2 percent of them had assisted vaginal delivery. It means that majority of the respondents had normal delivery or assisted vaginal delivery which showed good pattern of birth.
Table 4.39: Distribution of the respondents according to the place of delivery
Place of delivery Frequency Percentage Home 290 48.3 Hospital 270 45.0 Maternity home 40 6.7 Total 600 100.0
It is very dangerous to deliver at home because of potential complications. Delivering baby at home increase the probability of bleeding, stillbirth, neonatal or maternal mortality. High percentage of deliveries at home showed the condition of mothers. There is a close relationship between utilization of antenatal and postnatal services and the utilization of services of skilled birth attendants at the time of delivery. The mothers who got high level of antenatal care during pregnancy were four times more availed the services of skilled birth attendants at the time of delivery than the mothers who got low level of antenatal care (Bloom et al. 1999). Fikree et al. (2005) conducted a study at Karachi and reported that in slums of Karachi about half of the mothers delivered at home with the help of traditional birth attendants.
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Table 4.39 shows that 48.3 percent of the respondents delivered their baby at home, while 45.0 percent of them delivered their baby at a hospital and only 6.7 percent of them delivered their baby at maternity home. Table 4.40: Distribution of the respondents according to the handling of their delivery case
Handling their delivery case Frequency Percentage TBA 268 44.7 Doctor 262 43.7 LHW 37 6.2 Maternity home 22 3.7 Relatives 11 1.8 Total 600 100.0
In developing countries majority of deliveries take place at home especially in rural areas. These deliveries occur with the help of Dai/TBAs or relatives. Fauveau (1993) pointed out that in mothers vaginal infection took place because of the using unclean hands by TBAs for vaginal examination. In rural areas the application of herbs and dung are the practices which may cause genital infection. Traditional birth attendants (TBAs) continued to have a significant role in assisting deliveries. In Gorontalo 69.6 percent of the deliveries were assisted by TBAs and overall in the whole of Indonesia, 35 percent were assisted by a TBA (Govt. of Indonesia 2008). Table 4.40 reveals that 44.7 percent of the respondents reported that TBA were handling their delivery case, 43.7 percent of them told that a doctor were handled their delivery case and 6.2 percent of them said that LHWs handled their delivery case. About 3.7 percent of the respondents reported that maternity home were handling their delivery case and only 1.8 percent of them told that their relatives were handling their delivery case. The study showed that majority of the respondents (90 percent) received services of doctors and TBAs for delivery. 4.1.5: Stillbirths According to WHO (2014) stillbirths means a baby born with no signs of life at or after 28 weeks' gestation. In 2009 there were over 2.6 million stillbirths globally. The information related to stillbirth is given below.
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Table 4.41: Distribution the respondents according to having still birth
Have any stillbirth Frequency Percentage Yes 121 20.2 No 479 79.8 Total 600 100.0
In developing countries the rate of neonatal mortality and still births is high as compared with developed world. In Sub-saharan African countries they rate of still birth is highest (31 still births per 1000 live births) followed by Asia and then Latin America (Zupan, 2005). Pakistan had a rate of 47 stillbirths per 1000 total births compared to the global rate of 19 per 1000 births (Dawn, 2011) Table 4.41 reveals that 20.2 percent of the respondents had still births and big majority (79.8 %) did not experienced any still birth. Table 4.42: Distribution of the respondents according to the number of still births n=121 Have any still birth Frequency Percentage One 84 69.4
Two 25 20.7
Three 12 9.9
Total 121 100.0 *479 respondents did not experience any still birth (see table 4.41) Anne (1992) studied that significant number of still births neonatal deaths could be prevented if women were well nourished during pregnancy and good quality health care be provided to them during pregnancy, delivery and after birth. In order to achieve the goal the availability of health care service must be made sure not only to mother but also to neonates. Table 4.42 depicts that 69.4 percent (out of 121) of the respondents had one still birth, 20.7 percent had two and 9.9 percent had three still births. 4.1.5: Miscarriage Table 4.43: Distribution of the respondents according to have any miscarriage Have any miscarriage Frequency Percentage Yes 113 18.8 No 487 81.2 Total 600 100.0
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Mudasar (2008) reported that 5.8 percent of the females experienced miscarriage in Faisalabad which is an industrialized city having all good health facilities available. Table 4.43 reveals that only 18.8 percent of the respondents reported that they had have any miscarriage, while 81.2 percent had no miscarriage which showed a good reproductive health sign of rural women. Table 4.44: Distribution of the respondents according to the number of miscarriages n=113* Have any miscarriages Frequency Percentage One 72 63.7
Two 32 28.3
Three 9 8.0
Total 113 100.0 *487 did not face any abortion (see table 4.43) According to reports, miscarriages and abortions together accounts for 10-12 percent of maternal mortality in Pakistan (Business Recorder, 2013). Table 4.44 depicts that 63.7 percent (out of 113) of the respondents had one, 28.3 percent of them had two and 8.0 percent of the respondents had three miscarriages. 4.1.6: Abortion Table 4.45: Distribution of the respondents whether they faced an abortion
Face any abortion Frequency Percentage Yes 29 4.8 No 571 95.2 Total 600 100.0
Induced abortion may be the result of complications during pregnancy like severe anemia, urinary tract infections, respiratory tract infection and renal disability. Child birth can be fatal to the women who develop such pregnancy related complications. Abortion reduces the risk of death because of such pregnancies. Sunmola et al. (2003) reported that in Nigeria 6 percent women aborted because of one or the other reasons. Table 4.45 presents that only 4.8 percent of the respondents faced an abortion. Luthra (2005) identified that worldwide almost 20 million unsafe abortions happened which about 80,000 maternal deaths and hundreds of thousands of maternal disabilities. In Pakistan the rate of abortion is low and this is preventable.
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Table 4.46: Distribution of the respondents according to the number of abortion n=29 Have any abortion Frequency Percentage One 27 93 Two 2 7 Total 29 100.0
Singh et al. (2003) identified that out of all pregnancies more than one third were unplanned and one fifth of which aborted. Non use of contraceptive by the women in developing countries is the main cause of two third of unwanted pregnancies. Westoff (2005) identified that with the use of modern contraceptive methods, the rate of abortions declined very sharply. Table 4.46 presents the number of abortion of the respondents. Out of 29 (93 percent) 27 of the respondents had one abortion in their life, while only 2 respondents (7 percent) out of 29 had two abortions. Table 4.47: Distribution of the respondents according to their opinion about the “abortion is killing of fetus”
Respondents’ opinion about Frequency Percentage the “abortion is killing of fetus” Agree 463 77.2 Disagree 94 15.7 Don't know 43 7.2 Total 600 100.0
Unwanted pregnancies led to abortions and due to abortions life threatening complications arise. Most of the people believed that abortion is killing of fetus. Table 4.47 shows that a significant majority (77.2 percent) of the respondents agreed with the opinion “abortion is killing of fetus”, while 15.7 percent of them disagreed and 7.2 percent of the respondents had no knowledge about the opinion “abortion is killing of fetus”.
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4.1.7: Knowledge and Practices of Family Planning Methods Table 4.48: Distribution of the respondents according to their knowledge about the family planning methods
Knowledge about family Frequency Percentage planning methods Yes 591 98.5 No 9 1.5 Total 600 100.0
Shield (1997) reported that use of contraceptive was determined by the male children in family and preference for a male child increase the fertility rate. Kumar et al. (2011) carried out study in India and identified that 63 percent of the women had knowledge about contraceptive methods. Zaidi et al. (2011) carried out a study in Rawalpindi (Pakistan) and reported that 99 percent of the females had knowledge about the current method of contraceptive. Table 4.48 indicates that a huge majority (98.5%) of the respondents had knowledge about family planning methods, while only 1.5 percent of them had no knowledge about family planning methods. So awareness about family planning methods was high in the selected community. Table 4.49: Distribution of the respondents according to their awareness about the types of family planning methods N = 591* Awareness about methods Yes No F. % F. % Intra Uterine Contraceptive Device 416 70.4 175 29.6 Condom 446 75.5 145 24.5 Withdrawal 308 52.1 283 47.9 Tablet/Pills (oral) 480 81.2 111 18.8 Injections 487 82.4 104 17.6 Vasectomy and tubetomy 440 74.5 151 25.5 Avoid the active time 427 72.3 164 27.7 Nor plant 324 54.8 267 45.2 * 9 respondents had no knowledge about family planning methods (See Table 4.48).
Postnatal visits were also associated with contraceptive use after delivery to avoid repeated pregnancies in short time which lead to low birth weight and intra uterine growth retardation etc. (Kogan and Leary (1990). Kumar et al. (2011) identified in India that mothers who had knowledge about family planning, 95.7 percent of them knew about oral contraceptive pills, 34.1 percent knew nirodh (condom), 46.8 percent knew copper T,
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53.5 knew male sterilization, 79.7 percent knew female sterilization and only 1.1 percent knew injections as method of contraceptive. Table 4.49 presents the awareness about family planning methods. A majority i.e. 70.4 percent (out of 591) of the respondents had awareness about Intra Uterine Contraceptive Device (IUCD) contraceptive method, 75.5 percent of them had knowledge about condom and 52.1 percent of the respondents had knowledge about withdrawal contraceptive method. A number of the respondents (81.2 percent) had knowledge about the contraceptive tablets/pills (oral), 82.4 percent of the respondents had knowledge about injection, 74.5 percent, 72.3 percent and 54.8 percent of them had knowledge about vasectomy and tubetomy, avoid the active time and nor plant, respectively. It shows that significant awareness was there for family planning methods. Table 4.50: Distribution of the respondents according to the family members who had positive attitude towards family planning
Family members Frequency Percentage Husband 427 72.3
Mother-in-law 40 6.8
Friends 20 3.4
Relatives 21 3.6
Others (sister in-law, aunty 83 14.0 etc.) Total 591* 100.0 *9 respondents had No knowledge about family planning methods
Attitude of the husband is an important factor associated with the utilization and non utilization of contraceptive methods. Kumar et al. (2011) revealed that 17.5 percent of the respondent's husbands did not like to use contraceptive methods. Jaffar (1998) studied the factors influencing the practices of family planning among married women in Quetta, Pakistan. It was found out that almost fifty percent of mothers either did not have support of their husband for the use of family planning methods or they believed family planning is against Islam. Naqvi et al. (2011) in a study carried out in Karachi, Pakistan reported that 60 percent of the husbands supported the wives for the use of contraceptive methods. Table 4.50 reveals that 72.3 percent of the respondents reported that keeping in view the number of kids that had their husbands had positive attitude regarding family
81 planning, 6.8 percent of them told that their mother-in-laws had positive attitude towards family planning and only 3.4 percent of them said that their friends had positive attitude regarding family planning. Whereas, 3.6 percent of the respondents’ relatives and 14.0 percent of them told that other family members like sister-in-law, aunty and cousins etc. had positive attitude regarding family planning. Table 4.51: Distribution of the respondents according to their opinion towards the Islamic point of view about family planning
Islamic point of view about Frequency Percentage family planning Allows 263 43.8 Disallows 256 42.7 Neutral 81 13.5 Total 600 100.0
Kumar et al. (2011) conducted a study and the findings revealed that 30.7 percent of the respondents believed that use of contraceptive is against religion so they did not use contraceptive methods to avoid pregnancy and to control the size of family. Jaffar (1998) found that 50 percent of mothers either did not have support of their husband for the use of family planning methods or they believed that family planning is against their religion. Naqvi et al. (2011) in a study reported that 65 percent of mother in Pakistan thought that use of contraceptive is not allowed in Islam. Table 4.51 represents the respondents’ opinion towards the religious point of view about family planning. Table 46 indicates that 43.8 percent of the respondents had thinking that their religion allows the family planning, while 42.7 percent of them reported that their religion disallows the family planning and remaining 13.5 percent of the respondents were neutral about the religious point of view about family planning.
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4.1.8: Breast Feeding Table 4.52: Distribution of the respondents according to their family likes breast feeding
Family choices for breast Frequency Percentage feeding Yes 594 99.0 No 6 1.0 Total 600 100.0
Howlader and Bhuiyan (1999) reported that in Bangladesh 92 percent of mothers breast feed their children. McLachlan and Forster (2006) observed in a study that partners of 83 percent of the Turkish women like breast feeding of their kids while 64 percent of Australian mothers perceived that their partners wanted them to breast feed their children.
Table 4.52 indicates that respondents’ family’s point of view regarding breast feeding; it reflects that 99.0 percent of the respondents reported that their family likes breast feeding; only 1.0 percent of them gave negative point of view Table 4.53: Distribution of the respondents according to the feeding practice for their children Feeding practice Frequency Percentage Breast feeding 435 72.5 Bottle feeding 23 3.8 Both 142 23.7 Total 600 100.0
American Academy of Pediatrics recommended breast feeding from six months to twelve months for good for mothers and children. In Muslim society the duration of breast feeding can be prolonged up to two years. Thapa (1988) found out that breast feeding is most economical and best nutritional source for infants. Breast milk especially colostrums contains antibodies which are very important for the protection of infants from gastrointestinal diseases. It was also found out that breast milk feeding is very difficult for working women. McLachlan and Forster (2006) found that 98 percent of Turkish mothers breast fed their babies as compared to 84 percent Australian mothers. Table 4.53 indicates the feeding practices for their children. A number of the respondents (72.5 percent) had breast feeding practices for their children, only 3.8 percent
83 of them had bottle feeding practice and 23.7 percent of the respondents used breast and bottle feeding for their children.
Table 4.54: Distribution of the respondents according to the duration of breast feeding of last child
Duration of breast feeding Frequency Percentage 1-6 months 52 9.0 7-12 months 112 19.4 13-18 months 42 7.3 19-24 months 371 64.3 Total 577* 100.0 * 23 respondents had bottle feeding practices Colostrums or the first milk also called immune milk is a full of immune stimulating factors, proteins, antibodies, carbohydrates and low in fat. It is very important to develop immune system of newborns. Howlader and Bhuiyan (1999) reported that in Bangladesh 92 percent mother breast feed their children and mean duration of breast feeding was 30 months. Breast feeding is also encouraged by religion (Islam). It is narrated in Holy Quran that it is the responsibility of mothers to breast feed their kids for two years (Translation by Ali, 1975). Table 4.54 indicates that only 9.0 percent (out of 577) of the respondents had 1-6 months’ duration of breast feeding, 19.4 percent of them had 7-12 months duration, 7.3 percent of them had 13-18 months duration and 64.3 percent of the respondents had 19 and or above months duration of breast feeding of last child. This long breast feeding time showed very positive sign for the health of babies and gape between two babies. 4.1.9: Immunization (Injections and Polio drops) Table 4.55: Distribution of the respondents whether they immunized their baby
Immunized their baby Frequency Percentage Yes 583 97.2 No 17 2.8 Total 600 100.0
Immunization of children is an important step to prevent disease of children which can be prevented through vaccination and help to reduce neonatal mortality. A study conducted by Ayaz and Saleem (2010) showed that 81.1 percent of the newborns were vaccinated for BCG and polio and in our current study as Table 4.55 reveals that a huge majority i.e. 97.2 percent of the respondents immunized their baby, while 2.8 percent of
84 them replied negatively so there is increasing trend of immunization of baby among mothers. According to WHO (2013), the BCG vaccination coverage in Pakistan in year 2012 was 95 percent.
Table 4.56: Distribution of the respondents according to the place of getting immunization services/injection n = 583 Immunized their baby Yes No Frequency Percentage Frequency Percentage Government hospital 401 68.8 182 31.2 Pvt. Hospital 51 8.7 532 91.3 Doctor 41 7.0 542 93.0 Health Workers Team 570 97.8 13 2.2 came home *17 respondents did not vaccinate their babies Vaccination of children is global topic and is mostly run by Government agencies with the help of international donors like WHO, UNICEF. In Pakistan Expanded Program on Immunization (EPI) stated in 1976 with the help of WHO and UNICEF. The aim was to control six prominent childhood diseases (tuberculosis, diphtheria, pertussis, tetanus, polio and measles). For vaccination of children most of the population relied on government health facilities. Immunization of babies is a long process and continued up to five year of the age. Table 4.56 reveals that 97.8 percent of the respondents immunized their babies from health workers team. 68.8 percent of the respondents immunized their babies from Govt. hospitals and only small number i.e. 8.7 percent and 7.0 percent immunized their babies from pvt. hospital and doctor respectively.
Table 4.57: Distribution of the respondents whether they injected for tetanus texoid
Injection of tetanus texoid Frequency Percentage Yes 515 85.8 No 85 14.2 Total 600 100.0
Naeem et al. (2010) reported that in Peshawar, Pakistan 55 percent of mother were completely vaccinated for tetanus texoid and 78 percent of the mothers received at least one injection of tetanus texoid during pregnancy. According to WHO (2013), the
85 national immunization figure of Pakistan for year 2012 was 68 percent so in our current study the immunization was more than the national figure. Table 4.57 reveals that 85.8 percent of the respondents reported that they took the injection of tetanus texoid, while 14.2 percent of them replied negatively. Table 4.58: Distribution of the respondents according to the number of injection of tetanus texoid
No. of injection of tetanus Frequency Percentage texoid One 26 5.0 Two 212 41.2 Three 219 42.5 Four 20 3.9 Five 31 6.0 Six 7 1.4 Total 515 100.0
Table 4.58 reveals that only 5.0 percent (out of 515) of the respondents were taking one injection of tetanus texoid, while 41.2 and 42.5 percent of the respondents were taking injection of tetanus texoid twice and thrice, respectively. Just 3.9 percent, 6.0 percent and 1.4 percent of the respondents were taking injection of tetanus texoid 4th, 5th and 6th times, respectively.
Table 4.59: Distribution of the respondents according to the place of injection of tetanus texoid
Place of injection of tetanus Frequency Percentage texoid Government hospital 301 58.4 Pvt. Hospital 71 13.8 Doctor 68 13.2 Health Worker Team came 75 14.6 home Total 515* 100.0 * 85 respondents never taking tetanus toxoid injection
Table 4.59 shows that more than a half i.e. 58.4 percent (out of 515) of the respondents were taking injection of tetanus texoid from the government hospitals, while 13.8 percent of them from private hospitals and 13.2 percent of them told that they were taking injection of tetanus texoid during pregnancy from doctors. Whereas, 14.6 percent
86 of the respondents told that they were taking injection of tetanus texoid during pregnancy from health worker team. Government hospitals and health workers teams were the two dominants sources for tetanus texoid immunization which were used more than 60 percent collectively.
Table 4.60: Distribution of the respondents according to the most concerned about their health in their family Most concerned about their Frequency Percentage health in their family Husband 401 66.8 Mother in-law 56 9.3 Friends 2 .3 Mother 79 13.2 Any other (sister in-law, 62 10.3 uncle etc.) Total 600 100.0
The husband is the only person whose behavior and attitude give confidence to wife. The best husband always takes care of his wife and gives her authority and strength. ”. Allah says: "O you who believe! You are forbidden to inherit women against their will, and you should not treat them with harshness, that you may take away part of the Mahr (dowry, bridal-money given by the husband to his wife at the time of marriage) you have given them, unless they commit open illegal sexual intercourse. “And reside with them respectably. If you hate them, it is possible that you hate a thing and Allah gets through it a big deal of goodness" (Al-Quran-An-Nisa’ 4:19). Table 4.60 indicates that 66.8 percent of the respondents reported that their husbands were most concerned about their health, while 9.3 percent of the respondents told that their mother-in-law was most concerned about their health only two respondents (0.3%) said that their friends were concerned about their health, mothers of 13.2 percent of the respondents and other family members like sisters in law, uncles, brothers etc. of 10.3 percent of the respondents were most concerned about their health. Table 4.61: Distribution of respondents regarding who accompanied them Who accompanied them to go to Frequency Percentage health center Husband 378 63.0 Mother in-law 62 10.3 Friends 13 2.2 Mother 67 11.2 Any other (sister in-law, uncle etc.) 80 13.3
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Total 600 100.0
In rural areas of Pakistan it is very difficult for the mothers to go out of home alone for hospital or at any health clinic. Cultural restrictions and other traditional norms make it difficult for them to go out and have access to health care facility. Khan et al. (2013) reported that in Swat (Pakistan) only 18 percent of mothers were allowed to go out alone to health facility and 82 percent of the mothers had to go to health care centers with family member like mother in law, husband or mother. Table 4.61 reveals that 63.0 percent of the respondents went to health care centers with their husbands, while 10.3 percent of them told that they went to health care center with mother-in-laws, 2.2 percent of them said that they went with their friends. About 11.2 percent of the respondents reported that they went to health care center with their mothers and 13.3 percent of them told that they went with others like sister-in-law, uncle, cousins etc.
Table 4.62: Distribution of the respondents regarding who supported them financially for medicine
Financial support by Frequency Percentage Husband 413 68.8 Mother in-law 49 8.2 Friends 5 .8 Mother 61 10.2 Any other (brother in-law, 72 12.0 uncle etc.) Total 600 100.0
Culturally in a family, husband had to look after her wife and to fulfill all her financial requirements. In Islam it is the responsibility of the husband to fulfill all the needs of wife and children. Whether joint family system or nuclear family system main responsibility of wife lies with husband. Table 4.62 shows that 68.8 percent of the respondents reported that their husbands supported them financially for medication, while 8.2 percent of them told that their mother in-laws supported them financially to get medicine and other services and 0.8 percent reported that their friends supported them financially to get medicine and other services. About 10.2 percent of the respondents’ mothers supported them and others like
88 uncle, brother, brother-in-law of 12.0 percent supported them financially to get medicine and other medical services. Table 4.63: Distribution of the respondents according to prefer TBAs for these services in their locality
Preference of TBAs for Frequency Percentage these services in their locality Yes 437 72.8 No 163 27.2 Total 600 100.0
Khalil (2004) reported that almost 70 percent of the mothers prefer TBA (locally called Dai) of the area for delivery care services. Poor quality of services provided by the hospitals also prevented them for going to hospital to avail health services. So role of TBAs cannot be denied as in our current study as shown in the Table 4.63 reflects that a large majority i.e., 72.8 percent of the respondents liked TBAs in their locality while 27.2 percent of them were replied negatively. Table 4.64: Distribution of the respondents according to their knowledge of any other mother die during delivery in their locality
Any other mother die Frequency Percentage during delivery in their locality Yes 335 55.8 No 265 44.2 Total 600 100.0
Rate of maternal mortality rate in Pakistan in 2007 was 500 maternal deaths per 100,000 live births (UNFPA, 2007) but over the period of time there was improvement in the health status of mothers. Rate of maternal mortality Pakistan reduced up to 260 deaths per 100,000 live births (CIA, 2013) but still it is very high. It is very common for the rural mother to know about any death during delivery in the locality. Table 4.64 shows that a substantial proportion (55.8 percent) of the respondents reported positively about any mother died during the delivery in their locality, while 44.2 percent of them told that they did not know the death of any mother who died during delivery in their locality.
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4.1.10: Influence of culture Table 4.65: Distribution of the respondents according to their opinion about the some traditional believes N = 600 Scale: 1 = strongly agree, 2 = agree, 3 = don’t know, 4 = disagree and 5 = strongly disagree Statements Strongly Agree Don’t Disagree Strongly Mean Std. agree know disagree Dev. Within 40 days 34.2 33.3 0.2 22.7 9.7 2.40 1.40 after delivery mother should not go for medical checkup With 40 days after 37.7 34.2 2.0 18.8 7.3 2.24 1.32 delivery a baby not taken medical treatment Traditional 33.5 35.8 0.2 20.0 10.5 2.38 1.39 treatment (herbs suggested by elders) was tested before going to the doctor for baby Sometimes 32.0 33.8 4.5 18.8 10.8 2.43 1.38 children become ill because of jado and tona by bad people Women should 49.8 33.3 1.2 8.7 7.3 1.91 1.23 avoid taking meat during post- delivery
Table 4.65 reveals that 34.3 percent of the respondents strongly agreed, 33.3 percent of them agreed with the statement “within 40 days after delivery mother did not go out of home ever for medical checkup”, only 0.2 percent of them had no knowledge, 22.7 percent of them disagreed and 9.7 percent of them strongly disagreed with this statement. About 37.7 percent of the respondents strongly agreed, 34.2 percent of them agreed with the statement “with 40 days after delivery a baby should not be taken out of home ever if baby needs medical treatment”, only 2.0 percent of them had no knowledge, 18.8 percent of them disagreed and 7.3 percent of them strongly disagreed with this statement.
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About one-third (33.5 percent) of the respondents strongly agreed, 35.8 percent of them agreed with the statement “traditional treatment (herbs suggested by elders) should be tested before going to the doctor for your child”, only 0.2 percent of them had no knowledge, 20.0 percent of them disagreed and 10.5 percent of them strongly disagreed with this statement. Little less than one-third i.e., 32.0 percent of the respondents strongly agreed, about one-third i.e., 35.3 percent of them agreed with the statement “some times children become ill because of jado and tona by bad people. Only 4.5 percent of the respondents had no knowledge, 18.8 percent of them disagreed and 10.8 percent of them strongly disagreed with this statement. About a half (49.8 percent) of the respondents strongly agreed, about one-third i.e., 33.3 percent of them agreed with the statement “women should avoid taking meat during post-delivery period because it is very heavy for both for mother and her baby”, only 1.2 percent of them had no knowledge, 8.7 percent of them disagreed and 7.3 percent of them strongly disagreed with this statement. 4.1.11: Constraints in Utilization of Antenatal and Postnatal Services. Table 4.66: Distribution of the respondents according to their opinion about maternal health services are costly for them to bear
Maternal health services are Frequency Percentage costly for them to bear To a great extent 117 19.5
To some extent 233 38.8
Not at all 250 41.7
Total 600 100.0
Table 4.66 represents the respondents’ opinion about maternal health services are costly for them to bear. About 19.5 percent of the respondents were agreed ‘to a great extent’ and 38.8 percent of them agreed ‘to some extent’ with the opinion “maternal health services are costly for them to bear”, whereas 41.7 percent of them were disagreed with this opinion. Khan et al. (2013) in a study also reported that 49 percent of the mothers delivered at home only because it was expensive to deliver at any health facility.
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4.1.12: Constraints Table 4.67: Distribution of the respondents according to their opinion about the following constraints N = 600 Constraints Strongly Agree No Disagree Strongly Mean Std. agree (%) opinion (%) disagree Dev. (%) (%) (%) Family annoyed, if you 15.5 43.2 17.8 19.5 4.0 2.53 1.09 receive antenatal and postnatal services Number of pregnancies 6.5 23.8 20.8 39.3 9.5 3.21 1.11 affect the reception of antenatal and postnatal services Sanitation standard of 10.5 38.3 12.3 34.0 4.8 2.84 1.15 the hospital is not likable by the mothers Service provider is not 9.0 37.2 11.3 36.7 5.8 2.93 1.15 up to mark of health measures Complete dosages of 5.0 8.5 18.5 56.3 11.7 3.61 .97 medicine by the staff as recommended by the doctors during your stay in hospital Behavior of the hospital 5.5 9.7 12.0 53.3 19.5 3.72 1.06 staff is satisfactory Home distance from 9.5 21.0 2.2 42.5 24.8 3.52 1.32 hospital is a big factor in receiving such services I face difficulties leaving 8.7 28.5 1.0 26.2 35.7 3.52 1.43 the home for visiting health care center because no one left to look after the home I face difficulties leaving 9.7 29.5 1.0 24.0 35.8 3.47 1.46 the home for receiving health care services because no one adult left to look after the children Scale: 1= Strongly Agree, 2 = Agree, 3 = Do not know, 4 = Disagreed, 5= St. disagree
Table 4.67 shows the constraints in utilization of antenatal and postnatal services. About 15.5 percent of the respondents strongly agreed, 43.2 percent of them agreed with the constraint “Family annoyed, if they receive antenatal and postnatal services”, 17.8
92 percent of them had no knowledge, 19.5 percent of them disagreed and 4.0 percent of them strongly disagreed with this constraint. Only 6.5 percent of the respondents strongly agreed, 23.8 percent of them agreed with the constraint “number of pregnancies affect on the reception of antenatal and postnatal services”, 20.8 percent of them had no knowledge, 39.3 percent of them disagreed and 9.5 percent of them strongly disagreed with this constraint. About 10.5 percent of the respondents strongly agreed, 38.3 percent of them agreed with the constraint “sanitation standard of the hospital is not acceptable by the mothers”, 12.3 percent of them had no knowledge, 34.0 percent of them disagreed and 4.8 percent of them strongly disagreed with this constraint. About 9.0 percent of the respondents strongly agreed, 37.2 percent of them agreed with the constraint “Service provider is not up to mark of health measures”, 11.3 percent of them had no knowledge, 36.7 percent of them disagreed and 5.8 percent of them strongly disagreed with this constraint. Only 5.0 percent of the respondents strongly agreed, 8.5 percent of them agreed with the constraint “complete dosages of medicine by the staff as recommended by the doctors during their stay in hospital”, 18.3 percent of them had no knowledge, 56.3 percent of them disagreed and 11.7 percent of them strongly disagreed with this constraint. Only 5.5 percent of the respondents strongly agreed, 9.7 percent of them agreed with the constraint “behaviour of the staff of the hospital is satisfactory”, 12.0 percent of them had no knowledge, little more than a half (53.3 percent) of them disagreed and 19.5 percent of them strongly disagreed with this constraint. Only 9.5 percent of the respondents strongly agreed, about one-fifth (21.0 percent) of them agreed with the constraint “distance of home from the hospital is a big factor in receiving such services”, 2.2 percent of them had no knowledge, a major proportion (42.5 percent) of them disagreed and 24.8 percent of them strongly disagreed with this constraint. Almost 9 percent of the respondents strongly agreed, 28.5 percent of them agreed with the constraint “they face difficulties leaving the home for visiting health care center because no one left to look after the home”, 1.0 percent of them had no knowledge, 26.2 percent of them disagreed and 35.7 percent of them strongly disagreed with this constraint.
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Almost 10 percent of the respondents strongly agreed, 29.5 percent of them agreed with the constraint “they face difficulties leaving home for receiving health care center because no one adult left to look after the children”, 1.0 percent of them had no knowledge, 24.0 percent of them disagreed and 35.8 percent of them strongly disagreed with this constraint. 4.1.13: Respondents’ opinion about the normative cost of health care services Table 4.68: Distribution of the respondents according to their opinion about the normative cost of health care services N = 600 Respondents’ opinion Strongly Agree No Disagree Strongly Mean Std. about the normative agree (%) opinion (%) disagree Dev. cost of health care (%) (%) (%) services Visit the health 40.0 33.5 0.2 20.2 6.2 2.19 1.32 clinics is fearful Community values do 36.7 28.3 1.5 23.8 9.7 2.41 1.43 not support the visit to the health clinics It is better to rely on 34.5 30.3 2.2 25.0 8.0 2.42 1.38 traditional medicines because of restriction on women mobility in rural areas. For young women, it 32.0 28.7 3.8 26.8 8.7 2.51 1.40 is not respectful to visit health clinics It is shameful and 33.2 40.0 1.2 16.2 9.5 2.29 1.33 embarrassing to discuss the reproductive matters with health care providers Husbands attitude 27.7 12.8 2.7 38.0 18.8 3.08 1.54 affect mother and child health in the perspective of receiving these services Problems faced by the 27.3 15.3 2.0 40.0 15.3 3.01 1.50 mother in receiving such services during her first delivery affect her later pregnancies Scale: 1= Strongly Agree, 2 = Agree, 3 = Do not know, 4 = Disagreed, 5= St. disagree
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The Table 4.68 shows that 40 percent of the respondents strongly agreed and 33.5 percent agreed of the constraints “I face hesitation to visit the health clinics because of fears of elders” while 0.2 percent didn’t know and 20.2 percent disagree with this statement and 6.2 percent strongly disagree. The data show that 36.7 percent of the respondents strongly agreed and 28.3 percent agreed that “Community values do not support the visit to the health clinics” and 1.5 percent don’t have any opinion and 23.8 percent disagreed and 9.7 percent strongly disagreed. Still huge percentage of the respondents confirmed community values as constraints to visit health clinic. The data show that 34.5 percent respondents strongly agreed that “It is better to rely on traditional medicines because of restriction on women mobility in rural areas” and 30.3 percent agreed with this statement while 2.2 percent did have any opinion about that. While 25 percent of the respondents disagreed with is statement and 8 percent strongly disagreed. It means two third of the respondents think that its better to rely on traditional medicines and they face mobility problem. The table shows that 32 percent of the respondent strongly agreed that “For young women like me it is not respectful to visit health clinics” and 28.7 percent agreed with this statement while 3.8 did not know about that and 26.8 percent disagreed with this statement and 8.7 percent strongly disagreed. The data analysis reveals that 33.2 percent of the respondents strongly agreed that “It is shameful and embarrassing to discuss the reproductive matters with health care providers” and 40 percent agreed that matter should discussed with health services providers. 1.2 percent did not have any opinion and 16.2 percent disagreed with this statement and 9.5 percent strongly disagreed with this statement. The data show that husband attitude is also an influencing factor and 27.7 percent of the respondents strongly agreed and 12.8 percent agreed that “Husbands attitude affects mother and child health in receiving these services” while 2.7 percent did not know about that and 38 percent disagreed and 18.8% strongly disagreed. The data show that 27.3 percent of the respondents strongly agreed and 15.3 percent agreed with the statement that “In your opinion the problems faced by the mother in receiving such services during her first delivery affect the last pregnancies” while 2 percent of the respondents did not have any opinion and 40 percent disagreed and 15.3 percent strongly disagreed with the statement.
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Table 4.69: Distribution of the respondents according to the means for reaching hospital
Transport used to go to the Frequency Percentage hospital On foot 58 9.7 Public transport 265 44.2 Personal 98 16.3 Pvt. Vehicle 179 29.8 Any other 45 7.5 Total 600 100.0
Distance of residence from health care facility and the socio economic status of the family determine the type of transport used to reach health care facility. Kaufmann (2002) also reported that availability of transport was associated with the utilization of maternal health care services. Ghaffar et al. (2012) also reported that distance from health care facility was associated with its utilization of health care services, more the distance less was the utilization of health facilities. Table 4.69 reflects that 9.7 percent of the respondents went hospital on foot, 44.2 percent used public transport (bus, van, motorcycle rikshaw), 16.3 percent used personal vehicles, 29.8 percent of the respondents used private vehicle to go the hospital and 7.5 percent of used any other transport to go to the hospital. As the most of the respondent belong to poor class with less than 10,000 rupees monthly income, majority of the respondents were using public transport.
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Table 4.70: Distribution of the respondents according to suggestions to the policymakers for creating and ensuring conducive environment at the health outlets for the maximum utilization of antenatal and postnatal heath care services N= 600 Suggestions Strongly Agree Don’t Disagree Strongly Mean Std. agree know disagree Dev. Service provider staff 25.3 62.3 5.8 1.5 5.0 2.02 .91 should be more trained and highly qualified For improving the 19.5 64.3 9.8 1.2 5.2 1.92 .89 standard of services, do you think that license from health department should be provided to TBAs for their authorized services Media plays 23.2 62.7 9.8 0.8 3.5 2.01 .82 important role in enhancement of mother health care Do you think family 31.3 59.7 4.5 0.5 4.0 2.14 .85 planning department is playing its role properly Do you think 39.3 55.0 1.8 0.5 4.0 2.26 .82 improvement of sanitation in hospitals can improve mother health Government should 45.3 45.5 5.2 0.5 3.5 2.29 .87 prepare a policy for the betterment of mother health How much 56.2 38.8 1.0 0.3 3.7 2.44 .85 importance you give to the mother health. Scale: 1= Strongly Agree, 2 = Agree, 3 = Do not know, 4 = Disagreed, 5= St. disagree
Table 4.70 presents the suggestions for policy making regarding safeguard antenatal and postnatal services. Quite big majority i.e. 25.3 percent of the respondents strongly agreed and 62.3 percent of them agreed with the suggestion “service provider
97 staff should be more trained and highly qualified”, 5.8 percent of them had no knowledge, only 1.5 percent of them disagreed and 5 percent of them strongly disagreed with this suggestion. About one fifth 19.5 percent of the respondents strongly agreed and 63.4 percent of them agreed with the suggestion “for improving the standard of services, do you think that license from health department should be provided to TBAs for their authorized services”, 9.8 percent of them had no knowledge, only small proportion 1.2 percent of them disagreed and 5.2 percent of them strongly disagreed with this suggestions. Out of the total respondents 23.2 percent strongly agreed and 62.7 percent of them agreed with the opinion “media may plays an important role in the enhancement of mother health care”, 9.8 percent of them had no knowledge, only 0.8 percent of them disagreed and 3.5 percent of them strongly disagreed with this opinion. About 31.3 percent of the respondents strongly agreed and 59.7 percent of them agreed with the opinion “family planning department is playing its role properly”, 4.5 percent of them had no knowledge, only negligible number 0.5 percent of them disagreed and 4.0 percent of them strongly disagreed with this opinion. More than one third of the respondents (39.3 percent) strongly agreed and 55.0 percent of them agreed with the opinion “improvement of sanitation in hospitals can improve mother health”, 1.8 percent of them had no knowledge, 0.3 percent of them disagreed and just 3.5 percent of them strongly disagreed with this opinion. A large number of the respondents (45.5 percent) strongly agreed and 45.3 percent of them agreed with the suggestion “Government should prepare a policy for the betterment of mother health”, 5.2 percent of them had no knowledge, a small proportion (0.5 percent) of them disagreed and only 3.5 percent of them strongly disagreed with this suggestion. More than half (56.2 percent) of the respondents strongly agreed and 38.8 percent of them agreed with the importance of mother health they received, while 1.0 percent of them had no knowledge, only 0.3 percent of them were disagreed and 3.7 percent of them were strongly disagreed with the importance of mother health they received. 4.2: BI-VARIATE ANALYSIS 4.2.1 Index Variable Construction To study the combine effect of all the variables in predicting the response variable all the statements in matrix questions are combined together to form a single prime or
98 main variable known as index variable. However, before the development of index variable, it is pre-requisite to ensure the element of consistency among all the items in the matrix question. For this purpose, a reliability check is carried out and the value of Cronbatch Alpha is determined. The Statistical Package for Social Sciences (SPSS) used to find Cronbatch Alpha values. The value of Alpha is 0.8 to 1.0 shows good reliability; however the value of Alpha 0.7 to 1.0 is acceptable. Furthermore, the suitable degree of reliability depends upon the use of the instrument. The goal in designing a reliable instrument is for scores on similar items to be related (internally consistent), but for each to contribute some unique information as well (Cronbach, 1951). So all of the statements in the matrix questions can be combined to develop an index variable. This facilitates the study of combine effect that otherwise is not possible. In reliability if a value of Alpha is lower than accepted value, then the element of consistency between different items is determined individually and weaker item is excluded from the variable to improve the value of Alpha. On confirmation of element of consistency, the score on all the items in a matrix question recorded through response categories is summed up. The minimum and maximum value is determined through sub-menu descriptive statistics followed by frequencies. The next step the maximum and the remainder is divided with the number of descried level or categories in index variable. Example This procedure can be explained, for example the variable ‘awareness about antenatal services’ asked during field survey comprised of a set of five antenatal services with three response categories. It is possible to study the responses recorded on each of the individual statement in the variable representing awareness about antenatal services by employing descriptive statistics and calculating the percentages. But in order to find combine affect of all the five services of awareness about antenatal care, an index variable is required to be constructed after ensuring the element of consistency among all the five dimensions through reliability analysis. To construct index variable, the scores on all the items in the matrix question representing awareness about antenatal services will be summed up and minimum and maximum score, mean score and value of standard deviation are determined. The subtraction of minimum score from the maximum and by dividing the remainder with the required levels or categories (which are three). This value will be used to calculate the 99 range of score in each level or category of the index variable. Actually this value is added to the lowest level of category and likewise the other levels or categories of index variable are constructed. For example, the index variable “awareness about antenatal services” has maximum and minimum score 15 and 7. The difference between maximum and minimum score is 8. It is desired to have three categories or levels of index variable “awareness about antenatal services”. 8 is divided by 3 (the level of categories) yielding the class interval of each category which is almost 3. The first category of awareness about antenatal services index variable is ranging from 7-9 indicating low level of awareness of antenatal services, the second category is ranging from 10-12 reflecting medium level of awareness of antenatal services, while the third category of the response variable is ranging from 13-15 indicating the high level of awareness of antenatal services index variable. By adopting the principle as discussed above, the index variables were subsequently used during bivariate analysis. Table 4.71: Indexation of different variables
Variables No. of items No. of Min. Max. Mean Standard Alpha in Matrix categories Score Score Score Dev. value Questions in Index variable Awareness about 5 3 7 15 12.27 2.58 0.8290 antenatal services Awareness about 8 3 11 22 18.25 2.47 0.7590 postnatal services Utilization of 5 2 5 10 6.53 2.37 .8464 antenatal services Utilization of 8 2 8 14 8.90 2.76 .7762 postnatal services Availability of 8 2 8 16 11.42 2.87 0.7195 health facilities Influence of 3 5 3 15 9.41 2.91 0.7413 culture
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4.2.2: TESTING OF HYPOTHESES Hypothesis 1: Distance from health facilities and utilization of antenatal care services are associated
Table 4.72: Association between distance of any health facility and utilization of antenatal care services
Distance any health Utilization of antenatal care services Total care center for Low Medium High antenatal care services 1 to 5 km 29 139 154 322 9.0% 43.2% 47.8% 100.0% More than 5 km 73 132 73 278 26.3% 47.5% 26.3% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 45.08 (P-value = .00**) γ = -.443 (P-value = .00**) ** = Highly-significant
Table 4.72 presents the association between distance of any health facility and utilization of antenatal care services. The chi-square value (45.08) shows a highly significant association between respondents’ residential distance to any health care center for antenatal and postnatal care services and utilization of antenatal care services. The gamma value shows a negative relationship between the variables. It means more the distance of any health care center; less is the utilization of antenatal care services. Above table shows that if the respondents had less distance (1-5 km) from health care facility then they had low (9.0%), medium (43.2%) and high (47.8%) utilization of antenatal care services. On the other hand if the respondents had more distance (more than 5 km) from health care services then they had low (26.3%), medium (47.5%) and high (26.3%) level utilization of antenatal care services. So the hypothesis “distance from health facilities and utilization of antenatal care services are associated” is accepted. Ghaffar et al. (2012) also reported that distance from health care facility was associated with its utilization, more the distance less will be the utilization. Mwaniki et al. (2002) reported that in mothers living in areas less than 5km away from health facility more likely to use health care facilities than mothers living in areas 5km or more
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Hypothesis 2: Age of the respondents and utilization of antenatal care services are associated
Table 4.73: Association between age of the respondents and utilization of antenatal care services
Age of the Utilization of antenatal care services Total respondents Low Medium High Up to 25 24 68 68 160 15.0% 42.5% 42.5% 100.0% 26-35 46 171 139 356 12.9% 48.0% 39.0% 100.0% 36 and above 32 32 20 84 38.1% 38.1% 23.8% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 33.10 (P-value = .00**) γ = -.210 (P-value = .00**) ** = Highly Significant
Table 4.73 presents the association between age of the respondents and utilization of antenatal care services. The chi-square value (33.10) shows a highly significant association between age of the respondents and utilization of antenatal care services. The gamma value shows a negative relationship between the variables. It means young respondents had more utilization of antenatal care services as compared to old age respondents. Above table shows that young age (up to 25) respondents had low (15.0%), medium (42.5%) and high (42.5%) level utilization of antenatal care services, while middle age (26-35) respondents had low (12.9%), medium (48.0%) and high (39.0%) level utilization of antenatal care services, whereas old age (36 and above) respondents had low (38.1%), medium (38.1%) and high (23.8%) level utilization of antenatal care services. Data clearly indicate that majority of the low age respondents had medium to high level use of antenatal care services as compared to old age. Wong et al. (1987) reported that in Philippines older mothers needed less prenatal services both in rural and urban areas. In study older women avoid medicine and gave less importance to modern health care services (Raghupathy, 1996). So the hypothesis “age of the respondents and utilization of antenatal care services are associated” is accepted.
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Hypothesis 3: Monthly family income of the respondents and utilization of antenatal care services are associated
Table 4.74: Association between monthly family income of the respondents and the utilization of antenatal care services
Monthly Income Utilization of antenatal care services Total (Rs.) Low Medium High Upto 5000 71 89 61 221 32.1% 40.3% 27.6% 100.0% 5001-10000 26 124 93 243 10.7% 51.0% 38.3% 100.0% 10001 and above 5 58 73 136 3.7% 42.6% 53.7% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 68.53 (P-value = = .00**) γ = .404 (P-value = = .00**) ** = Highly-significant
Table 4.74 presents the association between monthly income of the respondents’ family and the utilization of antenatal care services. Chi-square value show a highly significant association between family income of the respondents and utilization of antenatal care services. The gamma value shows a strong positive relationship between the variables. It means that high income respondents had more utilization of antenatal care services as compared to low income respondents. Above table also shows that low income (up to Rs. 5000) respondents had low (32.1%), medium (40.3%) and high (27.6%) level utilization of antenatal care services, middle income (Rs. 5001-10000) respondents had low (10.7%), medium (51.0%) and high (38.3%) level utilization of antenatal care services, whereas high income (Rs. 10001 and above) had low (3.7%), medium (42.6%) and high (53.7%) level utilization of antenatal care services. Family wealth has always a significant association with the place of delivery and utilization of maternal health care services which is one of the strongest factors associated with the use of skilled birth attendants (Fotso et al. 2009, Hazarika, 2010). Above results indicated that high income respondents had more utilization of antenatal care services as compared to low income respondents. So the hypothesis “family income of the respondents and utilization of antenatal care services are associated” is accepted.
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Hypothesis 4: Husbands education and utilization of antenatal care services are associated
Table 4.75: Association between husband’s education and the utilization of antenatal care services
Education Utilization of antenatal care services Total (husband) Low Medium High Illiterate 49 42 19 110 44.5% 38.2% 17.3% 100.0% Upto Middle 31 80 54 165 18.8% 48.5% 32.7% 100.0% Matric 17 87 90 194 8.8% 44.8% 46.4% 100.0% Above Matric 5 62 64 131 3.8% 47.3% 48.9% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0% χ2 = 104.59 (P-value = .00**) γ = .421 (P-value = .00**) ** = Highly significant
Table 4.75 presents the association between husband’s education and the utilization of antenatal care services. The chi-square value showed a highly significant association between husband’s education and the utilization of antenatal care services. The gamma value shows a strong positive relationship between the variables. It means husband’s education is positively associated with the utilization of antenatal care services. Above table shows that the illiterate respondents’ wives had low (44.5%), medium (38.2%) and high (17.3%) utilization level of antenatal care services, while wives whose husbands had up to Middle level education had low (18.8%), medium (48.5%) and high (32.7%) level utilization of antenatal care services. The wives whose husbands were having matriculate education level had low (8.8%), medium (44.8%) and high (46.4%) utilization of antennal care services whereas the wives of above matriculated husbands had low (3.8%), medium (47.3%) and high (48.9%) utilization of antenatal care services. Data clearly indicate that educated husbands’ wives had more utilization as compared to illiterate or low educated husband’s wives. So the hypothesis “Husbands education and utilization of antenatal care services are associated” is accepted. It is clear from the above table husband’s education positively associated with the utilization of antenatal care services. Similarly Kistiana (2009) reported that education level of husband and mother is
104 a strong independent variable significantly associated with utilization of antenatal care services. Hypothesis 5: Respondents’ education and utilization of antenatal care services are associated
Table 4.76: Association between education of the respondents and the utilization of antenatal care services
Respondents Utilization of antenatal care services Total education Low Medium High Illiterate 68 82 46 196 34.7% 41.8% 23.5% 100.0% Upto Middle 22 115 65 202 10.9% 56.9% 32.2% 100.0% Matric 7 47 65 119 5.9% 39.5% 54.6% 100.0% Above Matric 5 27 51 83 6.0% 32.5% 61.4% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 99.00 (P-value = .00**) γ = .461 (P-value = .00**) ** = Highly significant
Table 4.76 presents the association between education of the respondents and the utilization of antenatal care services. The chi-square value show a highly significant association between education of the respondents and their utilization of antenatal care services. The gamma value shows a strong positive relationship between the variables. Above table shows that illiterate respondents had low (34.7%), medium (41.8%) and high (23.5%) level utilization of antenatal care services, while respondents who had up to Middle level education had low (10.9%), medium (56.9%) and high (32.2%) level utilization of antenatal care services. The respondents who were matriculate had low (5.9%), medium (39.5%) and high (54.6%) utilization of antennal care services. Above matriculated respondents had low (6.0%), medium (32.5%) and high (61.4%) level utilization of antenatal care services. Data clearly indicates that educated respondents had more utilization as compared to low educated respondents. So the hypothesis “respondents’ education and utilization of antenatal care services are associated” is accepted. Khan et al. (1994) also found a positive association between mothers’ education
105 and utilization of maternal health care services. Mothers with high degree of literacy were more likely to avail modern antenatal and delivery services than those with low degree of literacy. Hypothesis 6: Total live births and utilization of antenatal care services are associated
Table 4.77: Association between total live births of the respondents and utilization of antenatal care services
Total live births Utilization of antenatal care services Total Low Medium High 1-2 26 119 104 249 10.4% 47.8% 41.8% 100.0% 3-4 34 93 89 216 15.7% 43.1% 41.2% 100.0% 5 and above 42 59 34 135 31.1% 43.7% 25.2% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 30.34 (P-value = .00**) γ = -.238 (P-value = .00**) ** = Highly Significant
Table 4.77 presents the association between total number live births of the respondents and utilization of antenatal care services. The chi-square value (30.34) shows a highly significant association between total live births of the respondents and utilization of antenatal care services. The gamma value shows a negative relationship between the variables. Above table also shows that majority of the respondents who had 1-2 live births had 10.4 percent, 47.8 percent and 41.8 percent of low, medium and high utilization of antennal care services respectively. The respondents who had 3-4 live births they had low (15.7%) medium (43.1%) and high (41.2%) utilization of antenatal care services, while if the respondents had 5 and above live births they had low (31.1%), medium (43.7%) and high (25.2%) level utilization of antenatal care services. It indicates that if the respondents had more live births then the utilization of antenatal care services by mothers was low. Mwaniki et al. (2002) also reported similar results that the mothers having more number of kids were less likely were interested to avail health care facilities. The research findings indicated that more live births had less utilization of antenatal care services. So
106 the hypothesis “total live births and utilization of antenatal care services are associated” is accepted. Hypothesis 7: Availability of medical health facilities and utilization of antenatal care services are associated
Table 4.78: Association between availability of medical health facilities and utilization of antenatal care services
Availability of Utilization of antenatal care services Total medical services Low Medium High Low 59 98 58 215 27.4% 45.6% 27.0% 100.0% Medium 38 163 143 344 11.1% 47.4% 41.6% 100.0% High 5 10 26 41 12.2% 24.4% 63.4% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 39.80 (P-value = .00**) γ = .382 (P-value = .00**) ** = Highly significant
Table 4.78 presents the association between availability of medical services and utilization of antenatal care services. The chi-square value (39.80) shows a highly significant association between availability of medical health services and utilization of antenatal care services. The gamma value shows a positive relationship between the variables. It means if the respondents had more availability of medical health facilities in their area then the utilization of antenatal health care services was increased by the respondents. Above table also shows that if the respondents had low level availability of medical health services then they had low (27.4%), medium (45.6%) and high (27.0%) level utilization of antenatal care services, while if the respondents had medium level availability of medical health facilities then had low (11.1%), medium (47.4%) and high (41.6%) level utilization of antenatal care services, whereas if the respondents had high level availability of medical health facilities then they had low (12.2%), medium (24.4%) and high (63.4%) level utilization of antenatal care services. So the hypothesis “availability of medical health facilities and utilization of antenatal care services are associated” is accepted.
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Hypothesis 8: Awareness level about antenatal care services and utilization of antenatal care services are associated
Table 4.79: Association between awareness about antenatal services and utilization of antenatal care services
Awareness level Utilization of antenatal care services Total about antenatal care Low Medium High services Low 14 5 5 24 58.3% 20.8% 20.8% 100.0% Medium 33 85 78 196 16.8% 38.4% 39.8% 100.0% High 55 181 144 380 14.5% 47.6% 37.9% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 35.03 (P-value = .00**) γ = .129 (P-value = .02*) * = Significant ** = Highly Significant
Table 4.79 presents the association between awareness about antental services and utilization of antenatal care services. The chi-square value (35.03) shows a highly significant association between awareness about antenatal services and utilization of antenatal care services. The gamma value shows a positive relationship between the variables. Above table represents that if the respondents had low level awareness about antenatal services then they had low (58.3%), medium (20.8%) and high (20.8%) level utilization of antenatal care services, whereas if the respondents had medium level awareness then they had low (16.8%), medium (38.4%) and high (39.8%) level utilization of antenatal care services, whereas if the respondents had high level awareness then they had low (14.5%), medium (47.6%) and high (37.9%) level utilization of antenatal care services. It means awareness level of respondents for antenatal services are positively associated with the utilization of antenatal care services. Similarly Sheriff and Singh (2002) reported that the women who were exposed to radio, television and newspaper for maternal care services their rate of utilization of these services was significantly high. Studies conducted by Obermeyer (1993) in Morocco and Tunisia found that listening radio and watching television were significantly associated with the utilization of pre and
108 postnatal care services. Bhattacherjee et al. (2013) found lack of awareness as one of the barriers for utilization of maternal health care services. Data clearly depicts that those respondents who had more awareness had more use of antenatal care services. So the hypothesis “awareness about antenatal care services and utilization of antenatal care services are associated” is accepted. Hypothesis 9: Influence of culture and utilization of antenatal care services are associated
Table 4.80: Association between influence of culture and utilization of antenatal care services
Influence of Utilization of antenatal care services Total culture Low Medium High Low 12 92 115 219 5.5% 42.0% 52.5% 100.0% Medium 43 132 87 262 16.4% 50.4% 33.2% 100.0% High 47 47 25 119 39.5% 39.5% 21.0% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 78.34 (P-value = .00**) γ = -.453 (P-value = .00**) ** = Highly Significant
Table 4.80 presents the association between influence of culture and utilization of antenatal care services. The chi-square value (78.34) shows a highly significant association between influence of culture on the respondents and utilization of antenatal care services. The gamma value shows a strong negative relationship between the variables. It means if the culture had more influence on the utilization of antenatal care services then the utilization of antenatal care services was low. Above table depicts that if the culture had low level influence the respondents had low (5.5%), medium (42.0%) and high (52.5%) level utilization of antenatal care services, while if the culture had medium level influence they the respondents had low (16.4%), medium (50.4%) and high (33.2%) level utilization of antenatal care services, whereas if the culture had high level influence then they had low (39.5%), medium (39.5%) and high (21.0%) level utilization of antenatal care services The collected data and its analysis clearly indicate that low influence of culture, more utilization of antenatal care services and high influence of
109 culture and low utilization of antenatal care services. Choudhry and Ahmad (2011) reported that due to traditional beliefs and rituals mothers delayed to avail the health care services even in case of complications. So the hypothesis “influence of culture and utilization of antenatal care services are associated” is accepted.
Hypothesis 10: Cost of maternal health services and utilization of antenatal care services are associated Table 4.81: Association between cost of maternal health services and utilization of antenatal care services
Cost of maternal Utilization of antenatal care services Total health services Low Medium High Not at all 29 98 123 250 11.6% 39.2% 49.2% 100.0% To some extent 49 116 68 233 21.0% 49.8% 29.2% 100.0% To a great extent 24 57 36 117 20.5% 48.7% 30.8% 100.0% Total 102 271 227 600 17.0% 45.2% 37.8% 100.0%
χ2 = 25.44 (P-value = .00**) γ = -.258 (P-value = .00**) ** = Highly Significant Table 4.81 presents the association between respondents’ perception that maternal health services are costly for them to bear and utilization of antenatal care services. The chi-square value (25.44) shows a highly significant association between respondents’ perception that maternal health care services are costly for them to bear and utilization of antenatal care services. Gamma value shows a negative relationship between the variables. It means cost of maternal health care services is negatively associated with the utilization of antenatal care services. Above table shows that the if the respondents bear the cost of maternal health services then they had low (11.6%), medium (39.2%) and high (49.2%) level utilization, while if the respondents felt that the maternal health care services were ‘to some extent’ costly then they had low (21.0%), medium (49.8%) and high (29.2%) level utilization, whereas if the respondents had opinion that the maternal health services were costly ‘to a great extent’ then they had low (20.5%), medium (48.7%) and high (30.8%) level utilization of antenatal care services. Similarly Harris et al. (2010) in China reported that the cost of antenatal and postnatal care services was one of the important factors affecting the utilization of antenatal and postnatal care. So the
110 hypothesis “cost of antenatal care services and utilization of antenatal care services are associated” is accepted. Hypothesis 11: Distance from health facilities and utilization of postnatal care services are associated
Table 4.82: Association between distance from care facility and utilization of postnatal care services
Distance from Utilization of postnatal care services Total health care facility Low Medium High Up to 5 km 100 180 42 322 31.1% 55.9% 13.0% 100.0% More than 5 km 134 117 27 278 48.2% 42.1% 9.7% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 18.43 (P-value = .00**) γ = -.286 (P-value = .00**) ** = Highly Significant
The chi-square value (18.43) shows a highly significant association (P-value = .00) between distance from health care facility and utilization of postnatal care services. The gamma value shows a negative relationship between the variables. It means distance for health facility is negatively associated with the utilization of postnatal care services. Table 4.82 indicates 31.1 percent of the respondents who had low distance (up to 5 km) 31.1 percent of them had low utilization of postnatal services, 55.9 percent of them had medium and 13.0 percent of them had high utilization of postnatal services. If the respondents had more than 5 km distance then they had low (48.2%), medium (42.1%) and high (9.7%) utilization of postnatal care services. Bicego et al. (1997) found that due to long distance, lack of roads and transport facilities more than 84% of women who delivered their babies at home wanted to avail the facility of health care center for delivery. So the hypothesis “distance from health facilities and utilization of postnatal care services are associated” is accepted.
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Hypothesis 12: Age of the respondents and utilization of postnatal care services are associated
Table 4.83: Association between age of the respondents and utilization of postnatal care services
Age of the Utilization of postnatal care services Total respondents Low Medium High Upto 25 66 76 18 160 41.3% 47.5% 11.3% 100.0% 26-35 129 184 43 356 36.2% 51.7% 12.1% 100.0% 36 and above 39 37 8 84 46.4% 44.0% 9.5% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 3.46 (P-value = .483NS) γ = -.019 (P-value = .547NS) NS = Non-significant The chi-square value (3.46) shows a non-significant association between age of the respondents and utilization of postnatal care services. Gamma value also shows non- significant and negative relationship between the variables. Its mean young respondents had little more utilization as compared to old respondents. Table 4.83 shows that the 41.3 percent of the young (up to 25) respondents had low utilization, 47.5 percent of them had medium and only 11.3 percent of them had high utilization of postnatal care services. In middle age group (26-35), more than a half (51.7 percent) of the respondents had medium utilization, 12.1 percent of them had high and 36.2 percent of them had low utilization of postnatal care services. Whereas, in last age group (36 and above), 46.4 percent had low utilization, 44.0 percent of them had medium and 9.5 percent of them had high utilization of postnatal care services. Data clearly indicate that all age groups had similar utilization of postnatal care services. Similar findings were reported by Paul and Rumsey (2002) who found that in Bangladesh the type of facilities used at the type of delivery were the same regardless of the age of the mothers. So the hypothesis “age of the respondents and utilization of postnatal care services are associated” is rejected.
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Hypothesis 13: Monthly family income of the respondents and utilization of postnatal care services are associated
Table 4.84: Association between monthly family income of the respondents and the utilization of postnatal care services
Monthly Income Utilization of postnatal care services Total (Rs.) Low Medium High Upto 5000 108 90 23 221 48.9% 40.7% 10.4% 100.0% 5001-10000 95 126 22 243 39.1% 51.9% 9.1% 100.0% 10001 and above 31 81 24 136 22.8% 59.6% 17.6% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 27.13 (P-value = .00**) γ = .273 (P-value = .00**) ** = Highly Significant
The chi-square value shows a highly significant association between family income of the respondents and utilization of postnatal care services. The gamma value shows a strong positive relationship between the variables. Above results indicate that high income respondents had more utilization of postnatal care services as compare low income respondents. Above table depicts that 48.9 percent of low income families (up to Rs. 5000) had low utilization and 40.7 percent of them had medium and only 10.4 percent of them had high utilization of postnatal care services. In medium income group (Rs. 5001-10000) had low (39.1%), medium (51.9%) and high (9.1%) utilization of postnatal care services. On the other hand in high income group (10001 and above), 22.8 percent of the respondents had low, 59.6 percent of them had medium utilization and 17.6 percent of them had high utilization of postnatal care services. Above results indicate that high income respondents had more utilization of postnatal care services as compared to low income respondents. It was also proved that women with high social and economic status more likely to avail maternal health care services than women with low status (Addai, 2000; Addai, 1998; Leslie and Gupta, 1989). So the hypothesis “monthly family income of the respondents and utilization of postnatal care services are associated” is accepted.
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Hypothesis 14: Husbands’ education and utilization of postnatal care services are associated
Table 4.85: Association between husband’s education and utilization of postnatal care services
Education Utilization of postnatal care services Total (husband) Low Medium High Illiterate 63 41 6 110 57.3% 37.3% 5.4% 100.0% Upto Middle 66 80 19 165 40.0% 48.5% 11.5% 100.0% Matric 84 90 20 194 43.3% 46.4% 10.3% 100.0% Above Matric 21 86 24 131 16.0% 65.6% 18.3% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 25.07 (P-value = .00**) γ = .214 (P-value = .00*) * = Significant ** = Highly Significant
Table 4.85 presents the association between husband’s education and the utilization of postnatal care services. The chi-square value (25.07) shows a highly significant association between husband’s education and the utilization of postnatal care services. The gamma value shows a positive relationship between the variables. Data clearly indicates educated husband’s wives had more utilization of postnatal care services as compared to those whose husbands were illiterate or low educated. Data in above table depicted that the 57.3 percent of illiterate husbands’ wives had low utilization of postnatal care services, 37.3 percent of them had medium and only 5.4 percent of them had high utilization of postnatal care services. Table also indicated that less than a half (48.5 percent) of wives of up to middle level of education of husbands had medium level utilization, 40.0 percent of them had low and 11.5 percent of them had high utilization of postnatal care services. However, matriculate husbands’ wives had 43.3 percent, 46.4 percent and 10.3 percent of them had low, medium and high utilization of postnatal care services, respectively. Whereas above matriculated husbands’ wives had 16.0 percent, 65.6 percent and 18.3 percent of them had low, medium and high utilization of postnatal
114 care services, respectively. Data clearly indicates that literate husbands’ wives had more utilization as compared to illiterate or low educated husband’s wives. Previous studies also showed similar results, husbands with higher education levels proved to be more positive for utilization of child care services than those with lower level of education or illiterate (Cardwell, 1986). Alam et al. (2004) reported in their study a positive association between utilization of health care services and the education level of husband and wife.
So the hypothesis H1 “husbands education and utilization of postnatal care services are associated” is accepted.
Hypothesis 15: Respondents’ education and utilization of postnatal care services are associated
Table 4.86: Association between education of respondents and the utilization of postnatal care services
Respondents Utilization of postnatal care services Total education Low Medium High Illiterate 110 73 13 196 56.1% 37.2% 6.6% 100.0% Upto Middle 86 100 16 202 42.6% 49.5% 7.9% 100.0% Matric 30 68 21 119 25.2% 57.1% 17.6% 100.0% Above Matric 8 56 19 83 9.6% 67.5% 22.9% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 37.91 (P-value = .00**) γ = .251 (P-value = .00**) ** = Highly Significant Table 4.86 presents the association between education of the respondents and the utilization of postnatal care services. The chi-square value shows a highly significant association between education of the respondents and utilization of postnatal care services. The gamma value shows a strong positive relationship between the variables. Above table indicates that illiterate respondents had less utilization of postnatal care services i.e., 56.1 percent, 37.2 percent and 6.6 percent of them had low, medium and high utilization, respectively, while if the respondents had up to middle level education
115 then they had low (42.6%), medium (49.5%) and high (7.9%) utilization of postnatal care services. On the other hand matric and above matric level educated respondents had more utilization of postnatal care services i.e., 25.2 percent matriculated respondents had low utilization, 57.1 percent of them had medium utilization and 17.6 percent of them had high utilization. Whereas if the respondents had above matric level education then they had 9.6 percent, 67.5 percent and 22.9 percent low, medium and high utilization of postnatal care services respectively. Data clearly indicates that educated respondents had more utilization as compared to low educated respondents. It was confirmed by lot of researchers that education is one of the factors that are positively associated with the utilization of maternal health care services (Addai, 2000; Addai, 1998; Akin and Munevver, 1996; Beker et al., 1993; Celik and Hotchkiss, 2000; Ferdnandez, 1984; Stewart and Sommerfelt, 1991). Kogan and Leary (1990) reported that higher the education level of the mother more likely she returned for postnatal visits after delivery. So the hypothesis “respondents’ education and utilization of postnatal care services are associated” is accepted. Hypothesis 16: Total live births and utilization of postnatal care services are associated
Table 4.87: Association between total live births of respondents and utilization of postnatal care services
Total Live births Utilization of postnatal care services Total Low Medium High 1-2 75 139 35 249 30.1% 55.8% 14.1% 100.0% 3-4 71 116 29 216 32.9% 53.7% 13.4% 100.0% 5 and above 88 42 5 135 65.2% 31.1% 3.7% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 25.95 (P-value = .000**) γ = -.216 (P-value = .00***) ** = Highly Significant
The chi-square value (25.95) shows a highly significant association between total live births of the respondents and utilization of postnatal care services. The gamma value shows a negative relationship between the variables. It means more live births had less
116 utilization of postnatal care services. Above Table 4.87 also reveals that if the respondents had less live birth (1-2) then 55.8 percent of them had medium and 14.1 percent of them had high utilization of postnatal care services and 30.1 percent of them had less utilization. Whereas if the respondents had 3-4 live births then a major proportion (53.7 percent) of them had medium, 13.4 percent of them had high and 32.9 percent of them had low utilization of postnatal care services. Whereas if the respondents had 5 and above live birth then 65.2 percent of them had low, 31.1 percent of them had medium and 3.7 percent of them had high utilization of postnatal care services. Above findings indicate that if respondents had 1-2 and 3-4 live births then they had more utilization as compared to those respondents who had 5 and above live births. Mwaniki et al. (2002) conducted a study in Kenya and observed that utilization dof health care services is associated with number of kids she had. The mothers having more number of kids less likely they will be interested to avail health care facility. So the hypothesis “Total live births and utilization of postnatal care services are associated” is accepted. Hypothesis 17: Availability of medical health facilities and utilization of postnatal care services are associated
Table 4.88: Association between availability medical health facilities and utilization of postnatal care services
Availability of Utilization of postnatal care services Total medical health Low Medium High facilities Low 100 94 21 215 46.5% 43.7% 9.8% 100.0% Medium 121 181 42 344 35.2% 52.6% 12.2% 100.0% High 13 22 6 41 31.7% 53.7% 14.6% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 9.29 (P-value = .05*) γ = .184 (P-value = .006**) * = Significant ** = Highly Significant
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The chi-square value (9.29) shows a significant association between availability of medical health facilities and utilization of postnatal care services. The gamma value shows a positive relationship between the variables. The table 4.88 indicates that if the respondents had more availability of medical health facilities then they had also more utilization of postnatal care services. Above table also reveals that in the category of low availability of services, 46.5 percent, 43.7 percent and 9.8 percent of the respondents had low, medium and high utilization of postnatal services, respectively. While in the category of medium availability of services, 35.2 percent, 52.6 percent and 12.2 percent of the respondents had had low, medium and high utilization of postnatal services, respectively. Whereas 31.7 percent of the respondents of high availability of services category had low utilization, 53.7 percent of them had medium and 14.6 percent of them had high utilization of postnatal care services. Above table shows that more the availability of medical services, more is the use of postnatal care services. Safe Motherhood (1998) also reported that poor quality of care is one of the most common reasons why women do not seek care or seek it late. So the hypothesis “Availability of medical health facilities and utilization of postnatal care services are associated” is accepted. Hypothesis 18: Awareness about postnatal care services and utilization of postnatal care services are associated
Table 4.89: Association between awareness about postnatal care services and utilization of postnatal care services
Awareness about Utilization of postnatal care services Total postnatal services Low Medium High Low 34 25 5 64 53.1% 39.1% 7.8% 100.0% Medium 79 72 5 156 50.6% 46.2% 3.2% 100.0% High 121 200 59 380 31.8% 52.6% 15.5% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0% χ2 = 31.64 (P-value = .000**) γ = .362 (P-value = .000**) ** = Highly Significant The chi-square value (31.64) shows a highly significant association between awareness about postnatal care services and utilization of postnatal care services. The
118 gamma value shows a positive relationship between the variables. It means if the respondents had more awareness about postnatal care services then they had more utilization of these services. Above table also indicates that majority (53.1%) percent the respondents who had less awareness had also low utilization of postnatal care services, 39.1 percent of them had medium level utilization of postnatal care services. While in the category of medium level awareness 50.6 percent of them had low, 46.2 percent of them had medium and 3.2 percent of them had high level utilization of postnatal care services. Whereas 31.8 percent of the respondents who had high level of awareness had low utilization, 52.6 percent of them had medium and 15.5 percent of the respondents had high utilization of postnatal care services. These results indicate that awareness about postnatal care services is positively associated with the utilization of postnatal care services. Sheriff and Singh (2002) found out in India that women who were exposed to radio, television and newspaper for maternal care services, their rate of utilization of these services was significantly high. Ejaz and Ahmad (2013) reported that awareness about pregnancy related complications increased the utilization of postnatal care 2.49 times. So the hypothesis “Awareness about postnatal care services and utilization of postnatal care services are associated” is accepted. Hypothesis 19: Influence of culture and utilization of postnatal care services are associated
Table 4.90: Association between influence of culture and utilization of postnatal care services
Influence of Utilization of postnatal care services Total culture Low Medium High Low 58 136 25 219 26.5% 62.1% 11.4% 100.0% Medium 106 121 35 262 40.5% 46.2% 13.4% 100.0% High 70 40 9 119 58.8% 33.6% 7.6% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 36.99 (P-value = .00**) γ = -.298 (P-value = .00**) ** = Highly Significant
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The chi-square value (36.99) shows a highly significant association between influence of culture and utilization of postnatal care services. The gamma value shows a negative relationship between the variables. Above table shows that 26.5 percent of the respondents who had low influence of culture had also low utilization of postnatal care services, 62.1 percent of them had medium and 11.4 percent of them had high utilization of postnatal care services. If the respondents belonged to medium influence of culture group then they had low (40.5%), medium (46.2%) and high (13.4%) utilization of postnatal care services. Whereas in high influence culture group, 58.8 percent of them had low utilization, 33.6 percent of them had medium and only 7.6 percent of them had high utilization of postnatal care services. Data clearly indicate that low influence of culture more utilization of antenatal care services and high influence of culture and low utilization of antenatal care services. Das et al. (2010) reported that the reasons influence the choice of mothers for the selection of delivery place, one of the most common reasons of the home delivery was their custom. So the hypothesis “influence of culture and utilization of postnatal care services are associated” is accepted. Hypothesis 20: Cost of maternal health services and utilization of postnatal care services are associated
Table 4.91: Association between cost of maternal health service and utilization of postnatal care services
Maternal health Utilization of postnatal care services Total services are costly for Low Medium High them to bear Not at all 66 144 40 250 26.4% 57.6% 16.0% 100.0% To some extent 106 106 21 233 45.5% 45.5% 9.0% 100.0% To a great extent 62 47 8 117 53.0% 40.2% 6.8% 100.0% Total 234 297 69 600 39.0% 49.5% 11.5% 100.0%
χ2 = 32.56 (P-value = .00**) γ = -.335 (P-value = .00**) ** = Highly Significant
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Table 4.91 presents the association between respondents’ perception that maternal health care services are costly for them to bear and utilization of postnatal care services. The chi-square value (32.56) shows a highly significant association between respondents’ perception that maternal health services were costly for them to bear and utilization of postnatal care services. Gamma value shows a negative relationship between the variables. It means cost of maternal health care services is negatively associated with the utilization of postnatal care services. Above table shows that the if the respondents bear the cost of maternal health services then they had low (26.4%), medium (57.6%) and high (16%) level utilization of postnatal car services, while if the respondents felt that the maternal health care services were ‘to some extent’ costly then they had low (45.5%), medium (45.5%) and high (9.0%) level utilization, whereas if the respondents had opinion that the maternal health services were costly ‘to a great extent’ then they had low (53.0%), medium (40.2%) and high (6.8%) level utilization of postnatal care services. Safe motherhood (1998) also reported similar findings who reported that the cost was one of the key factors which prevent the utilization of postnatal. So the hypothesis “Cost of postnatal care services and utilization of postnatal care services are associated” is accepted. 4.3: Multivariate Analysis Stepwise regression analysis Regression analysis is to determine the values of parameters for a function that cause the function to best fit a set of data observations that is provided. It is best technique to identify the small set of independent variables which produce the highest value of (R²). R² indicates the proportion of the variance of Y that is explained by a set of independent variables. Stepwise selection proposed as a technique that combines advantages of forward and backward selection. Most commonly it is a used method for model building and resembles with forward stepwise selection is also a possibility. In the forward approach, variable once entered may be dropped if it is no longer significant as other variables are added. It means that variables whose importance come to an end as additional predictors are added or removed from the model. So procedure of forward stepwise goes on progressing the model captures the maximum variation in the dependent variable. The Standardized (β’s) partial regression coefficients indicate the unique contribution of each independent variable in explaining the dependent variable. Each
121 regression coefficient is a partial slope the change in Y for a unit change in X, controlling for the other independent variables in the equation. The significance of each partial regression coefficient is tested with an F, which is the same for unstandardized and standardized. Multiple linear regression is used to measure three coefficients (untandardized regression coefficient, standardized regression coefficient and coefficient of determination R2. The coefficients are used to identify the relative importance of each of the independent variable in the regression model. Antenatal care is measured by different medical services utilized by the women before delivery. Two regression models were developed to estimate regression coefficients to know the relative importance of predicting variables in explaining response variables. Stepwise regression is used for estimation of unstandardized regression, standardized regression coefficients, standard error and value of t. In stepwise regression only significant variables are remained, others non-significant variables are dropped. Model No. 1
Table 4.92: Standardized regression coefficients, t values and level of significance of socio-economic, cultural and demographic variables regressed on utilization of antenatal care services
Variable Standardized T P-value Coefficients Education (husband) .162 4.040 .000 Respondents education .094 2.476 .014 Monthly income .123 3.411 .001 Influence of culture -.138 -4.038 .000 Distance -.145 -4.213 .000 Availability of services .075 2.181 .030 Cost -.127 -3.756 .000 Total live births -.276 -8.067 .000 Awareness about antenatal services .097 2.980 .003 R² 0.423 Non-significant variable: Age
In above table standardized regression coefficients of every predictive variable are discussed and levels of significance are given. Physical examination, iron and folic acid
122 tablets, counseling, immunization of herself and physiotherapy are dimensions of index variable (utilization of antenatal care services). The regression coefficient beta is used to identify the significance of independent variables. Higher regression value shows the elevated importance of that variables. It is evident from the table that education of husbands increases the utilization of antenatal care services. Value of regression coefficient 0.162 means with increase in one year of schooling respondents increased the utilization of antenatal care services by 0.162 units, significant at 0.000, level. Respondent’s education, monthly income, availability of services and awareness about antenatal services have a positive sign for their respective regression coefficient indicating a positive relationship with the dependent variable. Respondent's education has also a significant value for regression coefficient. It emerges that respondents own educational level also affects the utilization of antenatal care services. Among these factors family income has a coefficient of regression value 0.123 that reveals an increase in income of one thousand rupees caused an increase in respondent’s utilization of antenatal care services by 1 per cent. Availability of services and awareness are also in increasing the utilization of antenatal care services. Both have coefficient values significant at 5 percent level of significance. Influence of culture, distance, cost and total live birth variables showed an inverse and significant relationship with the utilization of antenatal care services. Fitness of the model is estimated through coefficient of determination R² indicating the contribution of the independent variables in the variation of dependent variable. In the table, the value of R² (0.423) indicates that independent variables explained 42 percent variation in the utilization of antenatal care services. In social sciences, the value of R² is more than 0.40, the model is considered as best fit model reflecting that predicting variables in the regression model are relevant and appropriate for issue or problem being investigated (Zafar, 1993). For this study the value of R² is 0.423 is an indication that explanatory variables given in model 1 (table) which explains the response of utilization of antenatal care services variable. Keeping into the values of regression coefficients (betas) the model for explaining utilization of antenatal care services is as follow.
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Fitted Model
Utilization of antenatal care services = 47.99 + 0.162X1 = 0.094 X2 + 0.123 X 3 - 0.138X4 - 0.145X5 + 0.075X6 - 0.127X7 - 0.276X8 + 0.097X9
X1 is education of the husbands, X2 is education of the respondents, X3 is monthly income, X4 is influence of culture, X5 is distance, X6 is availability of services, X7 is cost, X8 is total live birth and X9 is awareness about antenatal care services.
Age of the respondents was found non-significant in stepwise regression. So this factor (variable) has not been considered for explanation. The next section 2, the utilization of postnatal care services is taken as dependant variable.
Model No. 2
Table 4.93: Standardized regression coefficients, t values and level of significance of socio-economic, cultural and demographic variables regressed on utilization of postnatal care services
Variable Standardized T P-value Coefficients education (husband) .154 3.881 .000 Respondents education .231 5.779 .000 Monthly income .197 5.263 .000 Influence of culture -.197 -5.615 .000 Cost -.107 -3.095 .002 Awareness about postnatal services .123 3.735 .000 R² 0.375 Non-significant variable: Distance, availability of services, age, live birth
In above table standardized regression coefficients of every predictive variable are discussed and level of significance are given. Physical examination, iron and folic acid tablets, Immunization of baby, immunization of herself, Counseling, Family planning services, Breast feeding education and Physiotherapy are dimensions of index variable (utilization of postnatal care services). The regression coefficient beta is used to identify the significance of independent variables. Higher regression value shows the elevated importance of that variable. It is evident from the table that education of husbands increases the utilization of postnatal care services. Value of regression coefficient 0.154
124 means with increase in one year of schooling of respondents' husbands increased the utilization of postnatal care services by 0.154 units, significant at 0.000, level. Respondent’s education, monthly income and awareness about postnatal services showed a positive sign for their respective regression coefficient indicating a positive relationship with the dependent variable. Respondent's education has also a significant value for regression coefficient. It emerges that respondents own educational level also affects the utilization of postnatal care services. Among these factors family income has a coefficient of regression value 0.197 that reveals an increase in income of one thousand rupees caused an increase in respondent’s utilization of postnatal care services by 2 percent. Awareness plays an important role in increasing the utilization of postnatal care services. Awareness has coefficient values significant at 1 percent level of significance. Influence of culture and cost variables showed an inverse and significant relationship with the utilization of postnatal care services.
Fitness of the model is estimated through coefficient of determination R² indicating the contribution of the independent variables in the variation of dependent variable. In the table the value of R² (0.375) indicates that independent variables explained 37 percent variation in the utilization of antenatal care services. For this study, the value of R² is 0.375 is an indication that explanatory variables given in model 1(table) which best explain the response utilization of postnatal care services variable. Keeping into the values of regression coefficients (betas) the model for explaining utilization of postnatal care services is as follow.
Fitted Model
Utilization of postnatal care services = 36.11 + 0.076X1 + 0.107X2 + 0.172X3 - 0.177X4 - 0.194X5 + 0.1425X6
X1 is education of the husbands, X2 is education of the respondents, X3 is monthly income, X4 is influence of culture, X5 is cost, X6 awareness about postnatal care services.
Age, distance, availability of services and total live births were found non- significant in stepwise regression. So these factors (variables) have not been considered for explanation.
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Chapter-V
SUMMARY, FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
Pakistan is a developing country and health status of Pakistani women is quite poor in comparison with the developed countries of the world. Like other walks of life Pakistani women are far behind the world in health status. Pakistan being a poor country has poor population health and social status of women. Preventive maternal healthcare services are important tools to avoid the occurrence of complications; the preventive health care services are physiotherapy, health education and screening. It is very important for the mothers to go through a high quality antenatal care during pregnancy period even if they don't feel complications. Health care services are important and must be followed during pregnancy, delivery and in postpartum period to ensure health safety of a mother and an infant. For safety of both mother and her infant’s life, maternal health care services must be affordable, effective, appropriate, accessible and acceptable to the mothers at the time of need. The present study has been designed to probe into the factors and beliefs behind utilization of antenatal and postnatal services. The study was conducted in Punjab, the largest and most populated, province of Pakistan. The study was intended to gain immediate knowledge and information on attitudes and tendency of utilization of antenatal and postnatal services in Punjab Province. Three districts i.e. Rawalpindi, Faisalabad and Multan of Punjab 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 random sampling technique, who fall under the criteria already defined. 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. Univeriate, bivariate and multivariate statistical methods were used for data analysis.
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5.1: KEY FINDINGS Following findings are the main findings of the study. Socio-Economic and Demographic Characteristics: It was found that more than a half (53.5%) of the respondents lived closed the hospital facility with the distance less than 5 km and 46.5 percent of the respondents lived at the distance more than 5-km from the hospital facility. The chi-square value showed a highly significant association between respondents’ residential distance to the health care center and utilization of antenatal (χ2 = 45.08) and postnatal services (χ2 = 18.43). Gamma statistics showed negative relationship between residential distance and utilization of antenatal (γ = -.443) and postnatal (γ = -.286) services. Similarly multivariate analysis showed an inverse and significant impact of residential distance from health care facility on the utilization of antenatal care services with beta value -0.145 at one percent level of significance, while it has non-significant impact on the utilization of postnatal services. These findings are in accordance with the findings of Mwaniki et al. (2002) and Ghaffar et al. (2012) who reported that distance from health care facility was associated with the utilization of maternal health care services, more the distance less will be the utilization. A majority (60.2 percent) of the respondents fell in the age group of 26-35 years and about one-fourth (26.3%) of them had 16-25 years. In a similar type of study Ejaz and Ahmad (2013) also reported that majority of their respondents (73 percent) were below age of 24 years. The chi-square value (χ2 = 33.10) showed a highly significant association between age of the respondents and utilization of antenatal care services. The gamma value (-.210) showed a negative relationship between the variables, while age had non- significant association (χ2 = 3.46) with the utilization postnatal services. Similarly in multivariate analysis age had no impact on the utilization of antenatal and postnatal services. Bhattacherjee et al. (2013) did not found any relationship between age of respondents and utilization of prenatal, delivery care and postnatal services. Less than a half (47.5 percent) of the respondents were in the age group of 19-24 years at the time of marriage, more than one third (36.2%) of them belonged to the category whose duration of marriage was 6-10 years, more than one forth (27.5%) of the respondents were in the category of up to 5 years of duration of marriage. About 62.2 percent of the respondents belonged to the category with age difference between husband and wife was up to 5 years. About 40.5 percent of the respondents were in the group with monthly income ranges from 5001-10,000 rupees and more than one-third (37.2 percent)
127 of the respondents belonged to income group up to rupees 5,000. Chi-square test showed a highly significant association between family income of the respondents and utilization of antenatal (χ2 = 68.53) and postnatal (χ2 = 27.13) services. Gamma statistic showed a positive relationship between family income and utilization of antenatal (γ = .404) and postnatal (γ = .273) services. In multivariate analysis income had also positive impact on the utilization of antenatal (β=.123) and postnatal (β=.197) services. In previous studies Ghaffar et al. (2012) & Ejaz and Ahmad (2013) reported similar results that income of family has positive and significant association with the utilization of antenatal and postpartum health care services. About one-fifth (20.3 percent) husbands were laborers, 19.2 percent having their own business, 18.3 percent husbands were government servants. About one-third (32.3 percent) husbands had matriculation, more than quarter of the husbands (27.5%) had up to middle level education. The Chi-square value showed a highly significant association between husband’s education and the utilization of antenatal (χ2 = 104.69) and postnatal (χ2 = 25.07) services. Gamma statistic showed positive relationship between education level of husbands and utilization of antenatal (γ = .421) and postnatal (γ = .214) services. Multivariate analysis also shows a positive and significant impact of husbands’ education on utilization of antenatal (β=.162) and postnatal (β=.154) services. In previous studies Kistiana (2009) reported that education level of husband and mother is a strong independent variable significantly associated with utilization of antenatal care services. About one-third (33.7 percent) of the respondents had education level up to middle and about one-third (32.7 percent) were illiterate. Similarly the Chi-square value showed a highly significant association between respondents’ education and the utilization of antenatal (χ2 = 99.00) and postnatal (χ2 = 37.91) services. Gamma statistic also showed positive relationship between education level of respondents and utilization of antenatal (γ = .461) and postnatal (γ = .251) services. Similarly multivariate analysis also showed positive and significant impact of respondents’ education on the utilization of antenatal (β=.094) and postnatal (β=.231) services. There is positive association between utilization of health care services and the education level of husband and wife (Alam et al. 2004; Bhattacherjee et al. (2013); Zhao et al. 2012 and Bhattacherjee et al. (2013). Kogan and Leary (1990) found that higher the education level of the mother the more likely she returned for postnatal visits after delivery.
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More than half of the respondents (59.7%) were living in joint family system. A substantial proportion (44.0 percent) of the respondents had 1-2 children (<12 years old); while more than one-third (36.2 percent) of them had 3-4 children (<12 years old). About 41.5 percent of the respondents had only 1-2 live births and 36.0 percent of the respondents had 3-4 live births. The Chi-square test showed a highly significant association between total live births of the respondents and utilization of antenatal (χ2 = 30.34) and postnatal (χ2 = 25.95) services. Gamma statistics depicted negative relationship between total live births with utilization of antenatal (γ = -.238) and postnatal (γ = -.216) services. Multivariate analysis also represented that total live births were inversely related to utilization of antenatal (β=-.276) services. Abosse et al. (2010) reported that women with three or less than three children were eight times more likely to receive antenatal health care services than mothers with five or more than five children. Bhattacherjee et al. (2013) found that having a child reduced the use of antenatal care for subsequent pregnancies. Whereas 70.2 percent had no dead child, 18.3 percent of the respondents had only one dead child, 6.2 percent of the respondents had two dead children. A large number (87.2 percent) of the respondents reported that the health facilities were available in their area. Little less than one-third (31.5 percent) of the respondents had government hospital (THQ) in their locality, while 27.2 percent of them told that they had private hospitals and 54.2 percent of the respondents had Basic Health Units (BHUs) in their locality. The Chi-square test showed a significant association between available medical services and utilization of antenatal (χ2 = 39.80) and postnatal (χ2 = 9.29) services. Gamma statistics showed a positive relationship between available medical services with utilization of antenatal (γ = .382) and postnatal (γ = .184) services. Multivariate analysis indicated that availability of medical services had positive and significant impact on the utilization of antenatal (β=.075) services, while a non-significant impact on the utilization of postnatal services. Sharma et al. (2007) reported that employed women had high awareness about important maternal health care services and their rate of utilization of maternal health services was also high. A huge majority (97.3%) of the respondents had knowledge about the antenatal services. A large majority (82.2%) of the respondents had knowledge 'to a great extent' about physical examination, 75.5 percent of the respondents had knowledge 'to a great extent' of using iron and folic acid tablets and 86.2 percent of the respondents knew about 129 immunization of themselves. About 58.2 percent of the respondents knew about counseling and 36.1 percent of the respondents knew 'to a great extent' about physiotherapy and its impact on body. The chi-square test (χ2 = 35.03) showed a highly significant association between awareness about antenatal services and its utilization. Gamma statistics (γ = .129) showed a strong positive relationship between the variables. Multivariate analysis also showed that awareness had also positive and significant impact on the utilization of antenatal (β=.097) services. Sheriff and Singh (2002) reported that the women who were exposed to radio, television and newspaper for maternal care services their rate of utilization of these services was significantly high. Bhattacherjee et al. (2013) found lack of awareness as one of the barriers for utilization of maternal health care services. A huge majority (93.0 percent) of the respondents reported that they went for antenatal services. More than one-third (36.9 percent) of the respondents (out of 542) received antenatal services because they were ill and 63.1 percent of the respondents visited for antenatal care services without illness. Almost 92 percent of the respondents visited for antenatal care without advices of midwives and 62.9 percent of the respondents went for antenatal care to check well being of the fetus. More than a half (56.3 percent) of the respondents went for antenatal care to immunize themselves and 23.2 percent of the respondents went for antenatal care because of complications in child birth. A majority (62.4 percent) of the respondents (out of 542) received physical examination, 37.6 percent of the respondents did not receive physical examination, 21.8 percent of the respondents had counseling, 39.9 percent of the mothers received physiotherapy treatment. About one-fourth (25.3 percent) of the respondents received the antenatal services from government hospitals and about one-third (32.1 percent) of them received the antenatal services from TBAs. Nineteen out of 42 respondents (42.5%) who had to attend other family matters so they did not go for antenatal services and 33 out of 42 of the respondents (78.6%) considered that antenatal services were expensive so they never utilized it. A huge majority (87.7 percent) of the respondents had regular medical checkup during pregnancy period. A major proportion (53.6 percent) of the respondents had 1-3 visits to the health clinics for antenatal services, more than one-fourth (33.5 percent) of them had 4-6 visits. Little more than one-third (36.0 percent) of the respondents got information about
130 antenatal services from doctors and 33.6 percent from lady health workers, 27.6 percent of the respondents got that information from TV. A huge majority (82.3 percent) of the respondents liked to go to hospital, more than a half (56.3 percent) of the respondents weighed themselves during pregnancy. Little less than one-third (30.8 percent) of the respondents measured their height during pregnancy. Blood pressure of 77.7 percent of the respondents was checked during pregnancy 44.3 percent of the respondents were asked to repeat the visit. A number of the respondents (61.7 percent) were advised about diet during pregnancy, 68.7 percent of the respondents were advised to use supporting medicine, 51.5 percent of the respondents were gone through ultrasound diagnosis and 48.5 percent of the respondents did not go through ultrasound therapy. A big majority of the respondents (97 percent) had knowledge about the postnatal services. A significant number (56.7 percent) of the respondents had knowledge ‘to a great extent’ about physical examination, 47.4 percent of the respondents had knowledge ‘to a great extent’ about using iron and folic acid tablets. A large majority (79.7 percent) of the respondents had knowledge ‘to a great extent’ about immunization of baby. About a half (49.7 percent) of the respondents had knowledge ‘to a great extent’ about counseling. About 64.3 percent of them had knowledge ‘to a great extent’ about family planning services. Less than a half (46.7 percent) of the respondents had education ‘to a great extent’ about the impact of breast feeding of babies. The chi-square test (χ2 = 31.64) showed a highly significant association between awareness about postnatal services and its utilization. Gamma statistics (γ = .362) showed a strong positive relationship between the variables. Multivariate analysis depicted that awareness had also positive and significant impact on the utilization of postnatal (β=.123) services. Ejaz and Ahmad (2013) reported that awareness about pregnancy related complications increased the utilization of postnatal care 2.49 times. About 18.1 percent (out of 459) of the respondents reported that they went for postnatal services because of illness and a majority (67.5 percent) of the respondents (out of 459) told that they went for postnatal services because their baby needed an immunization. About one-fourth (27.2 percent) of the respondents received the postnatal services from government hospitals, about a half (49.7 percent) of them received the postnatal services from TBAs .
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Whereas, 13.8 percent of the respondents (out of 123) did not receive postnatal services because they were busy in attending to other family matter and 29.3 percent (out of 123) of the respondents reported that the postnatal services were expensive. About 46.3 percent of the respondents had no visit of health clinic for medical checkup after delivering the child. About 29.8 percent of them had one, 41.9 percent of them had two and 12.4 percent had three visits of health clinic for medical checkup after delivering the child, while 8.7 percent of the respondents had four visits and 7.1 percent of them had five or above visits of health clinics for medical checkup after delivering the child. Little more than one-third (36.1 percent) of the respondents got information about postnatal services from lady health workers, 28.4 percent of the respondents got information from traditional birth attendants (TBAs). A large majority of the respondents (72.5 percent) reported that they called a midwife at home for any service. A majority of the respondents (66.0 percent) had normal vaginal delivery, 16.8 percent of them faced caesarean section and 17.2 percent of them had assisted vaginal delivery. A major proportion (48.3 percent) of the respondents gave birth at home, while 45.0 percent of them delivered their baby at a hospital. A considerable number (44.7 percent) of the respondents reported that TBAs were handling their delivery case, 43.7 percent of them told that a doctors handled their delivery case and 6.2 percent of them said that LHVs handled their delivery case. Only 18.8 percent of the respondents reported that they had any miscarriage, while a majority (81.2 percent) of the respondents had no miscarriage which showed a good reproductive health sign of rural women. Only 4.8 percent of the respondents faced an abortion while a significant majority (95.2 percent) of the respondents faced no abortion. It is indicated that the selected respondents had good health status. A significant majority (77.2 percent) of the respondents agreed with the opinion “abortion is killing of feuts”. A huge majority (98.5%) of the respondents had knowledge about family planning methods. A majority i.e. 70.4 percent (out of 591) of the respondents had awareness about Intra Uterine Contraceptive Device (IUCD) contraceptive method, 75.5 percent of them had knowledge about condom and 52.1 percent of the respondents had knowledge about withdrawal contraceptive method. A number of the respondents (82.4 percent) had knowledge about the contraceptive tablets/pills, 81.2 percent of the respondents had knowledge about injection, 74.5 percent, 72.3 percent and 54.8 percent of them had 132 knowledge about vasectomy and tubetomy, avoid the active time and nor plant, respectively. It shows that significant awareness was there for family planning methods. A large majority (72.3 percent) of the respondents reported that their husbands had positive attitude regarding family planning, most of the respondents (43.8 percent) had thinking that the religion allowed the family planning, while 42.7 percent of them told that the religion disallowed the family planning. Naqvi et al. (2011) in a study carried out in Karachi, Pakistan reported that 60 percent of the husbands supported the wives for the use of contraceptive methods. A huge majority (99.0 percent) of the respondents reported that their family liked breast feeding. A vast majority (72.5 percent) of the respondents used breast feeding practice for their kids, only 3.8 percent of them had bottle feeding practice and slightly less than one-fourth (23.7 percent) of the respondents had both practices i.e. breast and bottle feeding for their children. A majority (64.3 percent) of the respondents continued 19-24 months breast feeding. Howlader and Bhuiyan (1999) reported that in Bangladesh 92 percent of mothers breast feed their children. McLachlan and Forster (2006) observed in a study that partners of 83 percent of the Turkish women like breast feeding of their kids while 64 percent of Australian mothers perceived that their partners wanted them to breast feed their children. A huge majority (97.2 percent) of the respondents immunized their children. A majority of the respondents (97.8 percent) immunized (BCG) their babies from health workers team and 68.8 percent of the respondents immunized their babies from Govt. hospitals, only small number i.e. 8.7 percent and 7.0 percent immunized their babies from pvt. hospital and doctor respectively. According to WHO (2013), the BCG vaccination coverage in Pakistan in year 2012 was 95 percent. A big majority (85.8 percent) of the respondents reported that they take the injection of tetanus texoid during pregnancy, 41.2 and 42.5 percent of the respondents were taking injection of tetanus texoid during pregnancy two and three times, respectively. More than half i.e. 58.4 percent (out of 515) of the respondents were taking injection of tetanus texoid during pregnancy from the government hospitals, Naeem et al. (2010) reported that in Peshawar, Pakistan 55 percent of mother were completely vaccinated for tetanus texoid and 78 percent of the mothers received at least one injection of tetanus texoid during pregnancy A majority (66.8 percent) of the respondents reported that their husbands were most concerned about their health, but a majority (63.0 percent) of the respondents went 133 to health care center with their husbands. A majority (68.8 percent) of the respondents reported that their husbands provided medicine and other services. One-third (34.2 percent) of the respondents strongly agreed, about one-third (33.3 percent) of them agreed with the statement “within 40 days after delivery mother should not go out of home ever for medical checkup”. About 37.7 percent of the respondents strongly agreed, little more than one-third (34.2 percent) of them agreed with the statement “with 40 days after delivery a baby should not be taken out of home ever if baby needs medical treatment”. About one-third (33.5 percent) of the respondents strongly agreed, slightly more than one-third (35.8 percent) of them agreed with the statement “traditional treatment (herbs suggested by elders) should be tested before going to the doctor for child”. Little less than one-third (32.0 percent) of the respondents strongly agreed, about one-third (33.8 percent) of them agreed with the statement “sometimes children become ill because of malpractices like jado and tona by bad people”. About a half (49.8 percent) of the respondents strongly agreed and about one-third (33.3 percent) of them agreed with the statement “women should avoid taking meat during post-delivery period because it is very heavy for both”. It was found that the chi-square test showed a highly significant association between influence of culture on the respondents and utilization of antenatal (χ2 = 78.34) and postnatal (χ2 = 36.99) services. Gamma statistics show negative relationship between influence of culture and utilization of antenatal (γ = -.453) and postnatal (γ = -.298) services. Multivariate analysis revealed that influence of culture had inverse and significant impact on the utilization of antenatal (β=-.138) and postnatal (β=- .197) services. In a similar study Choudhry and Ahmad (2011) reported that due to traditional beliefs and rituals mothers delayed to avail the health care services even in case of complications. About 19.5 percent of the respondents were agreed ‘to a great extent’ and 38.8 percent of them agreed ‘to some extent’ with the opinion “maternal health services are costly for them to bear”. The chi-square test showed a highly significant association between cost of medical services with utilization of antenatal (χ2 = 25.44) and postnatal (χ2 = 32.56) services. Gamma statistics showed negative relationship between cost of medical services with the utilization of antenatal (γ = -.258) and postnatal (γ = -.335) services. Multivariate analysis depicted that the cost had an inverse and significant impact on the utilization of antenatal (β=.-127) and postnatal (β=-.107) services. In a previous study Harris et al. (2010) reported that the cost of antenatal and postnatal care 134 services was one of the important factors affecting the utilization of antenatal and postnatal care which is in accordance with our current study. About 15.5 percent of the respondents strongly agreed and a major proportion (43.2 percent) of them agreed with the constraint “family annoyed, if they received antenatal and postnatal services”. Only 6.5 percent of the respondents strongly agreed, 23.8 percent of them agreed with the constraint “number of pregnancies affect on the reception of antenatal and postnatal services”. About 10.5 percent of the respondents strongly agreed, 38.3 percent of them agreed with the constraint “sanitation standard of the hospital is not likable by the mothers”. About 9.0 percent of the respondents strongly agreed, 37.2 percent of them agreed with the constraint “Service providers and not up to mark of health measures”. Only 5.0 percent of the respondents strongly agreed, 8.5 percent of them agreed with the constraint “complete dosages of medicine by the staff as recommended by the doctors during their stay in hospital”. Only 5.5 percent of the respondents strongly agreed, 9.7 percent of them agreed with the constraint “behaviour of the staff of the hospital is satisfactory”. Only 9.5 percent of the respondents strongly agreed, about one-fifth (21.0 percent) of them agreed with the constraint “distance of home from the hospital is a big factor in receiving such services”. Almost 9 percent of the respondents strongly agreed, 28.5 percent of them agreed with the constraint “they face difficulties leaving the home for visiting health care center because no one left to look after the home”. Almost 10 percent of the respondents strongly agreed, 29.5 percent of them agreed with the constraint “they face difficulties leaving the home for visiting health care center because no one adult left to look after the children”. About 40 percent of the respondents strongly agreed and 33.5 percent agreed of the constraints “They faced hesitation to visit the health clinics because of fears of elders”. 36.7 percent of the respondents strongly agreed and 28.3 percent agreed that “Community values did not support them to visit the health clinics”. About one-third (34.5 percent) respondents strongly agreed that “It is better to rely on traditional medicines because of restriction on women mobility in rural areas”. About one-third (32 percent) of the respondent strongly agreed the statement that “For young women it is not respectful to visit health clinics”. About one-third (33.2 percent) of the respondents strongly agreed that “It is shameful and embarrassing to discuss the reproductive matters with male health care providers”. The data showed that 135 husband attitude was an influencing factor and 27.7 percent of the respondents strongly agreed and 12.8 percent agreed that “Husbands attitude affected mother and child health in the perspective of receiving these services”. Little more than one-fourth (27.3 percent) of the respondents strongly agreed and 15.3 percent agreed with the statement that “In your opinion the problems faced by the mother in receiving such services during first pregnancy remain unchanged during later pregnancies”. Most of the respondents (44.2 percent) used public transport (bus, taxi and motorcycle rakshawa). About one forth i.e. 25.3 percent of the respondents strongly agreed and 62.3 percent of them agreed with the suggestion “service provider staff should be more trained and highly qualified” About one fifth 19.5 percent of the respondents strongly agreed and 63.4 percent of them agreed with the suggestion “for improving the standard of services, do you think that license from health department should be provided to TBAs for their authorized services”. Out of the total respondents 23.2 percent strongly agreed and 62.7 percent of them agreed with the opinion “media may plays an important role in the enhancement of mother health care”. About 31.3 percent of the respondents strongly agreed and 59.7 percent of them agreed with the opinion “family planning department is playing its role properly”.More than one third of the respondents (39.3 percent) strongly agreed and 55.0 percent of them agreed with the opinion “improvement of sanitation in hospitals can improve mother health”.
5.2: CONCLUSIONS Antenatal care leads to proper monitoring of mother and child during pregnancy and is a proactive approach to have knowledge about expected complications. Postnatal visits help mothers not only to cover up expected complications after delivery but also to maintain health of baby. Both antenatal and postnatal cares are equally important to reduce maternal and neonatal mortality and to overcome complications. From the study results it was found that a great majority of the rural women had knowledge about antenatal and postnatal services and their source of information were lady health workers (LHWs) and traditional birth attendants (TBAs). A majority of the respondents reported that government health facilities were available in their areas.
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Network of lady health workers and government health facilities proved to be an important link for the majority of masses to get health advice and services. It is concluded that majority of the respondents utilize the antenatal services due to illness, immunization, complications during pregnancy and to check well-being of fetus. The reasons for utilization of postnatal services were illness, immunization and check well-being of baby and to discuss family planning. A number of the respondents delivered at home with or without the help of TBAs. Similar conclusions were reported by Ejaz and Ahmad (2013). They also found that about one third of mothers delivered at home in Punjab, Pakistan. At bivariate and multivariatr level in current study it was found that education level of mothers and their husbands, income of respondents and their husbands, awareness and availability of medical health facilities had positive and significant association with the utilization of antenatal services. 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. Education level of the respondents, education level of their husbands, monthly income and availability of medical health facilities showed positive and significant association with the utilization of postnatal services. Influence of culture, distance of health care facilities and cost of postnatal services had negative but significant association with the utilization of postnatal services. Singh et al. (2012); Khan et al.(1999); Ghaffar et al. (2012) and Ejaz and Ahmad (2013) also found that socio-demographic factors like education level of husband and wife, distance of heath care facility, monthly income, influence of culture were association with the utilization of maternal health care services. 5.3: SUGGESTIONS/RECOMMENDATIONS • A comprehensive training program should be designed at government level to train LHVs and TBAs to improve their knowledge and practices because a huge majority of rural women rely on them for information about antenatal and postnatal services • There is a dire need to improve the health facilities available at government Health Centers especially at BHUs to address the reproductive health problems that will surely improve women’s health status. • Government should provide 24 hours services at BHU for birth delivery purposes.
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• Government of Pakistan should launch public health awareness campaigns to create awareness about the benefits of small families, antenatal and postnatal care utilization and utilization of health facilities at the time of delivery and home deliveries must be discouraged. • Education is the basic factor for change. Government should design strategies and policies to enhance women education to ensure their autonomy in socio-economic and cultural decisions, which directly and indirectly enhance women health status • There is desperate need to bring awareness about mothers and childcare among females through education. This can be achieved through mass media, which helps in diffusing ideas and knowledge. • A majority of the births in Pakistan, particularly in the rural areas, took place at home. Pelvic sepsis may follow after these deliveries or abortions and when untreated may led to blood loss, inflammatory disease which is the underlying cause of many cases of blood loss, menstrual disorders and tetanus. Government should address these issues to enhance women and child health. • For safety of both mother and her infant’s life, maternal health care services must be affordable, effective, appropriate, accessible and acceptable to the mothers at the time of need. • This study also urged the need to improve the education level of the girls and to improve the livelihood status to trigger the need to acquire the services of skilled birth attendants at the time of delivery. • It was found that the stillbirth rate was high so a separate study on the causes of stillbirths in rural areas in Pakistan should be design.
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LITERATURE CITED
Abosse, Z., M. Woldie, S. Ololo. 2010. Factors Influencing Antenatal Care Service Utilization In Hadiya Zone. Ethiopian Journal of Health Sciences, 20(2): 17-25. AbouZahr, C. 1997. Improve access to quality maternal health services. Presentation at Safe Motherhood Consultation in Sri Lanka, 18–23 October. AbouZahr, C. and T. Wardlaw. 2001. Maternal mortality at the end of a decade: Signs of progress. Bulletin of the World Health Organization, 79: 561-568. Abraham, M.F. and P.S. Abraham. 1988. Women development and change: The third world experience. Wyndham Hall Press, Bristol, 217-245. ADB. 2006. Pakistan: Women's Health Project-1999. Investing in Women's Health: Delivering Better Health Care to all. Asian Development Bank. Manila, Philippines. Addai, I. 1998. Demographic and sociocultural factors influencing use of maternal health services in Ghana. African Journal of Reproductive Health, 2(1):73-80. Addai, I. 2000. Determinants of use of maternal-child health services in rural Ghana. Journal of Biosocial Science, 32(1):1-15. Adekunle, C., V. Filippi, W. Graham, P. Onyemunwa, and E. Udjo. 1990. Patterns of maternity care among women in Ondo States, Nigeria. In Determinants of health and mortality in Africa, ed. Allan G. Hill, Demographic and Health Survey Further Analysis Series No. 10: 1-45. New York: The Population Council. Ahmad, A. 1990. Gender differentials in access to health care for Pakistani children. UNICEF, Vol. 1. Islamabad: UNICEF. Ahmad. S. 2008. Factors affecting mother and infant health in district Faisalabad. M.Sc. Population Science Thesis, Department of Rural Sociology, University of Agriculture Faisalabad. Ahmed, S., A.A. Creanga, D.G. Gillespie and A.O. Tsui. 2010. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS ONE 5(6): e11190. doi:10.1371/journal.pone.0011190.
139
Ajala, O.A., L. Sanni and S.A. Adeyinka. 2005. Accessibility to health care facilities: A panacea for sustainable rural development in Osun State south-western Nigeria. J. Hum. Ecol, 18(2): 121-128. Akin, A. and B. Munevver. 1996. Contraception, abortion and maternal health services in Turkey: Results of further analysis of the 1993 Turkish Demographic and Health Survey. Calverton, Maryland: Ministry of Health [Turkey] and Macro International Inc. Alam, A.Y., A.A. Qureshi, M.M. Adil and H. Ali. 2004. Comparative study of knowledge, attitude and practices among antenatal care facilities utilizing and non-utilizing women. Department of Community Health Sciences, Shifa College of Medicine, Islamabad. Ali, A.Y. 1975. The Holy Quran. 1st edition. Leicester, The Islamic Foundation; 1975. Ansar Burney Trust. 2007. Women’s rights: Our struggle to fight for the rights of women –vani. Retrieved on 4 August, 2013 from www.ansarburney.org/womens_rights-vani.html APWA. 2002. Children. The family and health: What it takes to give children long life. The Singapore Workshop: Pakistan-health problems children under 10 in Pakistan. Arora, S., C. McJunkin, J. Wehrer and P. Kuhn. 2000. Major factors influencing breastfeeding rates: mother's perception of father's attitude and milk supply. Pediatrics, 106: 67. Arshad, N. 2006. Impact of maternal health services on mother and child health. M.Sc. Thesis. Department of Rural Sociology, University of Agriculture, Faisalabad. Ashford, L. 2004. Hidden Suffering: Disabilities from pregnancy and childbirth in less developed countries. Population Reference Bureau, 1-6. Retrieved from http://www.prb.org/Template.cfm?Section=PRB&template=/ContentMana gement/ContentDisplay.cfm&ContentID=6658 on 23/06/2013. Awoyemi, T.T., O. A. Obayelu1 and H. I. Opaluwa. 2011. Effect of Distance on Utilization of Health Care Services in Rural Kogi State, Nigeria. Kamla- Raj 2011. J. Hum. Ecol., 35(1): 1-9.
140
Ayaz, A. and S. Saleem. 2010. Neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan: A cross- sectional study. PLoS ONE 5(11): e13783. doi:10.1371/journal.pone.0013783. Babar, T.S. and J. Hatcher. 2004. Health seeking behaviour and health service utilization in Pakistan: Challenging the policy makers. Journal of Public Health, 27(1): 49–54. Bari, F. and S.P. Mariam. 2000. Women in Pakistan: Country Briefing Paper. Asian Development Bank. Barkat, A., M. Rahman and M. L. Bose. 1997. Family planning choice behaviour in urban slums of Bangladesh: An econometric approach. Asia-Pacific Pop. J. 12(1): 17-32. Beeckman, K., F. Louckx and , K. Putman. 2011. Predisposing, Enabling and Pregnancy- Related Determinants of Late Initiation of Prenatal Care. Maternal and Child Health Journal, 15(7): 1067-1075. Beeckman, K., F. Louckx and, K. Putman., 2010. Determinants of the number of antenatal visits in a metropolitan region. BMC Public Health, 10(1): 527. http://www.biomedcentral.com/1471-2458/10/527 Beker S., D.H. Peters, R.H. Gray, C. Gultiano and R.E. Black. 1993. The determinants of use of maternal and child health services in Metro Cebu, the Philippines. Health Transition Review, 3(1):77-89. Bell, J., S.L. Curtis and S. Alayon. 2003 Trends in delivery care in six countries. Calverton, Maryland: ORC Macro and International Research Partnership for Skilled Attendance for Everyone (SAFE). Berger, NA; S.J. Berger, D.M. Catino, 1983. Abnormal NAD+ Levels in Cells from Patients with Fanconi's Anemia. Nature, 299(5880):271–273. Bhattacherjee, S., S. Datta, J. B. Saha and M. Chakraborty. 2013. Maternal health care services utilization in tea gardens of Darjeeling, India. Journal of Basic Clinical and Reproductive Sciences, 2(2):77-84. Bicego, G., S. Curtis, H. Raggers, S. Kapiga and S. Ngallaba. 1997. Sumve survey on adult and childhood mortality, Tanzania, 1995: In-depth study on estimating adult and childhood mortality in settings of high adult mortality. Calverton, Maryland: Macro International: Demographic and Health Survey Inc. Calverton, Maryland. 141
Billet, L. B. 1993. Modernization theory and economic development. Discontent in the Developing World, Prager, Westport-CTPublished by Praeger. Bloom, S.S., T. Lippeveld and , D. Wypij. 1999. Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning, 14:38-48. Borg, W.R. and M.D. Gall. 1989. Educational research: An Introduction (5th edition). Longman, New York Borghi, J., N. Sabina, L.S. Blum, M.E. Hoque, and C. Ronsmans. 2006. Household Costs of Healthcare during Pregnancy, Delivery, and the Postpartum Period: A Case Study from Matlab, Bangladesh. J. Health Popul. Nutr., 24(4):446- 455. Boserup, E. 1970. Women 's role in economic development. St. Martin 's Press, New York. Bryman, A. and D. Cramer, 1990. Qualitative data analysis for social scientist. Rout Ledge, London. Buor, D. 2003. Analyzing the primacy of distance in the utilization of health services in the Ahafo-Ano South district, Ghana. The International Journal of Health Planning and Management, 18(4): 293-311. Burtz, A.M., A. Funkhouser, L. Caleb, and B. Rosenstein. 1993. Infant health utilization predicted by pattern of prenatal care. Pediatrics, 92: 50-54. Business Recorder 2013, Miscarriages cause10-12 percent maternal deaths in Pakistan, retrieved from website on October 22, 2013. http://www.brecorder.com/general-news/172/1204537/ Campbell, O.M.R. and W.J. Graham. 2006. The lancet maternal survival series steering group: Maternal survival 2: Strategies for reducing maternal mortality: getting on with what works. Lancet, 368:1284-99. CDGF. 2006. City District Government Faisalabad. Retrieve on August 24, 2013 from: http://www.faisalabad.gov.pk/default.aspx Celik Y, D. R. Hotchkiss. 2000. The socio-economic determinants of maternal health care utilization in Turkey. Soc Sci Med., 50(12):1797-1806. Celik, Y. and D.R. Hotchkiss. 2000. The socio-economic determinants of maternal health care utilization in Turkey. Social Science and Medicine, 50: 1797–1806.
142
Chakraborty N., M. A. Islam, R. I. Chowdhury. W. Bari, H. H. Akhter. 2003. Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int., 18:327-37. Chakraborty, N., M.A. Islam, R.I. Chowdhury and W. Bari. 2002. Utilisation of postnatal care in Bangladesh: Evidence from a longitudinal study. Health and Social Care in the Community, 10(6): 492-502. Choudhry, N. and S.M. Ahmed. 2011. Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study. BMC Pregnancy and Childbirth 2011. Retrieve on August 28, 2013 from: www.biomedcentral.com/1471-2393/11/15. CIA. 2013. The World Fact Book, Retrieved from website on Oct. 01, 2013, https://www.cia.gov/library/publications/the-world- factbook/rankorder/2223rank.html Coria-Soto, I.L., J.L. Bobadilla and F. Notzon. 1996. The effectiveness of antenatal care in preventing intrauterine growth retardation and low birth weight due to preterm delivery. International Journal for Quality in Health Care, 8(1):13-20. Cronbach, L.J. and E.M. Paul. 1955. Construct validity in psychological tests. Psychological Bull., 52: 281-302. Daniels, A. A., A. Ahenken and K. A. Poku. 2013. Factors Influencing the Utilisation of Maternal Health Services: The Perspective of Rural Women in Ghana. Journal of Public Administration and Governance, 3(2): 17-25. Darmstadt, G.L., Z.A. Bhutta, S. Cousens, T. Adam, N. Walker and, L. de Bernis. 2005. Lancet Neonatal Survival Steering Team: Evidence-based, cost-effective interventions: How many newborn babies can we save? Lancet, 365(9463): 977-988 Das, S., U. Bapat, N.S. More, L. Chordhekar, W. Joshi and, D. Osrin. 2010. Prospective study of determinants and costs of home births in Mumbai slums. BMC Pregnancy and Childbirth, 10:38. Retrieve on 29 August, 2013 from www.biomedcentral.com/1471-2393/10/38. DAWN. 2011. Pakistan stillbirth rate second highest in world. The Daily "DAWN', 14 April, 2011.
143
Dhakal, S., G.N. Chapman, P.P. Simkhada, E.R. Teijlingen, J.S. and A.E Raja. 2007. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy and Childbirth, 7:19. Online Available on: http://www.biomedcentral.com/1471-2393/7/19 Dharmalingam, A., T.M. Hussain and J.F. Smith. 1999. Women’s education, autonomy and utilization of reproductive health services in Bangladesh. In A.I. Mundigo (Ed.), Reproductive health: programme and policy changes post- Cairo. Liege, Belgium: International Union for the Scientific Study of Population (IUSSP). Ejaz, S. and K. Ahmad. 2013. Postpartum care utilization among primigravida: A study in rural Punjab, Pakistan. Research on Humanities and Social Science, 3(4): 35-45. Elo, I.T. 1992. Utilization of maternal health care services in Peru: the role of women’s education. Health Transition Review, 2(1): 1-20. Elo, I.T. 1992. Utilization of maternal health-care services in Peru: the role of women’s education. Health Transition Review, 2(1): 49–69. Essex B. J, and V. J. Everett V. 1977. Use of an action-orientated record card for antenatal screening. Tropical Doctor, 7: 134-138. Fatmi, Z. and B.I. Avan. 2002. Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan. Journal of Pakistan Medical Association, 52(4): 138-142. Fauveau, V. 1993. Maternal tetanus; International Journal of Gyn & Obs, 40: 3-12. Fikree, F.F., T. Ali, J.M. Durocher, M.H. Rahbar. 2004. Health service utilization for perceived postpartum morbidity among poor women living in Karachi. Social Science & Medicine, 59: 681–694. Fikree, F.F., T.S. Ali, J.M. Durocher and M.H. Rahbar. 2005. Newborn care practices in low socioeconomic settlements of Karachi. Pak. Soc. Sci. Med., 60(5): 911-921. Filippi, V., C. Ronsmans, O.M. Campbell, W.J. Graham, A. Mills and, J. Borghi. 2006. Maternal health in poor countries: the broader context and a call for action. Lancet, 368(9546):1535–1541. Finger, W.R. 1997. Better postpartum care saves lives. Network, 17: 18-21.
144
Fisher, R. A. 1928. The general sampling distribution of the multiple correlations coefficient. Proceedings of Royal Society of London. 121(788). Roy. Soc. London, 121: 654-673. Fosteo, J.C., A.C. Ezeh and H. Essendi. 2009. Maternal health in resource-poor urban settings: how does women's autonomy influence the utilization of obstetric care services? Reproductive Health, 6: 9. Frost, J.J. 2001. Public or private providers? U.S. women’s use of reproductive health services. Family Planning Perspectives, 33(1): 4-12. Fujita, N., M. Matsui, S. Srey, C.S. Po, S. Uong and K. Koum. 2005. Antenatal care in the capital city of Cambodia: current situation and impact on obstetric outcome. J. Obstet. Gynaecol. Res. 31(2): 133–1399. Gautam, B.R. 1998. Factors affecting regular utilization ANC service among postnatal mothers in Chiangrai Regional Hospital Chiangrai province, Thailand, Master Thesis, Primary Health Care Management, Bangkok. Gertler, P.J., and J. van der Gaag. 1988. Measuring the willingness to pay for services in developing countries. LSMS Working Paper No. 45. Washington, D.C.: The World Bank. Gertler, P.J., L. Locay, and W. Sanderson. 1987. Are user fees regressive? The welfare implications of health care financing proposals in Peru. Working Paper No. 2299. National Bureau of Economic Research, Cambridge. Ghaffar, A., B. M. Kazi and M. Salman. 2000. Health care system in transition III. Pakistan, Part I. An overview of the healthcare system in Pakistan. Journal of Public Health Medicine, 22(1): 38-42. Ghaffar, A., S. Pongpanich, S. Robert, C. A. Panza, S. Mureed and N. Ghaffar. 2012. Provision and Utilization of Routine Antenatal Care in Rural Balochistan Province, Pakistan: Journal of Applied Medical Sciences, 1(1): 93-116 Gillani, W. 2004. PMA Report Roasts Health Policy, Practice, and Daily Times Tuesday, January 20, 2004. Goldman, N. and A.R. Pebley. 1994. Childhood immunization and pregnancy related services in Guatemala. Health Transition Review, 4(1): 29–44. Govt. of Indonesia, 2008. Indonesia Demographic and Health Survey 2007. Statistics Indonesia and Ministry of Health, Jakarta, Indonesia.
145
Government of Punjab. 2012. Development Statistics 2012, Punjab. Bureau of statistics planning and development department, Government of Punjab, Lahore. Retrieved on Oct. 13, 2013 from http://bos.gop.pk/?q=system/files/Development-Statistics-2012.pdf Government of Punjab. 2013. Annual Report 2012-13, Literacy and Non formal Education Department. Retrieved from website on September 12, 2013 http://www.literacy.gop.pk/docs/downloads/AnnualReportPDF.pdf Govindasamy, P. and B.M. Ramesh. 1997. Maternal education and utilization of maternal and child health services in India. NFHS Survey Subject Reports No. 5. Mumbai: International Institute for Population Sciences. Govt. of Pakistan. 2008. Economic Survey of Pakistan 2007-2008, Ministry of Finance, Government of Pakistan, Islamabad. Griffiths, P. and R. Stephenson. 2001. Understanding users’ perspectives of barriers to maternal health care use in Maharashtra, India. Journal of Biosocial Science, 33: 339-359. Harris, A., Y. Zhou, H. Liao, L. Barclay, W. Zeng and Y. Gao. 2010. Challenges to maternal health care utilization among ethnic minority women in a resource-poor region of Sichuan Province, China. Health Policy and Planning 2010. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. Hartfield, V.J. 1980. Maternal mortality in Nigeria compared with earlier international experience. Int. J. Gynecol. Obstet., 80(18): 70-75. Hazarika, I. 2010. Factors that Determine the Use of Skilled Care During Delivery in India: Implications for Achievement of MDG-5 Targets. Matern Child Health J. Springer Science+Business Media, LLC. Hollowell J., L. Oakley, J. J. Kurinczuk, P. Brocklehurst and R. Gray. 2011. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high- income countries: A systematic review. BMC Pregnancy Childbirth, 11:13. Hove, I., S. Siziya, C. Katilo and M. Tshimanga. 1999. Prevalence and associated factors for non-utilisation of postnatal care services: Population-based study in Kuwadzana Peri-urban area, Zvimba district of Mashonaland West Province, Zimbabwe. African Journal of Reproductive Health, 3(2): 25-32. 146
Howlader, A.A. and M.U. Bhuiyan. 1999. Mothers' health-seeking behaviour and infant and child mortality in Bangladesh. Asia-Pacific Population Journal, 14(1): 59-75 Hulsey, M. T., M. Laken, V. Miller and J. Ager. 2000. The influence of attitudes about unintended pregnancy on use of prenatal care and postpartum care. Journal of Perinatology, 20(8): 513-519. Inandi, T., R. Bugdayci, P. Dundar, H. Sumer and T. Sasmaz. 2005. Risk factors for depression in the first postnatal year: A Turkish study. Soc. Psychiatry Psychiatr. Epidemiol., 40: 725–730 Ishikawa, N., D.S. Bam and T. Mori. 2001. Gender difference in delays to diagnosis and health care seeking behaviour in a rural area Nepal. Int. J. Tuberc. Lungs Dis., 5: 24-31. Jaffar, J. K. 1998. Factors influencing the practice of family planning among married women in Quetta Balochistan province, Pakistan, Mahidol University, Thailand. Janes, C.R. and C. Oyuntsetseg. 2004. Free markets and dead mothers: The social ecology of maternal mortality in post-socialist Mongolia. Medical Anthropology Quarterly, 18(2): 102-129. Jejeebhoy, Shireen J., 1995. "Women's Education, Autonomy, and Reproductive Behaviour: Experience from Developing Countries," OUP Catalogue, Oxford University Press, No. 9780198290339. Kamal S. M. 2009. Factors affecting utilization of skilled maternity care services among married adolescents in bangladesh. Asian Popul. Stud., 5:153-70. Kaufmann, K. 2002. An analysis of transport in the Zululand Health District. Conference Report. Retrieved on July 1, 2013. from: www.rudasa.org.za/conference/conf.php/conf6/jass.php Kausar, F., P. Griffiths and Z. Matthews. 1999. Poverty and maternal health care utilizsation in Maharashtra: associated influences on infant mortality and morbidity. Department of Social Statistics, University of Southhampton, UK. Keeton, C. 2007. Nuclear family is always best for kids: love and money better ingredients for success than structure. Online Edition, “The Times”, November 18, 2007.
147
Khalil, M.M. 2004. Promoting safe motherhood initiatives, sharing population and development research across South and West Asia. Fifth Annual Res. Conf. Proc., 14-16 Dec. 2004, Karachi, Pakistan. Khan, M. E. 1987. Infant Mortality in Uttar Pradesh. Social Change, 17(3): 52-64. Khan, N., S. Khan, N. Khan and S. Khan. 2013. Factors Affecting Utilization of Maternal And Child Health Services: District Swat KPK. Pakistan International Journal of Innovative Research and Development, 2(8): 217- 227. Khan, Z., G.Y. Soomro and S. Soomro. 1994. Mother's education and utilization of health care services in Pakistan. Pak. Dev. Rev., 33(4 Pt 2): 1155-1563. Kistiana, S. 2009. Socio-economic and demographic determinants of maternal health care utilization in Indonesia. M.Sc. Thesis (Applied Population Studies) in School of Geography, Population and Environmental Management. Faculty of Social Sciences, The Flinders University of South Australia, Adelaide Koblinsky, M., Z. Matthews, J. Hussein, D. Mavalankar, M.K. Mritha, I. Anwar, E. Achad, S. Adjei, P. Padmanabhan, W. van Lerberghe. 2006. The lancet maternal survival series steering group: Maternal Survival 3: Going to scale with professional skilled care. Lancet, 368: 1377-1386. Kogan, M.D. and M. Leary. 1990. Factors associated with postpartum care among Massachusetts’s users of the maternal and infant care program. Family Planning Perspectives, 22(3): 128-131. Kongsri, S., S. Limwattananon, S. Sirilak, P. Prakongsai and , V. Tangcharoensathien. 2011. Equity of access to and utilization of reproductive health services in Thailand: national Reproductive Health Survey data, 2006 and 2009. Reproductive Health Matters, 19(37): 86–97. Kumar A. P. Bhardwaj, J.P. Srivastava and P. Gupta. 2011. A Study On Family Planning Practices And Methods Among Women Of Urban Slums Of Lucknow City. Indian Journal of Community Health, 23(2): 24-34. Kumar, D., N.K. Goel, M. Kalia, H.M. Swami and R. Singh. 2008. Gap Between Awareness and Practices Regarding Maternal and Child Health Among Women in an Urban Slum Community. Indian J. Pediatr., 75(5): 455-458.
148
Kunst, A.E. and T. Houweling. 2001. A global picture of poor-rich differences in the utilization of delivery care, in Safe Motherhood Strategies. A Review of the Evidence, 17: 297-315. Kwast, B.E. and J.M. Liff. 1993. Factors associated with maternal mortality in Southern India. Stud. Fam. Plann., 24: 310-318. Kwast, B.E., and J.M. Liff. 1988. Factors associated with maternal mortality in Addis Ababa, Ethiopia. International Journal of Epidemiology, 17(1): 115-121. Kyomuhendo, G.B. 2003. Low use of rural maternity services in Uganda: impact of women’s status, traditional belief and limited resources. Reproductive Health Matters, 11(21): 16-26. Lawn, J.E., S. Cousens and, J. Zupan. 2005. Lancet Neonatal Survival Steering Team: 4 million neonatal deaths: When? Where? Why? Lancet, 365(9462): 891- 900. Lerberghe, V. W and V. De Brouwere. 2001. Reducing maternal mortality in a context of poverty. Studies in Health Services Organization and Policy, 17: 1-4. Leslie, J., and G.R. Gupta. 1989. Utilization of formal services for maternal nutrition and health care. International Center for Research on Women, Washington, D.C. Liu, X., X. Zhou, H. Yan, and D. Wang. 2011. Use of maternal healthcare services in 10 provinces of rural western China. International Journal of Gynecology and Obstetrics, 114: 260–264. Llewellyn-Jones D. 1990. Fundamentals of Obstetrics and Gynaecology. Obstetrics, Vol. 1. Published by Faber and Faber, London. UK. Long, Q., T. Zhang, L. Xu, S. Tang and, E. Hemminki. 2010. Utilisation of maternal health care in western rural China under a new rural health insurance system (New Cooperative Medical System). Trop. Med. Int. Health, 15(10): 1210–1217. Luthra, R. 2005. Safe Motherhood: A matter of human rights and social justice. Retrieved on Sept.8, 2013 from www.safemotherood.org.html. Magadi, M.A., N.J. Madise and R.N. Rodrigues. 2000. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Social Science and Medicine, 51: 551–561. Maki, J.E.H, D.M. Offman and R.A. Bark. 1978. A time series analysis of the impact of a water conservation campaign. Evaluation Quarterly, 2(1): 107-118. 149
Mathole T., G. Lindmark and , F.A. Majoko. 2004. A qualitative study of women’s perspectives of antenatal care in a rural area of Zimbabwe. Midwifery, 20(2), 122-132. Matsumura, M. and B. Gubhaju. 2001. Women’s status, household structure and the utilization of maternal health services in Nepal. Asia-Pacific Population Journal, 1(16): 23-44. McCarthy, J. and D. Maine. 1992. A framework for analyzing the determinants of maternal mortality. Studies in Family Planning, 23: 23-33. McComas, J. and R.S. Harris. 1996. Women’s health research and practice: what can physiotherapist contribute? Physiotherapy Canada Winter, 48 (1): 6-7. McDonagh, M. 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning, 11(1): 1-15. McLachlan, H.L. and D.A. Forster. 2006. Initial breastfeeding attitudes and practices of women born in Turkey, Vietnam and Australia after giving birth in Australia. International Breastfeeding Journal, 1: 7. Meera Chatterjee and Julian Lambert. 2003. Women and Nutrition: Reflections from India. Retrieve on 13 December, 2013 from: http://www.unsystem.org. Mehboob-ul-Haq. 1997. Entitled Human Development in South Asia 1997. Retrived on Dec. 13, 2013 from: http://www.mhhdc.org/html/ahdr.htm. Mekonnen, Y. and A. Mekonnen. 2002. Utilization of maternal health care services in Ethiopia. Calverton. ORC Macro, Maryland, USA Melrose, E.B. 1984. Maternal deaths at King Edward VIII hospital, Durban. 1984. A review of 258 consecutive cases. South African Medical Journal, 65(5): 161-165. Mrisho, M., B. Obrist, J.A. Schellenberg, R.A. Haws, A.K. Mushi and H. Mshinda. 2009. The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy Childbirth, 9:10. Mrisho, M., J.A. Schellenberg, A.K. Mushi, B. Obrist, H. Mshinda, M. Tanner and D. Schellenberg. 2007. Factors affecting home delivery in rural Tanzania. Tropical Medicine & International Health, 12(7): 862-872. Mustafa, M. 2008. Factors Affecting Mother and Child Health Care in District Faisalabad. M.Sc. Population Sciences Thesis. Department of Rural Sociology, University of Agriculture, Faisalabad. 150
151
Mwaniki, P.K., E.W. Kabiru and G.G. Mbugua. 2002. Utilisation of antenatal and maternity services by mothers seeking child welfare services in Mbeere District, Eastern Province, Kenya. East African Medical Journal, 79(4): 184-187. Nachmias C.F. and D. Nachmias. D. 1992. Research Methods in Social Science. Fourth Edition. Edward Arnold. A division of Hodder and Stoughton London, Melbourne, Auchland. Naeem, M., M.Z.I. Khan, S.H. Abbas, M. Adil, A. Khan, S.M. Naz and M.U. Khan. 2010. Coverage and factors associated with tetanus Toxoid vaccination among married women of reproductive age: A cross sectional study in Peshawar. Journal of Ayub Medical College. Abbottabad, 22(3): 110-116. Naqvi, S., N. Hashim, N. Zareen and H. Fatima 2011. Knowledge, Attitude and Practice of Parous Women Regarding Contraception. Journal of the College of Physicians and Surgeons Pakistan 21 (2): 103-105 Navaneetham, K. and A. Dharmalingam. 2002. Utilization of maternal health care services in Southern India. Social Science & Medicine 55: 1849–1869. Nie, Hull and Bent, 1968. Statistical Package for the Social Sciences (SPSS) Inc. 233 S. Wacker Drive, Chicago. Nisar, N. and F. White. 2003. Factors affecting utilization of Antenatal Care among reproductive age group Women (15-49 years) in an urban squatter settlement of Karachi. Journal of Pakistan Medical Association, 53(2): 47- 53. Nwakoby B. N. 1994. Use of obstetric services in rural Nigeria. J. R. Soc. Health, 114(3):132-136. Obermeyer C.M. and J.E. Potter. 1991, Maternal health care utilization in Jordan: a study of patterns and determinants. Studies in Family Planning, 3(22): 177-187. Obermeyer, C.M. 1993. Culture, maternal health care and women’s status: a comparison of Morocco and Tunisia. Studies in Family Planning, 24(6): 354-365. Ovell, A. Abed, F.H. 1988. Scaling up in Health. Two Decades of Learning in Bangladesh. Oxford University Press. 212-32. Pallikadavath, M. and R.W. Foss. 2001. Stones, Antenatal care: provision and inequality in rural north India. Social Science and Medicine, 59(6): 1147-1158.
152
Paruzzolo, S, R. Mehra, A. Kes and C. Ashbaugh. 2010. Targeting Poverty and Gender Inequality to Improve Maternal Health. 2nd Global Conference 7–9 June, Organized by International Center for Research on Women, Washington, DC. Paul, B.K. and D.J. Rumsey. 2002. Utilization of health facilities and trained birth attendants for childbirth in rural Bangladesh: an empirical study. Social Science and Medicine, 54: 1755-1765. PDHS. 2008. Pakistan Demographic and Health Survey 2006-07. National Institute of Population Studies, Islamabad and Macro International Inc. PDHS. 2013. Pakistan Demographic and Health Survey 2012-13, Preliminary report, National Institute of Population Studies, Islamabad Pearson, K. 1896. Mathematical contributions to the theory of evolution. III. Regression, Heredity and Panmixia, Philosophical Transactions of the Royal Society, 187: 253-318. Peter C. Miller., Kayani A., and Minhas J. A. 2000. On the Dynamics of Contraceptive Use in Pakistan. Conference Proceedings. 55-65. Population Association of Pakistan Islamabad. Raghupathy, S. 1996. Education and the use of maternal health care in Thailand. Social Science Med., 43(4): 459-471. Rehman, S. and S. Younas. 2002. Sociology. Aali Publishers, Faisalabad, Pakistan Reichel, M., and& M. A. Ramey, M. A. (Eds.). 1987. Conceptual Frameworks for Bibliographic Education: Theory to Practice. Littleton Colorado: Libraries Unlimited Inc. Richard, A.B. 2004. Regression Analysis: A constructive critique. SAGE. Rizvi, N. and S. Nishtar. 2008. Pakistan’s health policy: Appropriateness and relevance to women’s health needs. Health Policy, 88: 269-281. Robert, J. I. L., J. A. Oduma, S. Bassol-Mayagoitia, A. M. Bacha, K. M. Grigor. 1993. Regional and geographical variations in infertility: Effects of environmental, cultural and socio-economic factors. Environmental Health Perspectives Supplements, 101(2):73-80. Ronsmans, C. and W.J. Graham. 2006. Lancet Maternal Survival Series steering group: Maternal mortality: who, when, where, and why. Lancet, 368(9542):1189- 1200.
153
Rooney, C. 1992. Antenatal care and maternal health: how effective is it? World Health Organization. Document WHO/MSM/92.4 Geneva: 6-9. Rower, R. and J. Garcia. 2003. Access to care for low-income child bearing women. Evidence on access to maternity and infant care in England. Unpublished project report. Oxford University Institute of Health Sciences: Maternal Prenatal Epidemiology Unit. Royal College of Obstetricians and Gynaecologists. 1979. Maternity Care in Developing Countries: What the Community Needs. London: Royal College of Obstetricians and Gynaecologists.UK. Royston, E., Armstrong, S. (Eds.), 1989. Preventing Maternal Deaths. World Health Organization, Geneva. Rusin, H. J. 1983. Applied Social Research. A Bell and Howell Company. Ohio, USA. Safe Motherhood. 1998. Improve access to quality maternal health services. Retrieved on Sep. 5, 2013 from www.safemotherood.org. Safe Motherhood. 2002. Safe Motherhood: a matter of human rights and social justice. Retrieved on Sep. 9, 2013 from www.safemotherood.org. Scholl, T.O., 1994. Prenatal Care and Maternal Health during Adolescent Pregnancy: A Review and Meta-analysis. Journal of Adolescent Health, 15(6): 444-456. Schultz, T.P. 1984. Studying the impact of household economic and community variables on child mortality. Population and Development Review, 10: 213-235. Shaikh, B.T. and J. Hatcher. 2005. Health seeking behaviour and health service utilization in Pakistan: Challenging the policy makers. Journal of Public Health, 27(1): 49-54. Shamsa, A., J. Bai, P. Raviraj and R. Gyaneshwar. 2013. Mode of delivery and its associated maternal and neonatal outcomes. Publications. Retrive on May 17, 2013 from http://dx.doi.org/10.4236/ojog.2013.33057. Shanna, E.B. Elaine, M.A. Rogan and V.R. . Virginia. 2004, Factors affecting maternal health utilization. Philippines 9th National Convention on Statistics (NCS) EDSA Shangri-La Hotel October 4-5, 2004. Shariff, A. and G. Singh. 2002. Determinants of Maternal Health Care Utilization in India: Evidence from a Recent Household Survey, NCAER, New Delhi. 83.India.
154
Sharma, S.K., Y. Sawangdee and B. Sirirassamee. 2007. Access to health: women’s status and utilization of maternal health services in Nepal. Journal of Biosocial Science, Cambridge, 39: 671-692. Shen, C., J. B. Williamson. 1997. Child mortality, women's status, economic dependency and state strength: A cross sectional study of less developed countries. Social Forces 76(2), 667-700 Sheskin D. J. 2007.Handbook of parametric and nonparametric statistical procedures. Fourth Edition. Chapman and Hall/CRP. Shield, M.P. 1997. Son preference and contraception in Egypt. Rural Development, P. 353-370. Shields, M., and S. Shooshtari. 2001. Determinants of self-perceived health. Health Rep., 13(1): 35-52. Sibanda, J.Q., I. Saungweme, C. Nleya, M.P. Mutyambizi and R.A. Rutgers. 2001. Postnatal care in Bubi district deserves more attention. Central African Journal of Medicine, 47(4): 103-108. Sibley, L. 1997. Obstetric First Aid in the Community Partners in Safe Motherhood. J. Nurse Midwifery, 42(2):117-121. Singh P. K, R. K. Rai, M. Alagarajan and L. Singh. 2012. Determinants of Maternity Care Services Utilization among Married Adolescents in Rural India. PLoS ONE 7(2): 31666. Singh, S., J.E. Darroch J.E, M. Vlassoff M. and J. Nadeau J. 2003. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: The Alan Guttmacher Institute and United Nations Population Fund; 2003. http://www.guttmacher.org/pubs/addingitup.pdf. Stewart, K., and A.E. Sommerfelt. 1991. Utilization of maternity care services: A comparative study using DHS data. Proceedings of the Demographic and Health Surveys World Conference, 3: 1645-1668. Washington, DC. Columbia, Maryland. Sunmola, A. M., M. Dipeolu, S. Babalola and O. D. Adebayo. 2003. Reproductive knowledge, sexual behavior and contraceptive use among Niger state of Nigeria. African Journal of Reproductive Health, 7(1):37-48. Swenson, I., N. Thang, V. Nhan and P. Tieu. 1993. Factors related to the utilization of antenatal services in Vietnam. Journal of Tropical Medical Hygiene, 96(2): 76-86. 155
Terzieff, J. 2006. Pakistan begins new reproductive health push. Women ‘s News Intl. Nov. 18, 2006. Pakistan: Population Planning Policies and Problems. Thaddeus and & Maine. 1994. Too far to walk: maternal mortality in context. Social Science & Medicine, 38(8): 1091-1110. Thapa, 1988. Breast Feeding and Birth Spacing Saves Lives. A Hazards Model Analysis of the Case of Malaysia. Social Biology, 34(1-2): 78-93. Titaley R.C., C.L. Hunter, M.J. Dibley, P. Heywood. 2010. Why do some women still prefer traditional birth attendants and home delivery? A qualitative study on delivery care services in West Java Province, Indonesia. BMC Pregnancy and Childbirth 2010. Retrived on January 2014 from: www.biomedcentral.com/1471-2393/10/43. Trinh, L.T., M.J. Dibley and J. Byles. 2007. Determinants of antenatal care utilization in three rural areas of Vietnam. Public Health Nurs., 24(4): 300–310. Ueda, M.A. 1997. Child feeding and caring behavior of mothers with 1-3 year old children of urban poor communities in Bangkok: A socio-behavioral perspective. An unpublished Thesis, Primary Health Care Management, Bangkok. UNDP. 2013. Human Development Report 2013,. Retrieved on Nov. 2, 2013 from http://hdr.undp.org/en/media/HDR2013_EN_Summary.pdf UNESCO. 2004. Literacy Trend in Pakistan UNESCO Office, Islamabad. UNFPA. 2004. Focus on: Reproductive health and safe motherhood, making pregnancy & childbirth safer. A workshop coordinated by German foundation for world population. Online available at: http://www.asia-initiative.org UNFPA. 2007. State of the world population - unleashing the potential of urban growth. New York. UNICEF. 2000. Maternal and Neonatal Tetanus Elimination by 2005-UNICEF. Retrieved on September 12, 2013 from: http://www.unicef.org/health/files/MNTE_strategy_paper.pdf UNICEF. 2000. Maternal and neonatal tetanus elimination by 2005-UNICEF. Retrieve on September 27, 2013 from: http://www.unicef.org/health/files/MNTE_strategy_paper.pdf. UNICEF. 2006. State of the World’s children 2006. New York. United Nations Children's Fund. UNICEF. 2008. Pakistan. Retrieved on August 12, 2013 from: http://www.unicef.org/rosa/Pakistan_PPTCT_Fact_Sheet.pdf 156
UNICEF. 2008. Progress for Children. A Report Card on Maternal Mortality, No. 7, September 2008. Retrieved from website on October 11, 2013 http://www.unicef.org/childsurvival/files/Progress_for_Children- No._7_Lo-Res_082008.pdf UNICEF. 2011. Definitions of indicators. Retrieve on September 12, 2013 from: http://www.unicef.org/infobycountry/stats_popup1.html UNICEF. 2013, Elimination of Maternal and Neonatal Tetanus. Retrieve on September 12, 2013 from: http://www.unicef.org/health/index_43509.html UNICEF. 2013. Elimination of maternal and neonatal tetanus. Retrieve on October 10, 2013 from: www.unicef.org/health/index_43509.htm. United Nations (UN). 2008. The Millennium Development Goals Report 2008, New York. United Nations Population Fund (UNFPA). 2004. State of the world’s population 2004: Maternal Health, New York. United Nations Population Fund (UNPF). 2011. Human rights: supporting the constellation of reproductive rights. Retrieved on Nov. 24, 2013 from
157
Weiner, R., C. Ronsmans, E. Dorman, H. Jilo, A. Muhoro, C. Shulman. 2003. Labour complications remain the most important risk factors for perinatal mortality in rural Kenya. Bull World Health Organ, 81(8): 561–6. Wellman, B. 1988. The community question re-evaluated. Pp. 81-107 in Power, Community and the City, edited by Michael Peter Smith. New Brunswick, New Jersey. Westoff, C. 2005. Recent Trends in Abortion and Contraception in 12 Countries. DHS Analytical Studies No. 8. Calverton, USA. http://www.measuredhs.com/pubs/pdf/AS8/AS8.pdf. WHO. 1998. Postpartum care of the mother and newborn: a practical guide WHO/RHT/MSM/983. Geneva: WHO. WHO. 2000. Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva: World Health Organization (WHO/NHD.007). WHO. 2005., Reducing risk, promoting health life. World Health Report 2005. WHO. 2008. Maternal Health. Retrieve on November 11, 2013 from: www.who.int/topics/maternal_health/en/ WHO. 2010. Maternal mortality. Retrieved on July 12, 2013 from: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. WHO. 2012. Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank Estimates. WHO. 2013. Antenatal Care. Retrieved on Oct. 23, 2013 from: http://www.who.int/gho/maternal_health/reproductive_health/antenatal_ca re_text/en/ WHO. 2013. Expanded Programme on Immunization. Receive on Oct. 21, 2013 from: http://www.emro.who.int/pak/programmes/expanded-programme-on- immunization.html WHO. 2013. Neonatal Mortality Trends 1990 to 2010. Retrieved on Oct.23, 2013 from: http://www.who.int/maternal_child_adolescent/topics/newborn/neonatal_ mortality/en/index.html WHO. 2013. WHO vaccine-preventable diseases: monitoring system: Global summary. World Health Organization.
158
WHO. 2014. Maternal, newborn, child and adolescent health. World Health Organization. Online available at: www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/ Williams, C.D., N. Baumslag, and D. B. Jelliffe. 1985. Mother and child health: Delivering the services. Second edition. London: Oxford University Press. Winch, P.J., M.A. Alam, A. Akther, D. Afroz, N.A. Ali, A.A. Ellis, A.H. Baqui, G.L. Darmstadt, S. Arifeen, M.H.R. Seraji. 2005. The Bangladesh PROJAHNMO study Group: Local understandings of vulnerability and protection during the neonatal period in Sylhet district, Bangladesh: A qualitative study. Lancet, 366(9484): 427-520 Winikoff, B. and M. Sullivan. 1987. Assessing the role of family planning in reducing maternal mortality. Studies in Family Planning, 18(3): 128-143. Woehr, D. J. and T.A. Cavell. 1993. Self report measures of ability, effort and nonacademic activity as predictors of introductory psychology test scores. Teaching of Psychology, 20: 156-160. Wong, E.L., B.M. Popkin, D.K. Guilkey and J.S. Akin. 1987. Accessibility, quality of care and prenatal use in the Philippines. Social Science & Medicine, 24(11): 927-944. World Bank. 1994. World development report: Infrastructure for development. New York, New York: Oxford University Press. World Bank. 2000. Making Motherhood Safer. Improving reproductive health: The role of the World Bank, Washington, D.C. World Health Organization (WHO). 2005. The World Health Report 2005: Make Every Mother and Child Count. Geneva. Yasir, P.K., Z.B. Sheree, M. Shama and, A.B. Zulfiqar. 2009. Maternal Health and Survival in Pakistan: Issues and Options. J. Obstet. Gynaecol. Can., 19(31): 920-929. York, R., L. Tulman and K. Brown. 2000. Postnatal care in low-income urban African American Women: Relationship to level of prenatal care sought. Journal of Perinatology, 20(1): 34-37. Zafar. M. I., F. Asif and S. Adil. 2003. Religiosity as a factor of fertility and contraceptive behavior in Pakistan. Pakistan Journal of Applied Sciences, 3(3)158-166.
159
Zaidi, N., M. Ahmd, M. W. Khan, M. Hussain, A. Hussain. 2011. Contraceptives knowledge and practices in district Rawalpindi: A hospital based study. Pakistan Armed Forces Journal, 2(1): Zhao Q., Z. J. Huang, S. Yang, J. Pan, B. Smith and B. Xu. 2012. The Utilization of Antenatal Care Among Rural to Urban Migrant Women in Shanghai: A hospital based cross-sectional study. . BMC Public Health, 12:1012 Zupan, J. 2005. Prenatal mortality in developing countries. New. England. Journal of Medicine, 352:2047-2048.
160