Factors associated with non-utilization of postnatal care among newborns in the first 2 days after birth in Pakistan: a nationwide cross-sectional study

Global Health Action, Volume 14, No. 1, Year 2021

Interpretation

Background: Recent data indicated that approximately four in every ten newborns in Pakistan do not receive postnatal care (PNC) services in the first 48 hours after delivery. Objectives: This study aimed to identify factors associated with the non-utilization of PNC for newborns in Pakistan using the 2017–18 Pakistan Demographic and Health Survey (PDHS). Methods: This was a cross-sectional analytical study utilizing data from 3887 live-born newborns recorded in the 2017–18 PDHS. Non-utilization of PNC was assessed against a set of independent factors using multilevel logistic regression analysis, and the population attributable risk estimates of factors associated with non-utilization of PNC were also calculated. Results: There were 1443 newborns (37%) in Pakistan whose mothers did not utilize PNC check-ups in the first 2 days after delivery. The non-utilization of PNC was largely attributable to newborns delivered at non-health facilities 53% (47% to 59%) and those born to uneducated women 27% (13% to 38%). Adjusted analyses indicated that newborns with higher birth order and with a birth interval of more than 2 years, women who perceived their baby to be small at birth, women with no formal education and those living in regional areas of Khyber Pakhtunkhwa and Federally Administered Tribal Areas were significantly associated with non-utilization of PNC services. Conclusions: Tailored health messages by community health workers, including door-to-door visits on utilizing health facilities through pregnancy to the postnatal periods, are needed and should target places of low socioeconomic status, including educationally disadvantaged women from regional areas of Pakistan. Data regarding factors related to PNC services were extracted from a national household survey recorded in the 2017–18 PDHS [5]. The survey is carried out in Pakistan approximately every 5 years since 2006–7 by the National Institute of Population Studies (NIPS) in collaboration with Measure DHS ICF International (Calverton, MD, USA). The statistical methodology used in obtaining demographic and health characteristics has been described elsewhere [5]. Data concerning PNC services for the most recent births in the 2 years preceding the 2017–18 PDHS survey were reported to minimize women’s differential recall of events, as deliveries occurred at different periods in time prior to the survey date. Data on PNC services usage were gathered from 12,364 eligible women (aged 15–49 years old) who were successfully interviewed during the survey. Sixty-two percent of these women had a total of 3,887 most recent live births in the 2 years prior to the survey data and were used for the current study analyses. Data collected from Azad Jammu and Kashmir, and Gilgit-Baltistan regions were not included in the study because those data were not incorporated in the total national estimates reported by the PDHS 2017–18 [5]. The dependent variable for this study was the non-utilization of PNC services. This was partitioned into two mutually exclusive parts, such that non-utilization of PNC was considered as a ‘case’ (1 = if newborns had no postnatal check-ups in the first 2 days after delivery) or a ‘non-case (0 = if newborns had check-ups in the first 2 days after delivery). Potential independent variables considered were based on similar past literature on non-utilization of PNC services in LMICs [7–9] and Andersen’s [15] behavioral theoretical framework of maternal health services. All the potential coexisting factors (Figure 1) were based on data availability in the 2017–18 PDHS, and these factors were categorized into six discrete groups: community-level factors, socio-demographic factors, health knowledge factors, enabling factors, need factors, and previous use of health services. The community-related confounders were residence type and region categorized into six groups (Punjab, Sindh, Balochistan, Islamabad capital territory (ICT), Khyber Pakhtunkhwa, and Federally Administered Tribal Areas (FATA). The residence type classified as (rural or urban) was included in the analysis because findings from earlier studies showed that living in rural areas was significantly associated with non-utilization of PNC [7,16]. Adherence to religious beliefs and cultural practices (e.g. keeping a newborn indoors for a specified period, particularly newborns delivered at non-health facilities) is more common in rural areas than in urban settings. Seclusion, part of cultural practices during the postnatal period, has been reported in past literature [17,18]. The study theoretical framework was adapted from Andersen’s behavioral model The possible independent socio-demographic level factors assessed consist of mother’s level of education, household wealth index, father’s level of education, mother’s age at birth, marital status, child sex, birth order/birth interval, and mother’s working status. A mother’s educational attainment has been previously reported to be strongly correlated with non-utilization of PNC [7,19,20]. It has been suggested that uneducated mothers may not be able to understand the full benefits of maternal health services and are less likely to appropriately utilize them than their educated counterparts. Mothers’ educational level was classified into three categories (no education, primary and secondary or higher education). Educated mothers, in turn, were more likely to obtain paid employment, which may likely increase access to modern health facilities. Hence, the inclusion of working status in the study analysis. Working status was divided into two groups (working or not working). We also adjusted for the mother’s age at the time of birth because it has been earlier opined that young maternal age (<20 years), inexperience in child-rearing and poor use of maternal health services have been attributed to morbidity and mortality of newborns [21]. It is possible that the infrequent use of maternal health services may vary as mothers get older. Maternal age was grouped into four classes (age <20, 20–29, 30–39 and 40–49 years). Findings from recent studies in Nepal [22] and Bangladesh [23] indicated that there is a strong relationship between PNC services usage and rich household, implying that households of low socioeconomic status were less likely to patronize PNC services. Accordingly, the household wealth index was incorporated, and it was grouped into three classes (rich, middle and poor). The household wealth index in the 2017–2018 PDHS was constructed using a weighted factor score based on household facilities and assets available to the respondents at the time of the survey [5]. Facilities and assets included were the type of floor material used in rooms, ownership of agricultural land, electricity, television, radio, refrigerator, telephone, car, bicycle, motorcycle and canoe, and a livestock farm or a bank account. Health knowledge factors (listening to the radio, watching television and reading newspapers or magazines) were also included in the study because previous studies [7,9,24] have shown that mothers who had inadequate or no access to mass media had a significantly increased odds of non-utilization of PNC services. Information through mass media can enhance mother’s knowledge and improve their ability to seek timely health-care services [25]. In the 2017–2018 PDHS, women participants (15–49 years) were asked if the following enabling factors ‘(getting permission to seek medical advice, getting money for advice or treatment, distance to a health facility, not wanting to go alone)’ constituted hindrance in accessing health-care services for themselves. The prevalence report showed that 58%, 42%, 30% and 21% of women reported not wanting to go alone, distance to the health facility, getting money for treatment, and getting permission to seek medical advice, respectively, encumbered their ability to access healthcare services. As a result of these statistics, we considered enabling factors in the study analysis. Need factors such as perceived newborn’s size at birth by mothers and desire for pregnancy were also included because similar studies by Agho et al. [7] and Titaley et al. [9] opined that smaller sized newborns had a significantly increased likelihood of non-utilization of PNC services. Perceived newborn’s size was classified into three groups (small, average and large). It was utilized as a proxy for the actual newborn’s weight at birth due to over 50% were not weighed at birth. This proxy approach was not unreasonable due to an earlier study that has indicated that there exists a close relationship between mean birth weight and perceived newborn size by the mother [26]. Mode of delivery, place of delivery and delivery assistance were grouped as previous use of health-care services. There was inconsistency in the relationship between place of delivery and non-utilization of PNC services; for example, Somefun and Ibisomi, in their study, revealed that newborns delivered in a non-health facility (or home facility) were more likely to use PNC services [27]. Whilst other studies suggested that newborns delivered in non-health facilities were less likely to use PNC services [9,16,28]. As a result of this inconsistency, we included the place of delivery in the current study.

AI Digest

Study Justification:

The study aimed to investigate the factors associated with the non-utilization of postnatal care (PNC) services for newborns in Pakistan. This is important because recent data showed that a significant proportion of newborns in Pakistan do not receive PNC within the first 48 hours after birth. Understanding the factors contributing to this non-utilization can help inform interventions and policies to improve newborn health outcomes.

Study Highlights:

– The study utilized data from the 2017-18 Pakistan Demographic and Health Survey (PDHS) and analyzed information from 3,887 live-born newborns.
– The study found that 37% of newborns in Pakistan did not receive PNC check-ups in the first 2 days after delivery.
– Factors associated with non-utilization of PNC included newborns delivered at non-health facilities (53%) and newborns born to uneducated women (27%).
– Other significant factors included higher birth order, birth interval of more than 2 years, perception of the baby being small at birth, and living in certain regional areas of Pakistan.
– The study recommended tailored health messages by community health workers, including door-to-door visits, to promote the utilization of health facilities during pregnancy and the postnatal period. These interventions should specifically target areas of low socioeconomic status and educationally disadvantaged women.

Recommendations for Lay Readers and Policy Makers:

1. Increase awareness and education: Implement targeted health messages and educational campaigns to inform mothers and families about the importance of PNC services for newborns.
2. Improve access to health facilities: Enhance the availability and accessibility of health facilities, particularly in rural areas, to ensure that mothers can easily access PNC services.
3. Strengthen community health worker programs: Invest in training and supporting community health workers to provide door-to-door visits and personalized support for pregnant women and newborns.
4. Address socioeconomic disparities: Implement interventions that address socioeconomic inequalities, such as providing financial assistance or incentives for families with low socioeconomic status to seek PNC services.
5. Monitor and evaluate interventions: Establish a system for monitoring and evaluating the effectiveness of interventions aimed at improving PNC utilization, to ensure continuous improvement and evidence-based decision-making.

Key Role Players:

1. Ministry of Health: Responsible for developing and implementing policies and programs related to maternal and newborn health.
2. National Institute of Population Studies (NIPS): Provides data and research support for evidence-based decision-making.
3. Community Health Workers: Play a crucial role in delivering health messages, conducting door-to-door visits, and providing support to pregnant women and newborns.
4. Non-Governmental Organizations (NGOs): Collaborate with government agencies to implement interventions and provide additional support and resources.
5. Health Facilities: Ensure the availability of quality PNC services and support the training and capacity-building of healthcare providers.

Cost Items for Planning Recommendations:

1. Training and capacity-building programs for community health workers.
2. Development and dissemination of health messages and educational materials.
3. Infrastructure improvement and expansion of health facilities, particularly in underserved areas.
4. Financial assistance or incentives for families with low socioeconomic status to access PNC services.
5. Monitoring and evaluation systems to assess the effectiveness of interventions.
Note: The actual cost of implementing these recommendations will depend on various factors and would require a detailed budget analysis.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a nationwide cross-sectional study using data from a large sample size. The study utilized multilevel logistic regression analysis to assess the factors associated with non-utilization of postnatal care (PNC) services for newborns in Pakistan. The study also calculated population attributable risk estimates. The abstract provides clear information on the methodology, results, and conclusions of the study. However, to improve the evidence, it would be helpful to include information on the sampling method used in the survey and any limitations of the study.

Abstract

Data regarding factors related to PNC services were extracted from a national household survey recorded in the 2017–18 PDHS [5]. The survey is carried out in Pakistan approximately every 5 years since 2006–7 by the National Institute of Population Studies (NIPS) in collaboration with Measure DHS ICF International (Calverton, MD, USA). The statistical methodology used in obtaining demographic and health characteristics has been described elsewhere [5]. Data concerning PNC services for the most recent births in the 2 years preceding the 2017–18 PDHS survey were reported to minimize women’s differential recall of events, as deliveries occurred at different periods in time prior to the survey date. Data on PNC services usage were gathered from 12,364 eligible women (aged 15–49 years old) who were successfully interviewed during the survey. Sixty-two percent of these women had a total of 3,887 most recent live births in the 2 years prior to the survey data and were used for the current study analyses. Data collected from Azad Jammu and Kashmir, and Gilgit-Baltistan regions were not included in the study because those data were not incorporated in the total national estimates reported by the PDHS 2017–18 [5]. The dependent variable for this study was the non-utilization of PNC services. This was partitioned into two mutually exclusive parts, such that non-utilization of PNC was considered as a ‘case’ (1 = if newborns had no postnatal check-ups in the first 2 days after delivery) or a ‘non-case (0 = if newborns had check-ups in the first 2 days after delivery). Potential independent variables considered were based on similar past literature on non-utilization of PNC services in LMICs [7–9] and Andersen’s [15] behavioral theoretical framework of maternal health services. All the potential coexisting factors (Figure 1) were based on data availability in the 2017–18 PDHS, and these factors were categorized into six discrete groups: community-level factors, socio-demographic factors, health knowledge factors, enabling factors, need factors, and previous use of health services. The community-related confounders were residence type and region categorized into six groups (Punjab, Sindh, Balochistan, Islamabad capital territory (ICT), Khyber Pakhtunkhwa, and Federally Administered Tribal Areas (FATA). The residence type classified as (rural or urban) was included in the analysis because findings from earlier studies showed that living in rural areas was significantly associated with non-utilization of PNC [7,16]. Adherence to religious beliefs and cultural practices (e.g. keeping a newborn indoors for a specified period, particularly newborns delivered at non-health facilities) is more common in rural areas than in urban settings. Seclusion, part of cultural practices during the postnatal period, has been reported in past literature [17,18]. The study theoretical framework was adapted from Andersen’s behavioral model The possible independent socio-demographic level factors assessed consist of mother’s level of education, household wealth index, father’s level of education, mother’s age at birth, marital status, child sex, birth order/birth interval, and mother’s working status. A mother’s educational attainment has been previously reported to be strongly correlated with non-utilization of PNC [7,19,20]. It has been suggested that uneducated mothers may not be able to understand the full benefits of maternal health services and are less likely to appropriately utilize them than their educated counterparts. Mothers’ educational level was classified into three categories (no education, primary and secondary or higher education). Educated mothers, in turn, were more likely to obtain paid employment, which may likely increase access to modern health facilities. Hence, the inclusion of working status in the study analysis. Working status was divided into two groups (working or not working). We also adjusted for the mother’s age at the time of birth because it has been earlier opined that young maternal age (<20 years), inexperience in child-rearing and poor use of maternal health services have been attributed to morbidity and mortality of newborns [21]. It is possible that the infrequent use of maternal health services may vary as mothers get older. Maternal age was grouped into four classes (age <20, 20–29, 30–39 and 40–49 years). Findings from recent studies in Nepal [22] and Bangladesh [23] indicated that there is a strong relationship between PNC services usage and rich household, implying that households of low socioeconomic status were less likely to patronize PNC services. Accordingly, the household wealth index was incorporated, and it was grouped into three classes (rich, middle and poor). The household wealth index in the 2017–2018 PDHS was constructed using a weighted factor score based on household facilities and assets available to the respondents at the time of the survey [5]. Facilities and assets included were the type of floor material used in rooms, ownership of agricultural land, electricity, television, radio, refrigerator, telephone, car, bicycle, motorcycle and canoe, and a livestock farm or a bank account. Health knowledge factors (listening to the radio, watching television and reading newspapers or magazines) were also included in the study because previous studies [7,9,24] have shown that mothers who had inadequate or no access to mass media had a significantly increased odds of non-utilization of PNC services. Information through mass media can enhance mother’s knowledge and improve their ability to seek timely health-care services [25]. In the 2017–2018 PDHS, women participants (15–49 years) were asked if the following enabling factors ‘(getting permission to seek medical advice, getting money for advice or treatment, distance to a health facility, not wanting to go alone)’ constituted hindrance in accessing health-care services for themselves. The prevalence report showed that 58%, 42%, 30% and 21% of women reported not wanting to go alone, distance to the health facility, getting money for treatment, and getting permission to seek medical advice, respectively, encumbered their ability to access healthcare services. As a result of these statistics, we considered enabling factors in the study analysis. Need factors such as perceived newborn’s size at birth by mothers and desire for pregnancy were also included because similar studies by Agho et al. [7] and Titaley et al. [9] opined that smaller sized newborns had a significantly increased likelihood of non-utilization of PNC services. Perceived newborn’s size was classified into three groups (small, average and large). It was utilized as a proxy for the actual newborn’s weight at birth due to over 50% were not weighed at birth. This proxy approach was not unreasonable due to an earlier study that has indicated that there exists a close relationship between mean birth weight and perceived newborn size by the mother [26]. Mode of delivery, place of delivery and delivery assistance were grouped as previous use of health-care services. There was inconsistency in the relationship between place of delivery and non-utilization of PNC services; for example, Somefun and Ibisomi, in their study, revealed that newborns delivered in a non-health facility (or home facility) were more likely to use PNC services [27]. Whilst other studies suggested that newborns delivered in non-health facilities were less likely to use PNC services [9,16,28]. As a result of this inconsistency, we included the place of delivery in the current study.

Materials

https://efashare.b-cdn.net/materials/0f952e1af37ddd74babc2eb30118919826496da225f0e19739115bf6ee025537/ZGHA_A_1973714_SM7013.docx

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide tailored health messages and reminders for pregnant women and new mothers. These apps can provide information on the importance of postnatal care, schedule appointments, and offer guidance on utilizing health facilities.

2. Community Health Worker (CHW) Programs: Implement CHW programs that involve door-to-door visits to educate and support pregnant women and new mothers. CHWs can provide information on the benefits of postnatal care, address misconceptions, and help overcome barriers to accessing healthcare services.

3. Telemedicine Services: Establish telemedicine services that allow pregnant women and new mothers to consult healthcare professionals remotely. This can help overcome geographical barriers and provide timely advice and support for postnatal care.

4. Financial Incentives: Introduce financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women and new mothers to utilize postnatal care services. This can help offset the costs associated with accessing healthcare and incentivize utilization.

5. Public Awareness Campaigns: Launch public awareness campaigns to educate the general population about the importance of postnatal care and the available services. These campaigns can use various media channels, including radio, television, and newspapers, to reach a wide audience and promote behavior change.

6. Improving Health Facility Infrastructure: Invest in improving the infrastructure and quality of health facilities, particularly in rural and underserved areas. This can include building or renovating facilities, ensuring the availability of essential equipment and supplies, and training healthcare providers to deliver high-quality postnatal care.

7. Partnerships and Collaboration: Foster partnerships and collaboration between government agencies, non-governmental organizations, and private sector entities to pool resources and expertise. This can help maximize the impact of interventions and ensure a comprehensive approach to improving access to maternal health.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations. Additionally, ongoing monitoring and evaluation should be conducted to assess the effectiveness and sustainability of these interventions.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Tailored health messages and community health worker visits: Develop a program that utilizes community health workers to deliver tailored health messages and provide door-to-door visits to pregnant women and new mothers. These visits should focus on educating women about the importance of utilizing health facilities for prenatal and postnatal care, including postnatal check-ups in the first 2 days after delivery. The community health workers can address any concerns or misconceptions women may have and provide support in accessing and utilizing health services.

2. Target low socioeconomic status areas: The program should specifically target areas with low socioeconomic status, including educationally disadvantaged women from regional areas of Pakistan. These areas may have higher rates of non-utilization of postnatal care services. By focusing on these areas, the program can address the barriers faced by women in accessing and utilizing maternal health services.

3. Incorporate mass media: Utilize mass media platforms such as radio, television, and newspapers to disseminate information about the importance of postnatal care and the availability of health services. This can help improve health knowledge among women and increase their awareness of the benefits of utilizing postnatal care services.

4. Address enabling factors: Address the enabling factors that hinder women from accessing healthcare services, such as not wanting to go alone, distance to health facilities, and financial constraints. The program can provide solutions to these barriers, such as arranging transportation for women who do not want to go alone, establishing mobile health clinics in remote areas, and providing financial support for those who cannot afford the cost of care.

5. Improve data collection: Enhance data collection methods to ensure accurate and up-to-date information on the utilization of postnatal care services. This can help monitor the effectiveness of the program and identify areas that require further intervention.

By implementing these recommendations, it is expected that access to maternal health services, specifically postnatal care, will be improved, leading to better health outcomes for both mothers and newborns in Pakistan.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening Health Facilities: Enhance the quality and availability of maternal health services in health facilities, particularly in rural areas. This can be achieved by improving infrastructure, ensuring the availability of skilled healthcare providers, and equipping facilities with necessary medical supplies and equipment.

2. Community Health Worker Programs: Implement community health worker programs to provide tailored health messages and door-to-door visits to pregnant women and new mothers. These programs can help educate women about the importance of utilizing health facilities during pregnancy and the postnatal period, as well as address any concerns or misconceptions they may have.

3. Health Education and Awareness: Develop and implement health education campaigns to raise awareness about the benefits of maternal health services, including postnatal care. These campaigns can utilize various channels such as mass media (radio, television, newspapers), community meetings, and social media platforms to reach a wide audience.

4. Financial Support: Provide financial support or incentives to encourage women, especially those from low socioeconomic backgrounds, to seek and utilize maternal health services. This can include subsidies for transportation costs, cash transfers, or health insurance coverage for maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the Outcome: Clearly define the outcome measure that represents improved access to maternal health, such as the percentage of women receiving postnatal care within the first 48 hours after delivery.

2. Data Collection: Collect data on the relevant variables, including the factors associated with non-utilization of postnatal care identified in the study. This can be done through surveys, interviews, or analysis of existing data sources.

3. Model Development: Develop a statistical model, such as a logistic regression model, to assess the impact of the recommendations on the outcome measure. The model should include the independent variables identified in the study, as well as additional variables related to the recommendations (e.g., presence of community health worker programs, availability of financial support).

4. Simulate Scenarios: Use the developed model to simulate different scenarios by manipulating the variables related to the recommendations. For example, simulate the impact of increasing the number of community health workers or providing financial support to different proportions of the population.

5. Analyze Results: Analyze the simulated results to determine the potential impact of the recommendations on improving access to maternal health. This can be done by comparing the outcomes of different scenarios and assessing the magnitude of change.

6. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the results and identify any uncertainties or limitations in the methodology.

7. Interpret and Communicate Findings: Interpret the findings of the simulation analysis and communicate the potential impact of the recommendations to relevant stakeholders, such as policymakers, healthcare providers, and community organizations. This can help inform decision-making and prioritize interventions to improve access to maternal health.

Author

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1080/16549716.2021.1973714

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female