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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.
