You are viewing the site in preview mode

Skip to content

Advertisement

  • Research article
  • Open Access
  • Open Peer Review

Mothers employed in paid work and their predictors for home delivery in Pakistan

  • 1,
  • 2,
  • 3 and
  • 4Email author
BMC Pregnancy and Childbirth201818:316

https://doi.org/10.1186/s12884-018-1945-4

  • Received: 17 February 2018
  • Accepted: 19 July 2018
  • Published:
Open Peer Review reports

Abstract

Background

Pakistan has one of the highest rates of maternal and neonatal mortality in the world. It is assumed that employed mothers in paid work will be more empowered to opt for safer institutional deliveries. There is a need to understand the predictors of home deliveries in order to plan policies to encourage institutional deliveries in the region.

Methods

The study aimed to ascertain the predictors for home deliveries among mothers employed in paid work in Pakistan. Data analysis is based on secondary data taken from the Pakistan Demographic Health Survey 2012–13. Bivariate and multivariate logistic regression models were conducted.

Results

The findings show that the majority (53.6%) of employed mothers in Pakistan give birth at home. Employed mothers in paid work with the following characteristics had higher chances for delivering at home: (i) women from rural areas (AOR 1.26; 95% CI: 0.94–1.71), or specific regions within Pakistan, (ii) those occupied in unskilled work (AOR 2.61; 95% CI: 1.76–3.88), (iii) women married to uneducated (AOR 1.70; 95% CI: 1.08–2.66), unemployed (AOR 1.69; 95% CI: 1.21–2.35), or unskilled men (AOR 2.02; 95% CI: 1.49–2.72), (iv) women with more than 7 children (AOR 1.57; 95% CI: 1.05–2.35), (v) women who are unable in the prenatal period to have an institutional check-up (AOR 4.84; 95% CI: 3.53–6.65), take assistance from a physician (AOR 3.98; 95% CI: 3.03–5.20), have a blood analysis (AOR 2.63; 95% CI: 1.95–3.57), urine analysis (AOR 2.48; 95% CI: 1.84–3.33) or taken iron tablets (AOR 2.64; 95% CI: 2.06–3.38), and (vi) are unable to make autonomous decisions with regard to spending their earnings (AOR 1.82; 95% CI: 1.27–2.59) and healthcare (AOR 1.12; 95% CI: 0.75–1.65).

Conclusions

Greater efforts by the central and provincial state bodies are needed to encourage institutional deliveries and institutional access, quality and cost. Maternal and paternal benefits are needed for workers in both the formal and informal sectors of the economy. Finally, cultural change, through education, media and religious authorities, is necessary to support institutional deliveries and formal sector paid employment and out of home work opportunities for mothers of Pakistan.

Keywords

  • Mothers
  • Paid work
  • Employment
  • Delivery
  • Pakistan

Background

Pakistan has one of the highest maternal mortality ratios [1] and neonatal mortality rates [2] in the world. Common causes of maternal mortality includes sepsis, severe anemia, obstetric hemorrhage, prolonged and obstructed labor, and hypertensive crises [3]. Intraventricular hemorrhage, hypothermia, encephalopathy, infant respiratory distress syndrome, breech presentation, injury to child during delivery, and preterm birth complications [4] are the common causes for neonatal mortality in Pakistan [4]. Most of these causes can be prevented through institutional deliveries [5, 6].

Employment of women is understood to be a pathway to autonomy and empowerment for women, especially in terms of gaining improvements in rights for decision-making and health for themselves and their children [7]. Research from low-income regions shows that uneducated, unskilled and rural women working in the informal sector of the economy predominantly opt for home deliveries [8, 9]. There are many socio-economic and cultural barriers preventing employed mothers in paid work (EMPW) from electing institutional deliveries including: high cost of healthcare, lack of permission from family, traditional norms, religious misinterpretation, and increased fear of caesarian deliveries [8, 10, 11].

Efforts by development bodies have targeted short term improvements to reduce maternal and child mortality by supporting women from rural and distant locations to give birth in their homes by skilled birth attendants or at local health centers with women attendants [12]. However, the problem with community facilitators delivering in homes or at small and under-resourced health centers is that mothers are unable to seek prenatal check-ups and consultancy from specialised medical practitioners (such as a sonographer, surgeon, nurse, physician, and lab experts) with complete institutional support. Institutional support includes x-ray and ultrasound machines, blood and urine tests, refrigerated medicine, uterotonic agents, scanning machines and surgical theaters for emergency caesarean sections, and sterile instruments [13, 14]. There is also the dilemma that despite the availability of trained midwives, women from conservative communities still opt for traditional birth attendants for assistance in home deliveries [15].

Pakistan has been unable to reduce maternal and under-five child mortality rates, unlike other countries in South Asia, and is lagging behind targets to meet the former Millennium Development Goals (MDGs) [16, 17] and the subsequent Sustainable Development Goals (SDGs). The report by National Institute of Populations Studies suggests that reasons for mortality rates remaining high in the country include the absence of prenatal trained medical practitioner consultation, and institutional check-up in monitoring the health of the mother and fetus [18]. Critical mortality risks that have been researched in the country include postpartum hemorrhage, retained placenta [19], sepsis and tetanus [20], diarrhea [21], preterm birth [22], asphyxia [23], and unhygienic delivery and infections [24]. It has been found that more than 95% of uterus ruptures occur in home deliveries [25], even though uterus ruptures are preventable in institutional deliveries. Similarly, neonatal tetanus is a common but avertable cause of death in Pakistani infants [5], and is caused when deliveries take place at home, using soil surface and also when there are sheep in the house [26].

In addition, home deliveries pose great health risks to the mother and child during the postnatal period, in terms of neglect of (i) colostrum provision and breast feeding practices [27], (ii) immunisations and nutrition supplementation for mother and child [28, 29], and (iii) overall postnatal care and institutional check-up of mother and child [30]. Previous research has shown that mothers, including employed and unemployed women, are more likely to give birth at home when they are uneducated, from poorer and rural backgrounds, when they have lower autonomy, and when the costs of institutional deliveries are high [31, 32].

Despite known risks, home deliveries prevail in conservative counties like Pakistan due to (i) trust and comfort with local birth attendant’s and community midwives [33], (ii) unfavorable services by inferior public hospitals, with distant locations, presence of male practitioners, lack of privacy and separation of child from mother after delivery [34], (iii) the belief that the traditional birth attendant (TBA) will handle the mother better and have her walking and back to work sooner than in institutional deliveries [35], (iv) and mistrust with medical practitioners and “western” or modern solutions for birthing, which is perceived to be a natural and ‘private’ process [36, 37].

International and local development bodies like the World Health Organization (WHO) and the National Maternal and Child Health Program have invested considerable resources in order to improve maternal and child health in Pakistan [21, 38]. They have been supported by Partners in Population and Development (PPD) and Partnership for Maternal, Newborn & Child Health (PMNCH) in encouraging disadvantaged women to gain employment through skill development and small business mobilisation [39]. Program objectives are to ensure progress toward achieving the SDGs in maternal and child health, most specifically in newborn mortality, infant mortality and maternal mortality. Presently, however, there is no mention specifically for targeted objectives to reduce neonatal mortality and measures to encourage institutional check-ups with trained medical practitioners during pregnancy to ensure safe deliveries.

To help rural women in unskilled and agriculture based employment to give birth safely, the government of Pakistan launched the National Maternal, Neonatal and Child Health program in 2006. The aim of the program was to train and place TBAs in rural areas; however, the deployment of these workers has been limited [40]. Also, both the local midwives and trained community health workers have been unable to significantly reduce maternal and child mortality [19]. In addition, many working and non-working mothers do not seek assistance from TBA, as they assume that their delivery will be normal [41]. There is still a need to understand the predictors for home deliveries for employed mothers in Pakistan in order to formulate adequate policies to support employed women in choosing institutional deliveries for their own and their child’s safety [42]. Up to now, there has been no study conducted exploring predictors for why employed mothers in Pakistan give birth at home. This research aims to identify: (i) the socio-demographic and pre-natal characteristics, and decision-making characteristics of employed mothers in paid work of Pakistan, and (ii) the association between employed mothers in paid work of Pakistan and home deliveries.

Methods

Data and sample

Secondary data from the Pakistan Demographic and Health Survey (PDHS) 2012–13, the third survey conducted in the country as part of the Measure DHS international series, has been used for this study. A total of 12,943 households were sampled and 13,558 ever-married women of reproductive age were sampled through multi-stage cluster sampling across Pakistan [18]. For this study, a total of 1387 EMPW with a child born in the last 5 years were included. Mothers with children born in the last 5 years were selected in order to avoid memory recall bias of the respondents.

Variables included in analyses

The dependent variable was the place of delivery, distinguishing between home delivery and facility-based delivery.

The following socio-demographic characteristics were included in this study: age of employed mother, provincial belonging, regional belonging, education, wealth, marital status, occupation, husband’s education and occupation, total children born, head of household, and the place of delivery of last child born. Furthermore, seven independent variables were included in the analysis, which are based on a literature review: number of prenatal visits during pregnancy, prenatal assistance from physician, urine analysis taken during pregnancy, blood analysis taken during pregnancy, given/bought iron tablets during pregnancy, decision-maker for spending respondents’ money, and decision-maker for spending healthcare.

Statistical analyses

Descriptive statistics were used to describe the socio-demographic characteristics of EMPW. Before including variables in multivariate analyses, we controlled for multicollinearity. The variance inflation factor for each independent variable covered a range between 1.04 and 3.69, indicating no multicollinearity among the variables included in the regression model. Bivariate logistic regression was conducted to show the predictors for home delivery by EMPW. The multivariate logistic regression model, was controlled for age, wealth and education of mothers. Odds ratios (OR) and Adjusted odds ratios (AOR) with 95% confidence intervals (CI) with a significance level of α = 0.05 were calculated.

Results

Socio-demographic characteristics

Table 1 shows the socio-demographic characteristic of EMPW in Pakistan, of which 45.4% were between 15 and 29 years, 45.3% were between 30 and 39 years and 9.2% were between 40 and 44 years. The mean age was 30 years and the standard deviation was 8.5 years. The majority of the employed mothers belonged to urban regions (65.8%), the uneducated strata (65.5%), and the poor wealth bracket (58.1%). A greater number of mothers (78.6%) were involved in unskilled or semi-skilled work (49.2 and 32.4%). Nearly all of the EMPW (98.3%) were currently married and living with their husbands. Around 96% women reported to live in a male headed household (who were their husband, father, or father-in-law). About half of the employed woman had between 1 and 3 children, and 53.6% delivered their children at home.
Table 1

Socio-demographic characteristics of employed mothers in paid work with children born in the last 5 years (n = 1387)

Characteristics

n a

%

Age

 15–29 years

630

45.4

 30–39 years

629

45.3

 40–44 years

128

9.2

Province

 Baluchistan

195

14.1

 KPK

136

9.8

 Sindh

505

36.4

 Punjab

551

39.7

Region

 Rural

475

34.2

 Urban

912

65.8

Education

 No formal schooling

909

65.5

 Primary

169

12.2

 Secondary

124

8.9

 Higher

185

13.3

Wealth

 Poor

806

58.1

 Middle

226

16.3

 Rich

355

25.6

Marital status

 Divorced/separated/widowed

23

1.7

 Currently living with husband

1364

98.3

Mother’s occupation

 Unskilled

683

49.2

 Semi-skilled

449

32.4

 Skilled

254

18.3

Husband’s education

 No formal schooling

598

43.1

 Primary

216

15.6

 Secondary

340

24.5

 Higher

232

16.7

Husband’s occupation

 Unemployed

24

1.7

 Unskilled

798

57.5

 Semi-skilled

333

24.0

 Skilled

232

16.7

Total children born

 7 or more

270

19.5

 4–6

474

34.2

 1–3

643

46.4

Head of household

 Father/other

460

33.2

 Husband

872

62.9

 Self

55

4.0

Place of delivery

 Home

743

53.6

 Hospital/clinic

644

46.4

aSome of the descriptive statistics do not add up to 1387 due to missing values in the data

Table 2 shows the descriptive statistics for prenatal health practices of EMPW. According to this, 71.7% of employed mothers had at least one prenatal visit during pregnancy to a health center, clinic, or hospital. However, only 37.6% sought assistance from a physician for prenatal check-ups. A significant number of EMPW had not taken samples for urine (48.4%) and blood analysis (52.2%) during pregnancy. In addition, almost 60% had not consumed iron tablets during pregnancy. Only half of employed mothers indicated that they could exclusively decide on how to spend their earnings, and very few (14.1%) indicated ability to make health decisions independently.
Table 2

Descriptive statistics for employed mothers in paid work and their reproductive health practices before delivery (n = 1387)

Characteristics

n a

%

Number of prenatal visits during pregnancy

 None

393

28.3

 At least one

994

71.7

Prenatal assistance from physician

 

 No

521

62.4

 Yes

866

37.6

Urine analysis taken during pregnancy

 No

481

48.4

 Yes

513

51.6

Blood analysis taken during pregnancy

 No

518

52.2

 Yes

475

47.8

Given/bought iron tablets during pregnancy

 No

824

59.4

 Yes

563

40.6

Decision-maker for spending respondent’s earning

 Husband or elders

227

16.3

 Husbands, elders and self jointly

459

33.1

 Self

701

50.5

Decision-maker for respondent’s healthcare

 ‘Self and husband’ or ‘self and other’

1191

85.9

 Self

196

14.1

aSome of the descriptive statistics do not add up to 1387 due to missing values in the data

Simple bivariate logistic regression

Results of the bivariate logistic regression (Table 3) show that home deliveries were more likely to occur in Baluchistan (OR 4.79; 95% CI: 2.98–7.70), KPK (OR 3.07; 95% CI: 2.12–4.44), Sindh (OR 2.74; 95% CI: 1.89–3.94) as compared to Punjab. In addition, the likelihood for home deliveries was much higher in rural regions (OR 3.16; 95% CI: 2.50–3.98) than in urban areas. Employed mothers with no (OR 11.70; 95% CI: 7.56–18.10) or low (OR 2.45; 95% CI: 1.76–3.42) education were also significantly more likely to give birth to their children at home. Mothers from poor (OR 6.56; 95% CI: 4.94–8.72) and middle income (OR 2.17; 95% CI: 1.61–2.93) also had a higher likelihood for home deliveries than women from highest wealth group.
Table 3

Simple bivariate logistic regression for predictors of home delivery among mothers employed in paid work

Characteristics

OR (95% CI)

p-value

Age

 15–29 years

1.33 (0.90–1.96)

0.151

 30–39 years

1.14 (0.48–2.69)

0.578

 40–44 years

1

 

Province

 Baluchistan

4.79 (2.98–7.70)

< 0.001

 KPK

3.07 (2.12–4.44)

< 0.001

 Sindh

2.74 (1.89–3.94)

< 0.001

 Punjab

1

 

Region

 Rural

3.16 (2.50–3.98)

< 0.001

 Urban

1

 

Education

 No formal schooling

11.70 (7.56–18.10)

< 0.001

 Primary

3.24 (2.19–4.78)

< 0.001

 Secondary

2.45 (1.76–3.42)

< 0.001

 Higher

1

 

Wealth

 Poor

6.56 (4.94–8.72)

< 0.001

 Middle

2.17 (1.61–2.93)

< 0.001

 Rich

1

 

Marital status

 Divorced/separated/widowed

1.51 (0.66–3.46)

0.330

 Married

1

 

Mother’s occupation

 Unskilled

6.51 (4.67–9.07)

< 0.001

 Semi-skilled

1.86 (1.45–2.37)

< 0.001

 Skilled

1

 

Husband’s education

 No formal schooling

6.60 (4.66–9.36)

< 0.001

 Primary

2.15 (1.63–2.82)

< 0.001

 Secondary

1.43 (1.04–1.97)

0.028

 Higher

1

 

Husband’s occupation

 Unemployed

4.79 (1.93–6.89)

0.001

 Unskilled

3.56 (1.42–8.93)

0.007

 Semi-skilled

1.29 (0.53–3.17)

0.566

 Skilled

1

 

Total children born

 7 or more

2.32 (1.73–3.12)

< 0.001

 4–6

1.12 (0.82–1.52)

0.468

 1–3

1

 

Head of household

 Father/Other

0.94 (0.54–1.62)

0.824

 Husband

1.26 (0.72–2.21)

0.413

 Self

1

 

Number of prenatal visits during pregnancy

 None

7.72 (5.71–10.43)

< 0.001

 At least one

1

 

Prenatal assistance from physician

 No

6.10 (4.75–7.85)

< 0.001

 Yes

1

 

Urine analysis taken during pregnancy

 No

3.98 (3.04–5.21)

< 0.001

 Yes

1

 

Blood analysis taken during pregnancy

 No

4.30 (3.27–5.66)

< 0.001

 Yes

1

 

Given/bought iron tablets during pregnancy

 No

4.11 (3.27–5.16)

< 0.001

 Yes

1

 

Decision-maker for spending respondent’s earning

 Husband or elders

2.47 (1.77–3.44)

< 0.001

 Husband, elder and self jointly

2.36 (1.66–3.33)

< 0.001

 Self

1

 

Decision-maker for respondent’s healthcare

 Self and husband’ or ‘self and other’

1.87 (1.32–2.65)

< 0.001

 Self

1

 

Employed mothers in unskilled work (OR 6.51; 95% CI: 4.67–9.07) or semi-skilled work (OR 1.86; 95% CI: 1.45–2.37) showed higher odds of delivering at home. Similarly, mothers with husbands who were unemployed (OR 4.79; 95% CI: 1.93–6.89) or employed in unskilled work (OR 3.56; 95% CI: 1.42–8.93) also had higher odds of delivering at home. EMPW with husbands who had no formal schooling (OR 6.60; 95% CI: 4.66–9.36), or with primary (OR 2.15; 95% CI: 1.63–2.82) and secondary (OR 1.43; 95% CI: 1.04–1.97) schooling had higher odds of home deliveries. Mothers with 7 or more children (OR 2.32; 95% CI: 1.73–3.12) or 4–6 children (OR 1.12; 95% CI: 0.82–1.52) have higher likelihood of delivering at home.

Mothers without institutional prenatal check-ups (OR 7.72; 95% CI: 5.71–10.43) and those who had not taken prenatal assistance from a physician (OR 6.10; 95% CI: 4.75–7.85) were more likely for delivering at home. Employed mothers who had not had urine or a blood analysis and did not consume iron supplements during pregnancy showed a higher likelihood to give birth to their children at home. Lastly, EMPW with decision-making for spending their earnings (OR 2.47; 95% CI: 1.77–3.44) and healthcare (OR 1.87; 95% CI: 1.32–2.65) being controlled by others (husbands or elders) or jointly (‘self and husband’ or ‘self and other’) had higher odds of home delivery.

Multivariate logistic regression

In the multivariate logistic regression adjusting for mother’s age, education, and wealth status, most of the socio-demographic variables were identified as covariates and thus showed no significance (Table 4). However, the model confirms the relevance of reproductive health practices associated with the place of delivery. According to these results, employed mothers who (i) had not been through a prenatal check-up (AOR 4.84; 95% CI: 3.53–6.65), (ii) had not taken prenatal consultancy from a physician (AOR 3.98; 95% CI: 3.03–5.20), (iii) did not have urine analysis (AOR 2.48; 95% CI: 1.84–3.33), (iv) did not have blood analysis (AOR 2.63; 95% CI: 1.95–3.57) or (v) had not taken iron supplements (AOR 2.64; 95% CI: 2.06–3.38) during pregnancy were more likely to give birth at home. Finally, EMPW who were unable to make autonomous decisions related to (i) spending their earnings [husbands or elders made the decision (AOR 1.82; 95% CI: 1.27–2.59); husbands, elders and self jointly made the decision (AOR 1.88; 95% CI: 1.29–2.73)] and, (ii) spending on healthcare (AOR 1.12; 95% CI: 0.75–1.65), have higher odds of giving birth at home.
Table 4

Multivariate logistic regression for predictors of home delivery among mothers employed in paid work

Characteristic

AORa (95% CI)

p-value

Province

 Baluchistan

1.63 (1.42–1.88)

< 0.001

 KPK

1.73 (1.46–2.05)

< 0.001

 Sindh

0.87 (0.78–0.98)

0.021

 Punjab

1

 

Region

 Rural

1.26 (0.94–1.71)

0.122

 Urban

1

 

Marital status

 Divorced/separated/widowed

0.62 (0.25–1.49)

0.282

 Married

1

 

Mother’s occupation

 Unskilled

2.61 (1.76–3.88)

< 0.001

 Semi-skilled

1.23 (0.94–1.61)

0.121

 Skilled

1

 

Husband’s education

 No formal schooling

1.70 (1.08–2.66)

0.020

 Primary

1.16 (0.85–1.58)

0.335

 Secondary

1.10 (0.79–1.54)

0.551

 Higher

1

 

Husband’s occupation

 Unemployed

1.69 (1.21–2.35)

0.002

 Unskilled

2.02 (1.49–2.72)

< 0.001

 Semi-skilled

0.52 (0.19–1.37)

0.518

 Skilled

1

 

Total children born

 7 or more

1.57 (1.05–2.35)

0.026

 4–6

0.92 (0.65–1.32)

0.682

 1–3

1

 

Head of household

 Father/other

1.07 (0.58–1.97)

0.816

 Husband

1.00 (0.77–1.30)

0.978

 Self

1

 

Number of prenatal visits during pregnancy

 None

4.84 (3.53–6.65)

< 0.001

 At least one

1

 

Prenatal assistance from physician

 No

3.98 (3.03–5.20)

< 0.001

 Yes

1

 

Urine analysis taken during pregnancy

 No

2.48 (1.84–3.33)

< 0.001

 Yes

1

 

Blood analysis taken during pregnancy

 No

2.63 (1.95–3.57)

< 0.001

 Yes

1

 

Given/bought iron tablets during pregnancy

 No

2.64 (2.06–3.38)

< 0.001

 Yes

1

 

Decision-maker for spending respondent’s earning

 Husband or elders

1.82 (1.27–2.59)

0.001

 Husbands, elders and self jointly

1.88 (1.29–2.73)

0.001

 Self

1

 

Decision-maker for respondent’s healthcare

 ‘Self and husband’ or ‘self and other’

1.12 (0.75–1.65)

0.058

 Self

1

 

aMultivariate logistic regression analysis was carried out to obtain AOR after controlling for mother’s age (continuous variable), education (categorical variable) and wealth status (categorical variable)

Discussion

The findings show that the majority of women employed in paid work in Pakistan give birth to their children at home, placing themselves and their child at risk of mortality. Research from high-income countries has shown that institutional deliveries reduce neonatal mortality, due to the presence of medical technologies [43]. We found that employed mother in rural areas and the provinces of KPK and Baluchistan are more likely to give birth at home, due to fewer rural and provincial structural healthcare support and policies, and possibly the sustenance of inflexible traditional practices [31]. Results indicate that provincial political devolution can have its limitations, in that maternal and child health programs are not having symmetrical improvements across provinces [44]. It was also found that EMPW who are employed in unskilled and semi-skilled work are more likely to give birth to their children at home. The implication is that most of the employed mothers in Pakistan are not gaining from the benefits of formal sector employment, with maternal benefits; which might be a strong contributing factor for lack of prenatal check-ups and institutional deliveries [45]. Our findings corroborate other literature from low-income countries, like Bangladesh, Kenya and Ghana, in that employed mothers in unskilled work are (i) unaware of the benefits of institutional delivery, (ii) unable to access institutional and trained healthcare practitioner assistance, and (iii) involved in the informal sector of the economy that provides them fewer health benefits, such as health insurance or medical allowances [10, 46, 47].

A significant predictor of home delivery found in our study was the absence of prenatal check-ups and consultation from physicians. Other research confirms that employed mothers with lack of prenatal consultancy and trained healthcare practitioner visitation are less likely to opt for institutional delivery, due to lack of guidance and skilled medical monitoring [48]. The main benefit of prenatal check-ups with physicians includes plans for safe delivery and timely referral for institutional delivery if risks are present. Research from neighboring India highlights that taking prenatal assistance from non-physicians can place the mother and child at more risks of not opting for institutional deliveries and mortality hazards from physical, environment, and cultural factors [49]. Additionally, trained care providers and LHWs attempting to provide healthcare for mothers and children complain of inability to deliver services in the community due to family resistance and obstruction, which is a patient safety hazard [50].

Our results support findings from India that employed mothers who, during pregnancy, did not have urine or blood analysis, or receive iron supplements were more likely to give birth to children at home [51, 52]. These findings imply that EMPW need prenatal services from experienced and skilled health providers in order to secure institutional deliveries and reproductive health. It is also empirically evidenced that when mothers are able to secure health through institutional consultation during the prenatal period they are more likely to opt for post-natal check-ups and nutritional supplementation, newborn check-ups and immunisation, and early breastfeeding practices [53].

We also found that mothers with seven or more children are more likely to give birth at home. Other literature from the region suggests that women are less likely to give birth in institutions after the birth of their first child [54]. This may be because of cost issues, lack of time to pursue prenatal check-ups, and the belief that multiple births make the mother, and community midwives, experienced enough to manage home deliveries [55]. In fact, mothers with multiple children are at risk of self and child mortality during home delivery due to complications caused by repeat pregnancies and physical weakness of the mother [56].

Our results highlight that the literacy and employment of husbands plays a key role in the health of the mother and child. Other literature from low-income countries, like Nepal and Nigeria, confirms that more educated and skilled husbands with higher pay (i) are more aware of the health risks of home deliveries, (ii) are more able to resist regressive traditional practices of the family and kin, and (iii) have more money to support institutional delivery costs [57, 58].

Of utmost concern is the finding that EMPW in Pakistan are unable to autonomously make decisions with regard to spending their earnings, and are also unable to make independent decisions regarding their health practices. Studies, from Nepal and Sialkot, show that many employed mothers are unable to autonomously control spending on health and household purchases [59, 60]. Scholars and experts agree that when cultural constraints prevent employed women from making their own decisions, their financial autonomy is of benefit primarily to their husbands, in-laws and male relatives, and not their self and children [61]. This can result in multiple challenges for them extending beyond reproductive health, such as inability to control: large and small household consumption, education of their children, early marriage of their daughters, domestic and intimate partner violence, and overall psychological stability of self and child.

The main limitations of this study are associated with the usage of secondary data, which are e.g. the inability to investigate other variables that may influence home deliveries, such as permission from in-laws, traditional customs and the social stigma of institutional deliveries. Also, this study has not been able to investigate the problems unemployed mothers or employed mothers without paid cash, especially in the rural regions, may face in preventing institutional deliveries. In addition, the data rely on a cross-sectional study design, which do not allow for causal inferences. However, this study has its strengths. Significant predictors of home deliveries have been found which will help policy makers to develop improved programs to meet the SDGs.

Conclusions

Pakistan needs more long-term solutions for encouraging institutional deliveries. Public health strategies involving encouragement of institutional consultation during the prenatal period might be the most important vehicle for reducing maternal and child mortality rates in low-income and conservative societies [15]. Central state and provincial bodies need to promote institutional deliveries across provinces and rural areas in terms of access, cost, subsidisation, and quality. Assistance in developing cash payments and employer coverage of institutional deliveries for both working mothers and fathers is needed. Finally, increase in institutional deliveries and health decision-making of mothers requires a change in the cultural mindset of the nation, with combined structural and civilian mobilisation across sectors like education and media, and agencies like community notables and religious authorities [61].

Abbreviations

AOR: 

Adjusted odds ratio

CI: 

Confidence interval

EMPW: 

Employed mothers in paid work

MDG: 

Millennium Development Goal

MNCH: 

Maternal, newborn and child health

OR: 

Odds ratio

PMNCH: 

Partnership for Maternal, Newborn & Child Health

PPD: 

Partners in Population and Development

SDG: 

Sustainable Development Goal

TBA: 

Traditional birth attendant

WHO: 

World Health Organization

Declarations

Acknowledgements

Measure DHS is thanked for their permission to use the PDHS dataset. We are grateful to Mr. Muhammad Ali Raza, data processing manager for PDHS, and Mr. Zafar Zahir, Associate Fellow at NIPS, for their support and assistance.

We acknowledge support of the publication fee by Deutsche Forschungsgemeinschaft and the Open Access Publication Funds of Bielefeld University.

Funding

The study received no funding.

Availability of data and materials

Data is available from Measure DHS upon request (https://dhsprogram.com/).

Authors’ contributions

SRJ designed the study and analysis. RZ supervised the study. MM contributed to the interpretation of data. SRJ drafted the manuscript and RZ, MM and FF revised it critically. All authors approved the final version.

Ethics approval and consent to participate

The study is based on secondary data taken from Measure DHS. Data is available from Measure DHS upon request. For that reason, no ethical approval or consent to participate is needed for this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Sociology, Forman Christian College, Lahore, Pakistan
(2)
Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
(3)
Department of Sociology, Institute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan
(4)
Department of Public Health Medicine, School of Public Health, Bielefeld University, Bielefeld, Germany

References

  1. Alkema L, Chou D, Hogan D, Zhang S, Moller A, Gemmill A, Fat D, Boerma T, Temmerman M, Mathers C. United Nations Maternal Mortality Estimation Inter-Agency Group collaborators and technical advisory group. Global, regional, and national levels and trends in maternal mortality between 1990 And 2015, with scenario-based projections to 2030: a systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;387(10017):462–74.View ArticlePubMedGoogle Scholar
  2. Oestergaard MZ, Inoue M, Yoshida S, Mahanani WR, Gore FM, Cousens S, Lawn JE, Mathers CD. United Nations Inter-Agency Group for Child Mortality Estimation and the Child Health Epidemiology Reference Group. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med. 2011;8(8):e1001080.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–74.View ArticlePubMedGoogle Scholar
  4. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151–61.View ArticlePubMedGoogle Scholar
  5. Bhutta ZA, Hafeez A. What can Pakistan do to address maternal and child health over the next decade? Health Res Pol Sys. 2015;13(1):S49.View ArticleGoogle Scholar
  6. Mutharayappa K, Prabhuswamy P. Factors and consequences of home deliveries: a study in rural Karnataka. J Health Manag. 2003;5(1):17–35.View ArticleGoogle Scholar
  7. World Health Organization. Women and health: today's evidence tomorrow's agenda. Geneva: World Health Organization; 2009. p. 91.Google Scholar
  8. Belay A, Sendo E. Factors determining choice of delivery place among women of child bearing age in Dega Damot District, north west of Ethiopia: a community based cross-sectional study. BMC Pregnancy Childbirth. 2016;16(1):229.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Ahmed T. Knowledge, attitude and practice regarding hospital delivery among rural married women in northern Bangladesh. Ibrahim Medical Coll J. 2009;3(1):1–4.View ArticleGoogle Scholar
  10. Sarker BK, Rahman M, Rahman T, Hossain J, Reichenbach L, Mitra DK. Reasons for preference of home delivery with traditional birth attendants (TBAs) in rural Bangladesh: a qualitative exploration. PLoS One. 2016;11(1):e0146161.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Cofie LE, Barrington C, Singh K, Sodzi-Tettey S, Akaligaung A. Birth location preferences of mothers and fathers in rural Ghana: implications for pregnancy, labor and birth outcomes. BMC Pregnancy Childbirth. 2015;15(1):165.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, De Bernis L, Team LNSS. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005;365(9463):977–88.View ArticlePubMedGoogle Scholar
  13. Mir AM, Wajid A, Gull S. Helping rural women in Pakistan to prevent postpartum hemorrhage: a quasi experimental study. BMC Pregnancy Childbirth. 2012;12(1):120.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, Walraven G, Hatcher J. Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. Int J Obstet Gynaecol. 2011;118(3):353–61.View ArticleGoogle Scholar
  15. Titaley CR, Hunter CL, Dibley MJ, Heywood P. 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 Childbirth. 2010;10(1):43.View ArticlePubMedPubMed CentralGoogle Scholar
  16. Agha S. Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health. 2011;8(1):10.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Ayaz A, Saleem S. Neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan: a cross-sectional study. PLoS One. 2010;5(11):e13783.View ArticlePubMedPubMed CentralGoogle Scholar
  18. PDHS: Pakistan Demographic and Health Survey 2012–13. Islamabad and Calverton: National Institute of Population Studies and ICF International; 2013.Google Scholar
  19. Shah N, Rohra DK, Shams H, Khan NH. Home deliveries: reasons and adverse outcomes in women presenting to a tertiary care hospital. J Pak Med Assoc. 2010;60(7):555.PubMedGoogle Scholar
  20. Raza SA, Akhtar S, Avan BI, Hamza H, Rahbar M. A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan. J Postgrad Med. 2004;50(4):247.PubMedGoogle Scholar
  21. Siddiqi S, Haq I, Ghaffar A, Akhtar T, Mahaini R. Pakistan’s maternal and child health policy: analysis, lessons and the way forward. Health Policy. 2004;69(1):117–30.View ArticlePubMedGoogle Scholar
  22. Baig SA, Khan N, Baqai T, Fatima A, Karim SA, Aziz S. Preterm birth and its associated risk factors. A study at tertiary care hospitals of Karachi, Pakistan. J Pak Med Assoc. 2013;63(3):414–8.PubMedGoogle Scholar
  23. Kiyani AN, Khushdil A, Ehsan A. Perinatal factors leading to birth asphyxia among term newborns in a tertiary care hospital. Iran J Pediatr. 2014;24(5):637.Google Scholar
  24. Agha S. A profile of women at the highest risk of maternal death in Pakistan. Health Policy Plan. 2014;30(7):830–6.View ArticlePubMedGoogle Scholar
  25. Qudsia Q, Akhtar Z, Kamran K, Khan AH. Woman health; uterus rupture, its complications and management in teaching hospital Bannu, Pakistan. Maedica. 2012;7(1):49.Google Scholar
  26. Quddus A, Luby S, Rahbar M, Pervaiz Y. Neonatal tetanus: mortality rate and risk factors in Loralai District, Pakistan. Int J Epidemiol. 2002;31(3):648–53.View ArticlePubMedGoogle Scholar
  27. Subbulakshmi G, Udipi S, Nirmalamma N. Feeding of colostrum in urban and rural areas. Indian J Pediatr. 1990;57(2):191–6.View ArticlePubMedGoogle Scholar
  28. Hu Y, Li Q, Chen E, Chen Y, Qi X. Determinants of childhood immunization uptake among socio-economically disadvantaged migrants in East China. Int J Environ Res Public Health. 2013;10(7):2845–56.View ArticlePubMedPubMed CentralGoogle Scholar
  29. You W, Boyle KJ, Tech V. Delivery at home versus delivery at a health care facility–a case study of Bihar, India. Seattle, Washington: Agricultural & Applied Economics Association’s 2012 AAEA Annual Meeting; 2012.Google Scholar
  30. Darega B, Dida N, Tafese F, Ololo S. Institutional delivery and postnatal care services utilizations in Abuna Gindeberet District, west Shewa, Oromiya region, Central Ethiopia: a community-based cross sectional study. BMC Pregnancy Childbirth. 2016;16(1):149.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Javed SA, Anjum MD, Imran W, Haider A, Shiraz A, Shaheen F, ul Husnain MI. Correlates of preferences for home or hospital confinement in Pakistan: evidence from a national survey. BMC Pregnancy Childbirth. 2013;13(1):137.View ArticlePubMedPubMed CentralGoogle Scholar
  32. Khan A, Zaman S. Costs of vaginal delivery and caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth. 2010;10(1):2.View ArticlePubMedPubMed CentralGoogle Scholar
  33. Mohammad YJ, Jan R. Community based midwives practice in patriarchal social system. J Asian Midwives. 2015;2(2):62–73.Google Scholar
  34. Memon Z, Zaidi S, Riaz A. Residual barriers for utilization of maternal and child health services: community perceptions from rural Pakistan. Glob J Health Sci. 2016;8(7):47.View ArticleGoogle Scholar
  35. Chesney M, Davies S. Women's birth experiences in Pakistan: the importance of the Dai. Evidence Based Midwifery. 2005;3(1):26–32.Google Scholar
  36. Varley E. Targeted doctors, missing patients: obstetric health services and sectarian conflict in northern Pakistan. Soc Sci Med. 2010;70(1):61–70.View ArticlePubMedGoogle Scholar
  37. Asim M, Mahmood B, Sohail MM. Infant health care; practices in Pakistan: a systematic review. Prof Med J. 2015;22(8):978–88.Google Scholar
  38. National Maternal and Child Health Program. http://dynasoft.org/mnch/index.php.
  39. Partners in Population and Development, The Partnership for Maternal, Newbprn & Child Health: Promoting Women's Empowerment for Better Health Outcomes for Women and Children. Beijing: Strategy Brief for the Inter Ministerial Conference on “South-South Cooperation in Post ICDP and MDGs”; 2013. p. 2013.Google Scholar
  40. Wajid A, Rashid Z, Mir AM. Initial assessment of community midwives in rural Pakistan. Islamabad: Population Council; 2010.Google Scholar
  41. Khadduri R, Marsh D, Rasmussen B, Bari A, Nazir R, Darmstadt G. Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan. J Perinatol. 2008;28(3):182–7.View ArticlePubMedGoogle Scholar
  42. Malik M, Kayani MA. Issues of maternal health in Pakistan: trends towards millennium development goal 5. J Pak Med Assoc. 2014;64(6):690–3.PubMedGoogle Scholar
  43. Daysal NM, Trandafir M, Van Ewijk R. Saving lives at birth: the impact of home births on infant outcomes. Am Econ J Appl Econ. 2015;7(3):28–50.View ArticleGoogle Scholar
  44. National Health Vision Pakistan 2016-2025 [http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/pakistan/national_health_vision_2016-25_30-08-2016.pdf].
  45. Prinja S, Bahuguna P, Gupta R, Sharma A, Rana SK, Kumar R. Coverage and financial risk protection for institutional delivery: how universal is provision of maternal health care in India? PLoS One. 2015;10(9):e0137315.View ArticlePubMedPubMed CentralGoogle Scholar
  46. Ngigi SK: Socio-demographic factors associated with skilled or unskilled delivery among parturient women in Bungoma East District, western Kenya. 2009.Google Scholar
  47. Nakua EK, Sevugu JT, Dzomeku VM, Otupiri E, Lipkovich HR, Owusu-Dabo E. Home birth without skilled attendants despite millennium villages project intervention in Ghana: insight from a survey of women’s perceptions of skilled obstetric care. BMC Pregnancy Childbirth. 2015;15(1):243.View ArticlePubMedPubMed CentralGoogle Scholar
  48. Mistry R, Galal O, Lu M. Women's autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009;69(6):926–33.View ArticlePubMedGoogle Scholar
  49. Wiley AS. Increasing use of prenatal care in Ladakh (India): the roles of ecological and cultural factors. Soc Sci Med. 2002;55(7):1089–102.View ArticlePubMedGoogle Scholar
  50. Closser S, Jooma R. Why we must provide better support for Pakistan's female frontline health workers. PLoS Med. 2013;10(10):e1001528.View ArticlePubMedPubMed CentralGoogle Scholar
  51. Wendt A, Stephenson R, Young M, Webb-Girard A, Hogue C, Ramakrishnan U, Martorell R. Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India. PloS One. 2015;10(3):e0120404.View ArticlePubMedPubMed CentralGoogle Scholar
  52. Kusuma YS, Kumari R, Kaushal S. Migration and access to maternal healthcare: determinants of adequate antenatal care and institutional delivery among socio-economically disadvantaged migrants in Delhi, India. Trop Med Int Health. 2013;18(10):1202–10.View ArticlePubMedGoogle Scholar
  53. Bhutta ZA, Cabral S, Cw C, Keenan WJ. Reducing maternal, newborn, and infant mortality globally: an integrated action agenda. Int J Gynecol Obstet. 2012;119(S1):S13–7.View ArticleGoogle Scholar
  54. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health. 2011;10(1):31.View ArticlePubMedPubMed CentralGoogle Scholar
  55. Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth. 2013;13(1):40.View ArticlePubMedPubMed CentralGoogle Scholar
  56. Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet. 2012;380(9837):111–25.View ArticlePubMedGoogle Scholar
  57. Dhakal S, Van Teijlingen E, Raja EA, Dhakal KB. Skilled care at birth among rural women in Nepal: practice and challenges. J Health Popul Nutr. 2011;29(4):371.View ArticlePubMedPubMed CentralGoogle Scholar
  58. Idris S, Gwarzo U, Shehu A. Determinants of place of delivery among women in a semi-urban settlement in Zaria, northern Nigeria. Ann Afr Med. 2006;5(2):68–72.Google Scholar
  59. Acharya DR, Bell JS, Simkhada P, Van Teijlingen ER, Regmi PR. Women's autonomy in household decision-making: a demographic study in Nepal. Reprod Health. 2010;7(1):15.View ArticlePubMedPubMed CentralGoogle Scholar
  60. Anwar B, Shoaib M, Javed S. Women’s autonomy and their role in decision making at household level: a case of rural Sialkot, Pakistan. World Appl Sci J. 2013;23(1):129–36.Google Scholar
  61. Bedford J, Gandhi M, Admassu M. Girma a: ‘a normal delivery takes place at home’: a qualitative study of the location of childbirth in rural Ethiopia. Matern Child Health J. 2013;17(2):230–9.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2018

Advertisement