Do empowered women receive better quality antenatal care in Pakistan? An analysis of demographic and health survey data

Abstract

Introduction Quality antenatal care is a window of opportunity for improving maternal and neonatal outcomes. Numerous studies have shown a positive effect of women empowerment on improved coverage of maternal and reproductive health services, including antenatal care (ANC). However, there is scarce evidence on the association between women’s empowerment and improved ANC services both in terms of coverage and quality. Addressing this gap, this paper examines the relationship between multi-dimensional measures of women empowerment on utilization of quality ANC (service coverage and consultation) in Pakistan. Methods We used Pakistan Demographic and Health Survey 2017–18 (PDHS) data which comprises of 6,602 currently married women aged between 15–49 years who had a live birth in the past five years preceding the survey. Our exposure variables were three-dimensional measures of women empowerment (social independence, decision making, and attitude towards domestic violence), and our outcome variables were quality of antenatal coverage [i.e. a composite binary measure based on skilled ANC (trained professional), timeliness (1st ANC visit during first trimester), sufficiency of ANC visits (4 or more)] and quality of ANC consultation (i.e. receiving at least 7 or more essential antenatal components out of 8). Data were analysed in Stata 16.0 software. Descriptive statistics were used to describe sample characteristics and binary logistic regression was employed to assess the association between empowerment and quality of antenatal care. Results We found that 41.4% of the women received quality ANC coverage and 30.6% received quality ANC consultations during pregnancy. After controlling for a number of socio-economic and demographic factors, all three measures of women’s empowerment independently showed a positive relationship with both outcomes. Women with high autonomy (i.e. strongly opposed the notion of violence) in the domain of attitude to violence are 1.66 (95% CI 1.30–2.10) and 1.45 (95% CI 1.19–1.75) and times more likely to receive antenatal coverage and quality ANC consultations respectively, compared with women who ranked low on attitude to violence. Women who enjoy high social independence had 1.87 (95% CI 1.44–2.43) and 2.78 (95% CI 2.04–3.79) higher odds of quality antenatal coverage and consultations respectively, as compared with their counterparts. Similarly, women who had high autonomy in household decision making 1.98 (95% CI 1.60–2.44) and 1.56 (95% CI 2.17–1.91) were more likely to receive quality antenatal coverage and consultation respectively, as compared to women who possess low autonomy in household decision making. Conclusion The quality of ANC coverage and consultation with service provider is considerably low in Pakistan. Women’s empowerment related to social independence, gendered beliefs about violence, and decision-making have an independent positive association with the utilisation of quality antenatal care. Thus, efforts directed towards empowering women could be an effective strategy to improve utilisation of quality antenatal care in Pakistan.

Women Empowerment and Access to Maternity and Reproductive Healthcare in Pakistan: Cross-validation of a Survey-based Index in Afghanistan (SWEI-A)

“…The results indicated higher access among those with higher education and income, those with managerial positions, those who can make a decision concerning their health care, mobility, and income, and those who are against wife-beating; however, the authors ignored the confounding effect of household's wealth index-which we did-in examing the effect of different women empowerment indicators on adequate ANC and yet reported it as an independent variable in uencing the access to ANC (22). Similar ndings were observed in Asim et al's study (23); however; the authors used the SWPER index which is to some degree similar to our index but developed based on pooled data from several countries in different regions around the globe and includes some indicators such as frequency of reading newspaper, age difference, and education difference that appeared as poor predictors of women empowerment in our study; meanwhile, it failed to take into account the women participation in the labor market which was the strongest predictor of women empowerment in our study (20), and emphasize the importance of a country-speci c scale. Another study by Hou and Ma supported the positive effect of women's decision-making on the utilization of reproductive and maternity care services using the data from Pakistan Social and Living Standards Measurement Survey, yet not addressed the impact of other domains of women empowerment that emerged in our study (21).…”

“…The original index was designed to measure women's empowerment in Afghanistan including seven domains; namely, labor force participation, attitude toward violence, decision-making, access to healthcare, literacy, age at critical life events, and property-owning; however, our analysis showed that the 6-factor model-excluding the property-owning-could better explain the woman empowerment among married women aged 15-49 years in Pakistan with an acceptable internal consistency (Cronbach's α = 0.70) and construct validity (SRSEA&SRMR < 0.05, CFI&TLI > 0.95). Moreover, to estimate the convergence validity of the developed index, we selected four indicators of access to reproductive and maternity care including the unmet need for family planning, adequate ANC, institutional delivery, and skilled birth attendance that have shown to be strongly associated with high women empowerment (9,19,20,23,42) and examine their associations with emerged domains. All six domains appeared to be strongly associated with at least one favorable outcome; indicative of a decent convergence validity of the 6-factor model.…”

“…The relevant questions had dichotomous response alternatives (i.e., 'yes' or 'no' responses) and unmet needs for family planning were coded as "yes=1" and "no=0". b) Adequate ANC: Based on the World Health Organization (WHO) recommendation, having at least four ANC visits is necessary for optimal maternal and child outcomes [23]. Therefore, adequate ANC was coded as 'yes=1' for women with at least four ANC visits before their most recent (4+ ANC visits) in the last ve years and coded as 'no=0' if there were fewer than four visits.…”

“…It has been well documented that there is a strong association between these indicators and women empowerment (19,20). Previous studies in Pakistan have failed to use a uni ed index to measure women's empowerment (21)(22)(23) and thus the results are often inconsistent across different settings. For all we know, this is the rst country-speci c survey-based index that has been developed to measure women's empowerment among married Pakistani women aged 15-49 and could have signi cant policy implications and enhance the comparability of the results across future studies in Pakistan.…”

Factors associated with utilization of quality antenatal care: a secondary data analysis of Rwandan Demographic Health Survey 2020

“…Working women had lower odds of receiving all ANC components. This is contrary to the evidence that women who work have higher prospects of effective maternal healthcare utilisation because they are likely to have a wider social network and receive information from other women they meet at the work place [ 6 , 54 , 55 ]. This may present an opportunity for them to learn about quality ANC and its importance and hence demand for it during ANC visits, unlike those who do not work.…”