RESEARCH ARTICLE Open Access
Mo he s employed in paid wo k and hei
p edic o s o home deli e y in Pakis an
Sa a Riz i Ja ee
1
, Rubeena Zaka
2
, Mudasi Mus a a
3
and Flo ian Fische
4*
Abs ac
Backg ound: Pakis an has one o he highes a es o ma e nal and neona al mo ali y in he wo ld. I is assumed
ha employed mo he s in paid wo k will be mo e empowe ed o op o sa e ins i u ional deli e ies. The e is a
need o unde s and he p edic o s o home deli e ies in o de o plan policies o encou age ins i u ional deli e ies
in he egion.
Me hods: The s udy aimed o asce ain he p edic o s o home deli e ies among mo he s employed in paid wo k
in Pakis an. Da a analysis is based on seconda y da a aken om he Pakis an Demog aphic Heal h Su ey 2012–13.
Bi a ia e and mul i a ia e logis ic eg ession models we e conduc ed.
Resul s: The indings show ha he majo i y (53.6%) o employed mo he s in Pakis an gi e bi h a home. Employed
mo he s in paid wo k wi h he ollowing cha ac e is ics had highe chances o deli e ing a home: (i) women om
u al a eas (AOR 1.26; 95% CI: 0.94–1.71), o speci ic egions wi hin Pakis an, (ii) hose occupied in unskilled wo k
(AOR 2.61; 95% CI: 1.76–3.88), (iii) women ma ied o uneduca ed (AOR 1.70; 95% CI: 1.08–2.66), unemployed (AOR
1.69; 95% CI: 1.21–2.35), o unskilled men (AOR 2.02; 95% CI: 1.49–2.72), (i ) women wi h mo e han 7 child en
(AOR 1.57; 95% CI: 1.05–2.35), ( ) women who a e unable in he p ena al pe iod o ha e an ins i u ional check-up
(AOR 4.84; 95% CI: 3.53–6.65), ake assis ance om a physician (AOR 3.98; 95% CI: 3.03–5.20), ha e a blood analysis
(AOR 2.63; 95% CI: 1.95–3.57), u ine analysis (AOR 2.48; 95% CI: 1.84–3.33) o aken i on able s (AOR 2.64; 95% CI:
2.06–3.38), and ( i) a e unable o make au onomous decisions wi h ega d o spending hei ea nings (AOR 1.82;
95% CI: 1.27–2.59) and heal hca e (AOR 1.12; 95% CI: 0.75–1.65).
Conclusions: G ea e e o s by he cen al and p o incial s a e bodies a e needed o encou age ins i u ional
deli e ies and ins i u ional access, quali y and cos . Ma e nal and pa e nal bene i s a e needed o wo ke s in bo h
he o mal and in o mal sec o s o he economy. Finally, cul u al change, h ough educa ion, media and eligious
au ho i ies, is necessa y o suppo ins i u ional deli e ies and o mal sec o paid employmen and ou o home
wo k oppo uni ies o mo he s o Pakis an.
Keywo ds: Mo he s, Paid wo k, Employmen , Deli e y, Pakis an
Backg ound
Pakis an has one o he highes ma e nal mo ali y a ios
[1] and neona al mo ali y a es [2] in he wo ld. Common
causes o ma e nal mo ali y includes sepsis, se e e
anemia, obs e ic hemo hage, p olonged and obs uc ed
labo , and hype ensi e c ises [3]. In a en icula
hemo hage, hypo he mia, encephalopa hy, in an espi a-
o y dis ess synd ome, b eech p esen a ion, inju y o
child du ing deli e y, and p e e m bi h complica ions [4]
a e he common causes o neona al mo ali y in Pakis an
[4]. Mos o hese causes can be p e en ed h ough ins i-
u ional deli e ies [5,6].
Employmen o women is unde s ood o be a pa hway
o au onomy and empowe men o women, especially in
e ms o gaining imp o emen s in igh s o decision-
making and heal h o hemsel es and hei child en [7].
Resea ch om low-income egions shows ha unedu-
ca ed, unskilled and u al women wo king in he in o mal
sec o o he economy p edominan ly op o home deli -
e ies [8,9]. The e a e many socio-economic and cul u al
ba ie s p e en ing employed mo he s in paid wo k
* Co espondence: [email p o ec ed]
4
Depa men o Public Heal h Medicine, School o Public Heal h, Biele eld
Uni e si y, Biele eld, Ge many
Full lis o au ho in o ma ion is a ailable a he end o he a icle
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Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316
h ps://doi.o g/10.1186/s12884-018-1945-4
(EMPW) om elec ing ins i u ional deli e ies including:
high cos o heal hca e, lack o pe mission om amily,
adi ional no ms, eligious misin e p e a ion, and in-
c eased ea o caesa ian deli e ies [8,10,11].
E o s by de elopmen bodies ha e a ge ed sho
e m imp o emen s o educe ma e nal and child
mo ali y by suppo ing women om u al and dis an
loca ions o gi e bi h in hei homes by skilled bi h
a endan s o a local heal h cen e s wi h women
a endan s [12]. Howe e , he p oblem wi h communi y
acili a o s deli e ing in homes o a small and
unde - esou ced heal h cen e s is ha mo he s a e un-
able o seek p ena al check-ups and consul ancy om
specialised medical p ac i ione s (such as a sonog aphe ,
su geon, nu se, physician, and lab expe s) wi h
comple e ins i u ional suppo . Ins i u ional suppo in-
cludes x- ay and ul asound machines, blood and u ine
es s, e ige a ed medicine, u e o onic agen s, scanning
machines and su gical hea e s o eme gency caesa ean
sec ions, and s e ile ins umen s [13,14]. The e is also
he dilemma ha despi e he a ailabili y o ained
midwi es, women om conse a i e communi ies s ill
op o adi ional bi h a endan s o assis ance in
home deli e ies [15].
Pakis an has been unable o educe ma e nal and
unde - i e child mo ali y a es, unlike o he coun ies
in Sou h Asia, and is lagging behind a ge s o mee he
o me Millennium De elopmen Goals (MDGs) [16,17]
and he subsequen Sus ainable De elopmen Goals
(SDGs). The epo by Na ional Ins i u e o Popula ions
S udies sugges s ha easons o mo ali y a es
emaining high in he coun y include he absence o
p ena al ained medical p ac i ione consul a ion, and
ins i u ional check-up in moni o ing he heal h o he
mo he and e us [18]. C i ical mo ali y isks ha ha e
been esea ched in he coun y include pos pa um
hemo hage, e ained placen a [19], sepsis and e anus
[20], dia hea [21], p e e m bi h [22], asphyxia [23], and
unhygienic deli e y and in ec ions [24]. I has been
ound ha mo e han 95% o u e us up u es occu in
home deli e ies [25], e en hough u e us up u es a e
p e en able in ins i u ional deli e ies. Simila ly, neona al
e anus is a common bu a e able cause o dea h in
Pakis ani in an s [5], and is caused when deli e ies ake
place a home, using soil su ace and also when he e
a e sheep in he house [26].
In addi ion, home deli e ies pose g ea heal h isks o
he mo he and child du ing he pos na al pe iod, in
e ms o neglec o (i) colos um p o ision and b eas
eeding p ac ices [27], (ii) immunisa ions and nu i ion
supplemen a ion o mo he and child [28,29], and (iii)
o e all pos na al ca e and ins i u ional check-up o
mo he and child [30]. P e ious esea ch has shown ha
mo he s, including employed and unemployed women,
a e mo e likely o gi e bi h a home when hey a e un-
educa ed, om poo e and u al backg ounds, when
hey ha e lowe au onomy, and when he cos s o ins i-
u ional deli e ies a e high [31,32].
Despi e known isks, home deli e ies p e ail in con-
se a i e coun ies like Pakis an due o (i) us and com-
o wi h local bi h a endan ’s and communi y
midwi es [33], (ii) un a o able se ices by in e io public
hospi als, wi h dis an loca ions, p esence o male p ac i-
ione s, lack o p i acy and sepa a ion o child om
mo he a e deli e y [34], (iii) he belie ha he ad-
i ional bi h a endan (TBA) will handle he mo he be -
e and ha e he walking and back o wo k soone han
in ins i u ional deli e ies [35], (i ) and mis us wi h
medical p ac i ione s and “wes e n”o mode n solu ions
o bi hing, which is pe cei ed o be a na u al and ‘p i-
a e’p ocess [36,37].
In e na ional and local de elopmen bodies like he
Wo ld Heal h O ganiza ion (WHO) and he Na ional
Ma e nal and Child Heal h P og am ha e in es ed con-
side able esou ces in o de o imp o e ma e nal and
child heal h in Pakis an [21,38]. They ha e been sup-
po ed by Pa ne s in Popula ion and De elopmen
(PPD) and Pa ne ship o Ma e nal, Newbo n & Child
Heal h (PMNCH) in encou aging disad an aged women
o gain employmen h ough skill de elopmen and
small business mobilisa ion [39]. P og am objec i es a e
o ensu e p og ess owa d achie ing he SDGs in ma e -
nal and child heal h, mos speci ically in newbo n mo -
ali y, in an mo ali y and ma e nal mo ali y. P esen ly,
howe e , he e is no men ion speci ically o a ge ed ob-
jec i es o educe neona al mo ali y and measu es o
encou age ins i u ional check-ups wi h ained medical
p ac i ione s du ing p egnancy o ensu e sa e deli e ies.
To help u al women in unskilled and ag icul u e
based employmen o gi e bi h sa ely, he go e nmen
o Pakis an launched he Na ional Ma e nal, Neona al
and Child Heal h p og am in 2006. The aim o he p o-
g am was o ain and place TBAs in u al a eas; how-
e e , he deploymen o hese wo ke s has been limi ed
[40]. Also, bo h he local midwi es and ained commu-
ni y heal h wo ke s ha e been unable o signi ican ly e-
duce ma e nal and child mo ali y [19]. In addi ion,
many wo king and non-wo king mo he s do no seek as-
sis ance om TBA, as hey assume ha hei deli e y
will be no mal [41]. The e is s ill a need o unde s and
he p edic o s o home deli e ies o employed mo he s
in Pakis an in o de o o mula e adequa e policies o
suppo employed women in choosing ins i u ional de-
li e ies o hei own and hei child’s sa e y [42]. Up o
now, he e has been no s udy conduc ed explo ing p e-
dic o s o why employed mo he s in Pakis an gi e bi h
a home. This esea ch aims o iden i y: (i) he
socio-demog aphic and p e-na al cha ac e is ics, and
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 2 o 9
decision-making cha ac e is ics o employed mo he s in paid
wo k o Pakis an, and (ii) he associa ion be ween employed
mo he s in paid wo k o Pakis an and home deli e ies.
Me hods
Da a and sample
Seconda y da a om he Pakis an Demog aphic and
Heal h Su ey (PDHS) 2012–13, he hi d su ey con-
duc ed in he coun y as pa o he Measu e DHS in e -
na ional se ies, has been used o his s udy. A o al o
12,943 households we e sampled and 13,558 e e -ma ied
women o ep oduc i e age we e sampled h ough
mul i-s age clus e sampling ac oss Pakis an [18]. Fo his
s udy, a o al o 1387 EMPW wi h a child bo n in he las
5 yea s we e included. Mo he s wi h child en bo n in he
las 5 yea s we e selec ed in o de o a oid memo y ecall
bias o he esponden s.
Va iables included in analyses
The dependen a iable was he place o deli e y, dis in-
guishing be ween home deli e y and acili y-based deli e y.
The ollowing socio-demog aphic cha ac e is ics we e
included in his s udy: age o employed mo he , p o incial
belonging, egional belonging, educa ion, weal h, ma i al
s a us, occupa ion, husband’s educa ion and occupa ion,
o al child en bo n, head o household, and he place o
deli e y o las child bo n. Fu he mo e, se en independ-
en a iables we e included in he analysis, which a e
based on a li e a u e e iew: numbe o p ena al isi s du -
ing p egnancy, p ena al assis ance om physician, u ine
analysis aken du ing p egnancy, blood analysis aken du -
ing p egnancy, gi en/bough i on able s du ing p eg-
nancy, decision-make o spending esponden s’money,
and decision-make o spending heal hca e.
S a is ical analyses
Desc ip i e s a is ics we e used o desc ibe he
socio-demog aphic cha ac e is ics o EMPW. Be o e in-
cluding a iables in mul i a ia e analyses, we con olled
o mul icollinea i y. The a iance in la ion ac o o
each independen a iable co e ed a ange be ween 1.04
and 3.69, indica ing no mul icollinea i y among he a i-
ables included in he eg ession model. Bi a ia e logis ic
eg ession was conduc ed o show he p edic o s o
home deli e y by EMPW. The mul i a ia e logis ic e-
g ession model, was con olled o age, weal h and edu-
ca ion o mo he s. Odds a ios (OR) and Adjus ed odds
a ios (AOR) wi h 95% con idence in e als (CI) wi h a
signi icance le el o α= 0.05 we e calcula ed.
Resul s
Socio-demog aphic cha ac e is ics
Table 1shows he socio-demog aphic cha ac e is ic o
EMPW in Pakis an, o which 45.4% we e be ween 15
and 29 yea s, 45.3% we e be ween 30 and 39 yea s and
9.2% we e be ween 40 and 44 yea s. The mean age was
30 yea s and he s anda d de ia ion was 8.5 yea s. The
majo i y o he employed mo he s belonged o u ban e-
gions (65.8%), he uneduca ed s a a (65.5%), and he
poo weal h b acke (58.1%). A g ea e numbe o
mo he s (78.6%) we e in ol ed in unskilled o
semi-skilled wo k (49.2 and 32.4%). Nea ly all o he
EMPW (98.3%) we e cu en ly ma ied and li ing wi h
hei husbands. A ound 96% women epo ed o li e in
a male headed household (who we e hei husband,
a he , o a he -in-law). Abou hal o he employed
woman had be ween 1 and 3 child en, and 53.6% deli -
e ed hei child en a home.
Table 2shows he desc ip i e s a is ics o p ena al
heal h p ac ices o EMPW. Acco ding o his, 71.7% o
employed mo he s had a leas one p ena al isi du ing
p egnancy o a heal h cen e , clinic, o hospi al. Howe e ,
only 37.6% sough assis ance om a physician o p ena al
check-ups. A signi ican numbe o EMPW had no aken
samples o u ine (48.4%) and blood analysis (52.2%) du -
ing p egnancy. In addi ion, almos 60% had no consumed
i on able s du ing p egnancy. Only hal o employed
mo he s indica ed ha hey could exclusi ely decide on
how o spend hei ea nings, and e y ew (14.1%) indi-
ca ed abili y o make heal h decisions independen ly.
Simple bi a ia e logis ic eg ession
Resul s o he bi a ia e logis ic eg ession (Table 3) show
ha home deli e ies we e mo e likely o occu in
Baluchis an (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 compa ed o Punjab. In addi ion, he likeli-
hood o home deli e ies was much highe in u al egions
(OR 3.16; 95% CI: 2.50–3.98) han in u ban a eas.
Employed mo he s wi h no (OR 11.70; 95% CI: 7.56–
18.10) o low (OR 2.45; 95% CI: 1.76–3.42) educa ion we e
also signi ican ly mo e likely o gi e bi h o hei child en
a home. Mo he s om poo (OR 6.56; 95% CI: 4.94–8.72)
and middle income (OR 2.17; 95% CI: 1.61–2.93) also had
a highe likelihood o home deli e ies han women om
highes weal h g oup.
Employed mo he s in unskilled wo k (OR 6.51; 95%
CI: 4.67–9.07) o semi-skilled wo k (OR 1.86; 95%
CI: 1.45–2.37) showed highe odds o deli e ing a home.
Simila ly, mo he s wi h husbands who we e unemployed
(OR 4.79; 95% CI: 1.93–6.89) o employed in unskilled
wo k (OR 3.56; 95% CI: 1.42–8.93) also had highe odds
o deli e ing a home. EMPW wi h husbands who had no
o mal schooling (OR 6.60; 95% CI: 4.66–9.36), o wi h
p ima y (OR 2.15; 95% CI: 1.63–2.82) and seconda y
(OR 1.43; 95% CI: 1.04–1.97) schooling had highe odds
o home deli e ies. Mo he s wi h 7 o mo e chil-
d en (OR 2.32; 95% CI: 1.73–3.12) o 4–6child en
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 3 o 9
(OR 1.12; 95% CI: 0.82–1.52) ha e highe likelihood o de-
li e ing a home.
Mo he s wi hou ins i u ional p ena al check-ups
(OR 7.72; 95% CI: 5.71–10.43) and hose who had no
aken p ena al assis ance om a physician (OR 6.10; 95%
CI: 4.75–7.85) we e mo e likely o deli e ing a home.
Employed mo he s who had no had u ine o a blood ana-
lysis and did no consume i on supplemen s du ing
Table 1 Socio-demog aphic cha ac e is ics o employed mo he s
in paid wo k wi h child en bo n in he las 5 yea s (n= 1387)
Cha ac e is ics n
a
%
Age
15–29 yea s 630 45.4
30–39 yea s 629 45.3
40–44 yea s 128 9.2
P o ince
Baluchis an 195 14.1
KPK 136 9.8
Sindh 505 36.4
Punjab 551 39.7
Region
Ru al 475 34.2
U ban 912 65.8
Educa ion
No o mal schooling 909 65.5
P ima y 169 12.2
Seconda y 124 8.9
Highe 185 13.3
Weal h
Poo 806 58.1
Middle 226 16.3
Rich 355 25.6
Ma i al s a us
Di o ced/sepa a ed/widowed 23 1.7
Cu en ly li ing wi h husband 1364 98.3
Mo he ’s occupa ion
Unskilled 683 49.2
Semi-skilled 449 32.4
Skilled 254 18.3
Husband’s educa ion
No o mal schooling 598 43.1
P ima y 216 15.6
Seconda y 340 24.5
Highe 232 16.7
Husband’s occupa ion
Unemployed 24 1.7
Unskilled 798 57.5
Semi-skilled 333 24.0
Skilled 232 16.7
To al child en bo n
7 o mo e 270 19.5
4–6 474 34.2
1–3 643 46.4
Table 1 Socio-demog aphic cha ac e is ics o employed mo he s
in paid wo k wi h child en bo n in he las 5 yea s (n= 1387)
(Con inued)
Cha ac e is ics n
a
%
Head o household
Fa he /o he 460 33.2
Husband 872 62.9
Sel 55 4.0
Place o deli e y
Home 743 53.6
Hospi al/clinic 644 46.4
a
Some o he desc ip i e s a is ics do no add up o 1387 due o missing alues
in he da a
Table 2 Desc ip i e s a is ics o employed mo he s in paid wo k
and hei ep oduc i e heal h p ac ices be o e deli e y (n= 1387)
Cha ac e is ics n
a
%
Numbe o p ena al isi s du ing p egnancy
None 393 28.3
A leas one 994 71.7
P ena al assis ance om physician
No 521 62.4
Yes 866 37.6
U ine analysis aken du ing p egnancy
No 481 48.4
Yes 513 51.6
Blood analysis aken du ing p egnancy
No 518 52.2
Yes 475 47.8
Gi en/bough i on able s du ing p egnancy
No 824 59.4
Yes 563 40.6
Decision-make o spending esponden ’s ea ning
Husband o elde s 227 16.3
Husbands, elde s and sel join ly 459 33.1
Sel 701 50.5
Decision-make o esponden ’s heal hca e
‘Sel and husband’o ‘sel and o he ’1191 85.9
Sel 196 14.1
a
Some o he desc ip i e s a is ics do no add up o 1387 due o missing alues
in he da a
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 4 o 9
p egnancy showed a highe likelihood o gi e bi h o hei
child en a home. Las ly, EMPW wi h decision-making
o spending hei ea nings (OR 2.47; 95% CI: 1.77–3.44)
and heal hca e (OR 1.87; 95% CI: 1.32–2.65) being
con olled by o he s (husbands o elde s) o join ly
(‘sel and husband’o ‘sel and o he ’) had highe odds o
home deli e y.
Mul i a ia e logis ic eg ession
In he mul i a ia e logis ic eg ession adjus ing o
mo he ’s age, educa ion, and weal h s a us, mos o he
socio-demog aphic a iables we e iden i ied as co a i-
a es and hus showed no signi icance (Table 4).
Howe e , he model con i ms he ele ance o ep o-
duc i e heal h p ac ices associa ed wi h he place o de-
li e y. Acco ding o hese esul s, employed mo he s
who (i) had no been h ough a p ena al check-up
(AOR 4.84; 95% CI: 3.53–6.65), (ii) had no aken p e-
na al consul ancy om a physician (AOR 3.98; 95% CI:
Table 3 Simple bi a ia e logis ic eg ession o p edic o s o home
deli e y among mo he s employed in paid wo k
Cha ac e is ics OR (95% CI) p- alue
Age
15–29 yea s 1.33 (0.90–1.96) 0.151
30–39 yea s 1.14 (0.48–2.69) 0.578
40–44 yea s 1
P o ince
Baluchis an 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
Ru al 3.16 (2.50–3.98) < 0.001
U ban 1
Educa ion
No o mal schooling 11.70 (7.56–18.10) < 0.001
P ima y 3.24 (2.19–4.78) < 0.001
Seconda y 2.45 (1.76–3.42) < 0.001
Highe 1
Weal h
Poo 6.56 (4.94–8.72) < 0.001
Middle 2.17 (1.61–2.93) < 0.001
Rich 1
Ma i al s a us
Di o ced/sepa a ed/widowed 1.51 (0.66–3.46) 0.330
Ma ied 1
Mo he ’s occupa ion
Unskilled 6.51 (4.67–9.07) < 0.001
Semi-skilled 1.86 (1.45–2.37) < 0.001
Skilled 1
Husband’s educa ion
No o mal schooling 6.60 (4.66–9.36) < 0.001
P ima y 2.15 (1.63–2.82) < 0.001
Seconda y 1.43 (1.04–1.97) 0.028
Highe 1
Husband’s occupa ion
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
To al child en bo n
7 o mo e 2.32 (1.73–3.12) < 0.001
4–6 1.12 (0.82–1.52) 0.468
1–31
Table 3 Simple bi a ia e logis ic eg ession o p edic o s o home
deli e y among mo he s employed in paid wo k (Con inued)
Cha ac e is ics OR (95% CI) p- alue
Head o household
Fa he /O he 0.94 (0.54–1.62) 0.824
Husband 1.26 (0.72–2.21) 0.413
Sel 1
Numbe o p ena al isi s du ing p egnancy
None 7.72 (5.71–10.43) < 0.001
A leas one 1
P ena al assis ance om physician
No 6.10 (4.75–7.85) < 0.001
Yes 1
U ine analysis aken du ing p egnancy
No 3.98 (3.04–5.21) < 0.001
Yes 1
Blood analysis aken du ing p egnancy
No 4.30 (3.27–5.66) < 0.001
Yes 1
Gi en/bough i on able s du ing p egnancy
No 4.11 (3.27–5.16) < 0.001
Yes 1
Decision-make o spending esponden ’s ea ning
Husband o elde s 2.47 (1.77–3.44) < 0.001
Husband, elde and sel join ly 2.36 (1.66–3.33) < 0.001
Sel 1
Decision-make o esponden ’s heal hca e
Sel and husband’o ‘sel and o he ’1.87 (1.32–2.65) < 0.001
Sel 1
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 5 o 9
3.03–5.20), (iii) did no ha e u ine analysis (AOR 2.48;
95% CI: 1.84–3.33), (i ) did no ha e blood analysis
(AOR 2.63; 95% CI: 1.95–3.57) o ( ) had no aken
i on supplemen s (AOR 2.64; 95% CI: 2.06–3.38) du ing
p egnancywe emo elikely ogi ebi ha home.
Finally, EMPW who we e unable o make au onomous
decisions ela ed o (i) spending hei ea nings
[husbands o elde s made he decision (AOR 1.82; 95%
CI: 1.27–2.59); husbands, elde s and sel join ly made
he decision (AOR 1.88; 95% CI: 1.29–2.73)] and, (ii)
spending on heal hca e (AOR 1.12; 95% CI: 0.75–1.65),
ha e highe odds o gi ing bi h a home.
Discussion
The indings show ha he majo i y o women employed
in paid wo k in Pakis an gi e bi h o hei child en a
home, placing hemsel es and hei child a isk o mo -
ali y. Resea ch om high-income coun ies has shown
ha ins i u ional deli e ies educe neona al mo ali y,
due o he p esence o medical echnologies [43]. We
ound ha employed mo he in u al a eas and he p o -
inces o KPK and Baluchis an a e mo e likely o gi e
bi h a home, due o ewe u al and p o incial s uc-
u al heal hca e suppo and policies, and possibly he
sus enance o in lexible adi ional p ac ices [31]. Resul s
indica e ha p o incial poli ical de olu ion can ha e i s
limi a ions, in ha ma e nal and child heal h p og ams
a e no ha ing symme ical imp o emen s ac oss p o -
inces [44]. I was also ound ha EMPW who a e
employed in unskilled and semi-skilled wo k a e mo e
likely o gi e bi h o hei child en a home. The impli-
ca ion is ha mos o he employed mo he s in Pakis an
Table 4 Mul i a ia e logis ic eg ession o p edic o s o home
deli e y among mo he s employed in paid wo k
Cha ac e is ic AOR
a
(95% CI) p- alue
P o ince
Baluchis an 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
Ru al 1.26 (0.94–1.71) 0.122
U ban 1
Ma i al s a us
Di o ced/sepa a ed/widowed 0.62 (0.25–1.49) 0.282
Ma ied 1
Mo he ’s occupa ion
Unskilled 2.61 (1.76–3.88) < 0.001
Semi-skilled 1.23 (0.94–1.61) 0.121
Skilled 1
Husband’s educa ion
No o mal schooling 1.70 (1.08–2.66) 0.020
P ima y 1.16 (0.85–1.58) 0.335
Seconda y 1.10 (0.79–1.54) 0.551
Highe 1
Husband’s occupa ion
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
To al child en bo n
7 o mo e 1.57 (1.05–2.35) 0.026
4–6 0.92 (0.65–1.32) 0.682
1–31
Head o household
Fa he /o he 1.07 (0.58–1.97) 0.816
Husband 1.00 (0.77–1.30) 0.978
Sel 1
Numbe o p ena al isi s du ing p egnancy
None 4.84 (3.53–6.65) < 0.001
A leas one 1
P ena al assis ance om physician
No 3.98 (3.03–5.20) < 0.001
Yes 1
U ine analysis aken du ing p egnancy
No 2.48 (1.84–3.33) < 0.001
Yes 1
Table 4 Mul i a ia e logis ic eg ession o p edic o s o home
deli e y among mo he s employed in paid wo k (Con inued)
Cha ac e is ic AOR
a
(95% CI) p- alue
Blood analysis aken du ing p egnancy
No 2.63 (1.95–3.57) < 0.001
Yes 1
Gi en/bough i on able s du ing p egnancy
No 2.64 (2.06–3.38) < 0.001
Yes 1
Decision-make o spending esponden ’s ea ning
Husband o elde s 1.82 (1.27–2.59) 0.001
Husbands, elde s and sel join ly 1.88 (1.29–2.73) 0.001
Sel 1
Decision-make o esponden ’s heal hca e
‘Sel and husband’o ‘sel and o he ’1.12 (0.75–1.65) 0.058
Sel 1
a
Mul i a ia e logis ic eg ession analysis was ca ied ou o ob ain AOR a e
con olling o mo he ’s age (con inuous a iable), educa ion (ca ego ical a iable)
and weal h s a us (ca ego ical a iable)
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 6 o 9
a e no gaining om he bene i s o o mal sec o
employmen , wi h ma e nal bene i s; which migh be a
s ong con ibu ing ac o o lack o p ena al check-ups
and ins i u ional deli e ies [45]. Ou indings co obo -
a e o he li e a u e om low-income coun ies, like
Bangladesh, Kenya and Ghana, in ha employed
mo he s in unskilled wo k a e (i) unawa e o he bene i s
o ins i u ional deli e y, (ii) unable o access ins i u ional
and ained heal hca e p ac i ione assis ance, and (iii)
in ol ed in he in o mal sec o o he economy ha p o-
ides hem ewe heal h bene i s, such as heal h insu -
ance o medical allowances [10,46,47].
A signi ican p edic o o home deli e y ound in ou
s udy was he absence o p ena al check-ups and con-
sul a ion om physicians. O he esea ch con i ms ha
employed mo he s wi h lack o p ena al consul ancy and
ained heal hca e p ac i ione isi a ion a e less likely o
op o ins i u ional deli e y, due o lack o guidance and
skilled medical moni o ing [48]. The main bene i o
p ena al check-ups wi h physicians includes plans o
sa e deli e y and imely e e al o ins i u ional deli e y
i isks a e p esen . Resea ch om neighbo ing India
highligh s ha aking p ena al assis ance om
non-physicians can place he mo he and child a mo e
isks o no op ing o ins i u ional deli e ies and mo -
ali y haza ds om physical, en i onmen , and cul u al
ac o s [49]. Addi ionally, ained ca e p o ide s and
LHWs a emp ing o p o ide heal hca e o mo he s and
child en complain o inabili y o deli e se ices in he
communi y due o amily esis ance and obs uc ion,
which is a pa ien sa e y haza d [50].
Ou esul s suppo indings om India ha employed
mo he s who, du ing p egnancy, did no ha e u ine o
blood analysis, o ecei e i on supplemen s we e mo e
likely o gi e bi h o child en a home [51,52]. These
indings imply ha EMPW need p ena al se ices om
expe ienced and skilled heal h p o ide s in o de o se-
cu e ins i u ional deli e ies and ep oduc i e heal h. I is
also empi ically e idenced ha when mo he s a e able o
secu e heal h h ough ins i u ional consul a ion du ing
he p ena al pe iod hey a e mo e likely o op o
pos -na al check-ups and nu i ional supplemen a ion,
newbo n check-ups and immunisa ion, and ea ly b eas -
eeding p ac ices [53].
We also ound ha mo he s wi h se en o mo e chil-
d en a e mo e likely o gi e bi h a home. O he li e a-
u e om he egion sugges s ha women a e less likely
o gi e bi h in ins i u ions a e he bi h o hei i s
child [54]. This may be because o cos issues, lack o
ime o pu sue p ena al check-ups, and he belie ha
mul iple bi hs make he mo he , and communi y mid-
wi es, expe ienced enough o manage home deli e ies
[55]. In ac , mo he s wi h mul iple child en a e a isk
o sel and child mo ali y du ing home deli e y due o
complica ions caused by epea p egnancies and physical
weakness o he mo he [56].
Ou esul s highligh ha he li e acy and employmen
o husbands plays a key ole in he heal h o he mo he
and child. O he li e a u e om low-income coun ies,
like Nepal and Nige ia, con i ms ha mo e educa ed
and skilled husbands wi h highe pay (i) a e mo e awa e
o he heal h isks o home deli e ies, (ii) a e mo e able
o esis eg essi e adi ional p ac ices o he amily and
kin, and (iii) ha e mo e money o suppo ins i u ional
deli e y cos s [57,58].
O u mos conce n is he inding ha EMPW in
Pakis an a e unable o au onomously make decisions
wi h ega d o spending hei ea nings, and a e also un-
able o make independen decisions ega ding hei
heal h p ac ices. S udies, om Nepal and Sialko , show
ha many employed mo he s a e unable o au ono-
mously con ol spending on heal h and household pu -
chases [59,60]. Schola s and expe s ag ee ha when
cul u al cons ain s p e en employed women om
making hei own decisions, hei inancial au onomy is
o bene i p ima ily o hei husbands, in-laws and male
ela i es, and no hei sel and child en [61]. This can
esul in mul iple challenges o hem ex ending beyond
ep oduc i e heal h, such as inabili y o con ol: la ge
and small household consump ion, educa ion o hei
child en, ea ly ma iage o hei daugh e s, domes ic and
in ima e pa ne iolence, and o e all psychological s a-
bili y o sel and child.
The main limi a ions o his s udy a e associa ed wi h
he usage o seconda y da a, which a e e.g. he inabili y
o in es iga e o he a iables ha may in luence home
deli e ies, such as pe mission om in-laws, adi ional
cus oms and he social s igma o ins i u ional deli e ies.
Also, his s udy has no been able o in es iga e he
p oblems unemployed mo he s o employed mo he s
wi hou paid cash, especially in he u al egions, may
ace in p e en ing ins i u ional deli e ies. In addi ion,
he da a ely on a c oss-sec ional s udy design, which do
no allow o causal in e ences. Howe e , his s udy has
i s s eng hs. Signi ican p edic o s o home deli e ies
ha e been ound which will help policy make s o de-
elop imp o ed p og ams o mee he SDGs.
Conclusions
Pakis an needs mo e long- e m solu ions o encou -
aging ins i u ional deli e ies. Public heal h s a egies in-
ol ing encou agemen o ins i u ional consul a ion
du ing he p ena al pe iod migh be he mos impo an
ehicle o educing ma e nal and child mo ali y a es
in low-income and conse a i e socie ies [15]. Cen al
s a e and p o incial bodies need o p omo e ins i u ional
deli e ies ac oss p o inces and u al a eas in e ms o
access, cos , subsidisa ion, and quali y. Assis ance in
Ja ee e al. BMC P egnancy and Childbi h (2018) 18:316 Page 7 o 9
de eloping cash paymen s and employe co e age o ins i-
u ional deli e ies o bo h wo king mo he s and a he s is
needed. Finally, inc ease in ins i u ional deli e ies and
heal h decision-making o mo he s equi es a change in
he cul u al mindse o he na ion, wi h combined s uc-
u al and ci ilian mobilisa ion ac oss sec o s like educa-
ion and media, and agencies like communi y no ables
and eligious au ho i ies [61].
Abb e ia ions
AOR: Adjus ed odds a io; CI: Con idence in e al; EMPW: Employed mo he s
in paid wo k; MDG: Millennium De elopmen Goal; MNCH: Ma e nal, newbo n
and child heal h; OR: Odds a io; PMNCH: Pa ne ship o Ma e nal, Newbo n &
Child Heal h; PPD: Pa ne s in Popula ion and De elopmen ; SDG: Sus ainable
De elopmen Goal; TBA: T adi ional bi h a endan ; WHO: Wo ld Heal h
O ganiza ion
Acknowledgemen s
Measu e DHS is hanked o hei pe mission o use he PDHS da ase . We
a e g a e ul o M . Muhammad Ali Raza, da a p ocessing manage o PDHS,
and M . Za a Zahi , Associa e Fellow a NIPS, o hei suppo and assis ance.
We acknowledge suppo o he publica ion ee by Deu sche Fo schungsgemeinscha
and he Open Access Publica ion Funds o Biele eld Uni e si y.
Funding
The s udy ecei ed no unding.
A ailabili y o da a and ma e ials
Da a is a ailable om Measu e DHS upon eques (h ps://dhsp og am.com/).
Au ho s’con ibu ions
SRJ designed he s udy and analysis. RZ supe ised he s udy. MM con ibu ed
o he in e p e a ion o da a. SRJ d a ed he manusc ip and RZ, MM and FF
e ised i c i ically. All au ho s app o ed he inal e sion.
E hics app o al and consen o pa icipa e
The s udy is based on seconda y da a aken om Measu e DHS. Da a is a ailable
om Measu e DHS upon eques . Fo ha eason, no e hical app o al o consen
o pa icipa e is needed o his s udy.
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published
maps and ins i u ional a ilia ions.
Au ho de ails
1
Depa men o Sociology, Fo man Ch is ian College, Laho e, Pakis an.
2
Ins i u e o Social and Cul u al S udies, Uni e si y o he Punjab, Laho e,
Pakis an.
3
Depa men o Sociology, Ins i u e o Social and Cul u al S udies,
Uni e si y o he Punjab, Laho e, Pakis an.
4
Depa men o Public Heal h
Medicine, School o Public Heal h, Biele eld Uni e si y, Biele eld, Ge many.
Recei ed: 17 Feb ua y 2018 Accep ed: 19 July 2018
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