April 2019, Volume 69, Issue 4

Short Reports

Women's preferences and factors influencing their obstetric care service utilization in rural Sindh: A Cross sectional Study

Saira Kanwal  ( Health Services Academy Islamabad )
Ramesh Kumar  ( Health Services Academy Islamabad )
Ratana Somrongthong  ( College of Public Health Sciences, Chulalongkorn University Thailand )
Ukasha Ashfaq  ( Health Services Academy Islamabad )


The objective of this study was to explore women's preferences and factors influencing the obstetric services in a rural setting of Sindh Province. This cross sectional study was conducted on 100 women who were interviewed by using a validated questionnaire. The women who had given birth during the year preceding the study were eligible for inclusion in the study. The mean age of the participants was 27.5±2.0 and majority 86 (86%) of them were housewives. About 87 (87%) participants had an opinion that their obstetrical health decisions were always taken by their household members and families. 65 (65.7%) women reported that they consulted public hospitals for their antenatal care visits and 69 (69.6%) women preferred private health facilities for antenatal visits. More than half (62.2%) of the participants had delivered their last child in a public health facility, however, 39 (39.2%) women still preferred to deliver at home. Factors such as availability and affordability for health services were significant among pregnant women, those with income more than twenty thousand rupees per month, those with formal education as they were getting better obstetric care compared to those who had less income (<0.05) and those with no formal education. Study concluded that affordability and availability of services around pregnancy and birth were major factors responsible for preference for maternal care and could be linked with poor obstetrical care among rural women of Sindh. However, it is imperative to provide the obstetric care which is accessible without inconvenience.
Keywords: Maternal care, Obstetric care, Antenatal care visit and affordability, availability


Although maternal survival continues to improve globally, yet many countries still struggle to contain the burden of maternal mortality.1 Annually about 358,000 maternal deaths are reported globally, despite of significant improvement in health care services. Huge inequalities across the countries underline the maternal mortality problem, for instance, 87% of maternal mortality burden is shared by South Asia and Sub Saharan African regions only. 2 Factors surrounding at the timeof birth are the main reasons for high burden of maternal deaths. Therefore, pregnant women are exposed to unidentified risks at the time of antenatal care visits so the skilled birth attendant is an excellent approach to ensure a successful delivery. 3 Labour and childbirth are important events of a woman's life during which she requires special care by her family and health care provider. Because the women and their babies are most vulnerable during the period surrounding the birth decisions about appropriate place of delivery can guarantee positive health outcomes for both mother and her child. 4 Latest reforms of the National Institute for Health and Care Excellence guidelines for Intra-partum care approves that women with healthy pregnancies must be provided with a choice of desired birth mode, place of birth and any desired setting which must be accessible to all pregnant women. 5 Giving birth is generally considered as a stressful event in the life of woman. 6 Mother's safety during birth must be an essential priority but it is often undermined. 7 Various factors can affect women and her newborn their timely management can bring positive outcomes. 8 Cheaper quality of drugs is another common problem while managing the health of mother and child in developing countries like Pakistan. 9 Women's survival during bir th is determined by management during labor, interest and care given by birth attendants, and attention given by their immediate family members. 10 The pregnant woman and her relatives usually prefer that the place of delivery is located near their home. 11 Facility based deliveries in rural areas need to increase so that these women deliver within a safe environment and with skilled providers. 12 World Health Organization recommends that for improvement of maternity services such as better quality of care, along with facility based births can significantly dent the burden of maternal mortality in countries struggling with maternal survival. 13  Better access to healthcare positively improves maternal and neonatal health resulting in better health outcome. 14 High burden of maternal mortality and morbidity in developing countries can be reduced by ensuring antenatal care visits and births with skilled and experienced care providers during labor .15-17 Although previous research has sought to identify risk factors of poor obstetrical care, the factors women's choice and preference for the birth attendants need further exploration in our local context. Therefore the present study aimed to investigate women's preferences and factors influencing the obstetric services in a rural setting in the province of Sindh.

Methods and Results

A cross sectional study was conducted from January to March 2017 in a rural area of Hyderabad district. A sample size of 100 women was calculated with 10% margin of error; alpha 5% and 50% estimated prevalence. Simple Random sampling methods was adopted for the selection of participants from the list of clients registered with lady health workers in Hyderabad. The women were inter viewed through a validated and pretested questionnaire. 18 Women who had delivered a child during the year preceding the study with an age range of 20 to 35 years were included in the study. However, women who experienced a stillbirth were excluded from the study. Dependent variables were preference for the health care providers for the maternal care services during pregnancy and childbirth and obstetrics factors, and in dependent included socio-demographic characteristics, marital status, education level and financial status of the participants. Proportions, mean (SD), median and mode were calculated by using descriptive analysis. The ethical approval was obtained from the institutional review board of Health Services Academy, Islamabad. A written informed consent was also obtained from the participants before the interviews. Strict anonymity and confidentiality was maintained for participants during this study. The average age of respondent was 27.5 ±2 years. The detailed socio-demographic characteristics are given in Table 1.

For the preference of women for seeking obstetrics care, 67 (66.8%) women had their antenatal care visit done in a public sector health facility and 71 (70.6%) women preferred private facilities for such care. Similarly, 62 (62.2%) women had their last birth in a health facility and 40 (39.5%) women delivered at their homes. Around 90 (90.1%) women could not afford a private sector facility but were willing to go there because they believed that the health care services in public sector health facilities were of poor quality (Table 2).

Availability of services in a health facility was consideredan important factor. The preference of health facility for maternal service utilization including antenatal care was preferred by women whose income was twenty thousand rupees or more per month and those with some formaleducation. The preference of obstetrics services was statistically significant (<0.05) with their husband's income. Likewise, the affordability as a factor for the preference of health services use during pregnancy and birth was significantly related for the monthly income of rupees, 20 thousand per month of the husband(p<0.05) and some formal education. Furthermore, for families whose income was more thantwenty thousand rupees per month could afford regular antenatal care compared to those who had income less than twenty thousand rupees per month. Likewise, the  educated families were aware of the importance andwanted to visit doctors regularly compared to those withno formal education (Table 3).


The choice of the place of delivery for pregnant women were very limited in public sector hospitals and these findings are consistent with other studies.19,20 Women also lacked the quality care and positive behaviour from the staff in health facilities. Hence, most of the women preferred to deliver at home rather than going to public health facilities. This is the reason that women were hesitating to attend all antenatal care sessions. 21 A recent study showed that due to high cost for obstetrics care services, most women were unable to obtain these services resulting in a high maternal mortality rate. This high cost associated with obstetric care services included costs incurred during antenatal care sessions and buying medicines during pregnancy. This made them prefer home deliveries rather than births in private or public hospitals. 19 Another research carried out to measure the level of quality of health services and barriers to the utilization of obstetr ic ser vices by commun ities, found that unavailability of health services and non-functional status of health facilities were the major obstacles. 22 Our results showed that lack of availability of services, poor supplies and equipment to enable institutional deliveries in the public hospitals were major factors for the selection of facilties for services around pregnancy and birth. These results are consistent with a study on women's perception about quality of maternal care services in Nepal. 23 In another study conducted in Cambodia, the utilization of obstetric services was greatly influenced by two main determinants. First, the behaviour of the care providers during institutional deliveries and secondly the cost associated with the service utilization. High cost of services, therefore, has been considered one of the major barriers in utilization of services. Our results are consistent with similar results from other regional countries. Cost of care during pregnancy and birth and unfriendly attitude of birth attendants as well as antenatal care providers in the health facilities are two major obstacles to the use of maternal care in many rural communities. 25High prices has led to discourage women from seeking consultations for antenatal care, which is again consistent with the findings from the present study.25 Another study from Pakistan explored the reasons for the low rates of utilization of obstetric services in Pakistan. The survey focused mainly on services like antenatal care, labour,and post-natal care. This study also showed that staff behavior and care providers' attitude were negatively impacting the use of these services.26,27 In conclusion, they found that the factors like affordability and availability of care services during pregnancy and birth were significantly influencing the preference for obstetrical care utilization among rural women of Sindh. Income and education were the main factors responsible for selecting the services. Pregnant women were found  to be interested in visiting private health facilities because of availability of proper treatment and positive staff attitude. Therefore it is necessary to provide similar care at public health facilities to ensure that women are encouraged to avail them at a reasonable and affordable price. The study also showed that women with empowerment for decision making and formal education were aware of the consequences of negligence of antenatal care.

Acknowledgments: This research was supported by Rachadapisek Sompote Fund for Postdoctoral Fellowship, Chulalongkorn University Thailand

Disclaimer: None to declare.
Conflict of Interest: None to declare
Funding Sources: None to declare.


1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609-23.
2. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic  analysis for the Global Burden of Disease Study 2013. Lancet 2014;384: 980-1004.
3. Bayu H, Adefris M, Amano A, Abuhay M. Pregnant women's preference and factors associated with institutional delivery service utilization in Debra Markos Town, North West Ethiopia: a community based follow up study. BMC Preg Childbirth 2015; 15: 1-9.
4. Murthy MS, Murthy PV, Hari M, Kumar VK, Rajasekhar K. Place of birth: why urban women still prefer home deliveries. J Human Ecol 2007; 21: 149-54.
5. Qureshi NR, Sikander R, Hoodbhoy Z, Bano R, Jabeen N. Referral pattern of emergencies in obstetrics: Implications for defining scope of services and policy. J Pak Med Assoc 2016; 12: 1606-10.
6. Chandraharan E. Fetal scalp blood sampling during labour: is it auseful diagnostic test or a historical test that no longer has a place in modern clinical obstetrics? BJOG 2014; 121: 1056-62.
7. Dahlen H. Undone by fear? Deluded by trust? Midwifery 2010; 26: 156-62.
8. Kruk ME, Paczkowski M, Mbaruku G, De Pinho H, Galea S. Women's preferences for place of delivery in rural Tanzania: a populationbased discrete choice experiment. Am J Public Health 2009; 99: 1666-72.
9. Kahabuka C, Kvale G, Moland KM, Hinderaker SG. Why caretakers bypass Primary Health Care facilities for child care-a case from rural Tanzania. BMC Health Serv Res 2011;11: 1-10.
10. Behruzi R, Hatem M, Fraser W, Goulet L, Ii M, Misago C. Facilitators and barriers in the humanization of childbirth practice in Japan. BMC Preg Childbirth 2010; 10: 1-18.
11. Hadjigeorgiou E, Kouta C, Papastavrou E, Papadopoulos I, Martensson LB. Women's perceptions of their right to choose theplace of childbirth: an integrative review. Midwifery 2012; 28: 380-90.
12. Ith P, Dawson A, Homer CS. Women's perspective of maternity care in Cambodia. Women Birth 2013; 26: 71-5.
13. Ferrer MB, Jordana MC, Meseguer CB, Garcia CC, Roche ME. Comparative study analysing women9s childbirth satisfaction and obstetric outcomes across two different models of maternity care. BMJ Open 2016; 6: e011362.
14. Wagner M. Fish can't see water: the need to humanize birth. Int J Gynecol Obstet 2001; 75: 25-37.
15. Silva LM, Barbieri M, Fustinoni SM. Living the birth process in a humanized assistance model. Rev Bras Enferm Brasfilia 2011; 64:60-5.
16. Hodnett ED, Downe S, Walsh D, Weston J. Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev 2010; 9: CD000012.
17. Maillefer F, De Labrusse C, Cardia-Vonèche L, Hohlfeld P, Stoll B. Women and healthcare providers' perceptions of a midwife-led unit in a Swiss university hospital: a qualitative study. BMC Preg Childbirth 2015; 15: 56.
18. Parveen Z, Sadiq M, Abbas F. Correlates of home and hospital delivery in Pakistan. J Pak Med Assoc 2017; 67: 1166-72.
19. Maher B, Kumar R. Rizvi N. Quantity and Quality Of Information, Education & Communication During Antenatal Visit at Private and Public Sector Hospitals of Bahawalpur, Pakistan. J Ayub Med Coll Abbotabad 2012; 24: 71-4.
20. Mateen A, Shaikh BT, Kumar R. How accessible are the emergency obstetrics care services? A cross sectional study in district Neelum, Azad Jammu and Kashmir. J Ayub Med Coll Abbotabad 2013; 25: 194-7.
21. Iyaniwura CA, Yussuf Q. Utilization of antenatal care and delivery services in Sagamu, south western Nigeria. Afr J Reprod Health 2009; 13: 111-22.
22. Wilunda C, Oyerinde K, Putoto G, Lochoro P, Dall'Oglio G, Manenti F, et al. Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facilitybased survey. Reprod Health 2015; 12: 30.
23. Karkee R, Lee AH, Pokharel PK. Women's perception of quality of maternity services: a longitudinal survey in Nepal. BMC Preg Childbirth 2014; 14: 45.
24. Bruce SG, Blanchard AK, Gurav K, Roy A, Jayanna K, Mohan HL, et al. Preferences for infant delivery site among pregnant women and new mothers in Northern Karnataka, India. BMC Preg Childbirth 2015; 15: 49.
25. Bhattacharyya S, Srivastava A, Roy R, Avan BI. Factors influencing women's preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis. BMC Preg Childbirth 2016; 16: 50.
26. Ashraf M, Ashraf F, Rahman A, Khan R. Assessing women's satisfaction level with maternity services: Evidence from Pakistan. Int J Collabo Res Int Med Pub Health 2012; 4: 1841-51.

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