Pakistan Demographic Health Survey Research Articles

On indirect estimation of small area parameters under ranked set sampling

In investigations of domains under post-stratified random sampling, it is difficult to get an acceptable precision for domain-specific estimates due to low sample sizes. Small area estimate, a popular technique that has been widely used over the past few decades, involves indirect estimating using the auxiliary data from the entire population. In this article, we utilize a ranked set sampling (RSS) technique to achieve a greater level of precision in area-specific estimations under the assumption that ranking the smaller sets is simple, inexpensive, and flawless. RSS optimizes sample size for a fixed degree of precision or increases precision for a fixed sample size. We create direct estimators for population total under homogeneous, ratio, and regression models that are area specific. To evaluate the effectiveness and application of the suggested RSS technique, data from the Pakistan Demographic Health Survey (PDHS 2017–18) and Iris flower data are used. The effectiveness of the RSS mechanism is supported by both theoretical characteristics and Bootstrapped tests.

Health insurance, social safety net and maternal health service utilisation in Pakistan: a population based cross-sectional study

ObjectiveThe objective of the study is to examine the impact of health insurance and social safety net programmes on maternal health service utilisation (MHSU) in Pakistan.DesignCross-sectional.SettingsData were obtained from Pakistan...

Assessing inequality of opportunities to child health and nutrition: comparison of Bangladesh and Pakistan

The bright future of any society is always associated with its upcoming generation. Children are the future prosperity of any nation as they are productive workers of tomorrow. The main objective of this study is to estimate the opportunities available for children under age of 5 years and their mothers for different regions of Pakistan and Bangladesh. The core idea of this study is to access and compare Pakistan with Bangladesh as it was previously a poor and struggling part of it. Data of this study are gathered from Bangladesh Demographic Health Survey and Pakistan Demographic Health Survey for the year 2017–18. The overall comparison of Pakistan and Bangladesh had put Pakistan in a situation where it lagged in every aspect of health-related facilities provided to its citizen. Governments should focus on providing economic opportunities, Health, education, and nutrition to enhance regional and area-level living standards. Further, rural areas should be more focused, especially by the Government of Pakistan.

Factors Influencing Health Facility Births: Insights from the 2017 Pakistan Demographic Health Survey

Factors Influencing Health Facility Births: Insights from the 2017 Pakistan Demographic Health Survey

Risk factors of child malnutrition under 5 years: Evidence from Pakistan using the Composite Index of Anthropometric Failure

ObjectivesChild malnutrition is a very serious health issue globally, particularly in emerging countries. Among South Asian countries, Pakistan has been observed to have a high prevalence of child malnutrition. In spite of the implementation of many health strategies and preventive measures for vulnerable populations, this issue is still unresolved and needs further investigation. The purpose of this study was to investigate the role of various social-, maternal-, and child-level factors considered to be responsible for nutritional health disparities among children. MethodsAn assessment method of malnutrition, i.e., Composite Index of Anthropometric Failure (CIAF), was used to detect the prevalence of malnutrition among children under 5 years of age in Pakistan in order to present a comprehensive view that was lacking conventional indices of malnutrition. A binary logistic regression model was fitted to assess the link between malnutrition and socioeconomic, maternal, and child attributes based on CIAF data compiled from weight-for-height, weight-for-age, and height-for-age Z-scores using data from the Pakistan Demographic Health Survey (2017–2018). ResultsA total of 4224 children under 5 years of age were included in the analysis. Approximately half of the children (45.34%) comprised anthropometric failures for the overall prevalence of undernutrition based on CIAF. The results of this study revealed that the leading determinant associated with CIAF was the child's age in months, small birth size, lack of breastfeeding, lack of maternal education, poor economic status of the household, and poor-quality water sources. The factors associated with stunting comprised the child's age in months, small child birth size, underweight maternal body mass index, and uneducated mothers. Only one factor—low household economic profile—was significantly associated with waste. Sindh, Baluchistan, and Khyber Pakhtunkhwa provinces had a higher risk of having wasted children. On the other hand, children aged 25-36 months had higher, small child birth size, underweight maternal BMI, un-educated mother, un-educated father, low economic profile of household experiencing of being underweight. ConclusionsThe findings of this study reinforce the significance of maternal health, parental education, and household economic profile in the prevention of malnutrition within young children of adequate birth size, as well as better overall health care up to adolescence in Pakistan. Well-nourished individuals are a valuable human resource and a requirement for a nation's progress and prosperity. In emerging nations such evidence-based policies are crucial for fostering children's optimal physical and mental development to ensure a healthier future generation. Therefore, the execution of national health policies aimed at the improvement of maternal and societal factors could result in improved nutrition levels among children below 5 years of age in Pakistan.

Evaluation of Emergency Contraceptive Pill Use with Health Management Information Systems Data in Pakistan.

According to the WHO, all clients should have access to a range of contraceptive methods, including at least one short-term, one long-term, one permanent, and one emergency method of contraception. While there are data on the contraceptive method mix available for many low- and middle-income countries, there are limited data on emergency contraception (EC). This is likely due to some surveys not routinely collecting this information, how survey questions are asked, dual method use, and/or low levels of reported use of EC pill (ECP). Even with low reported use in surveys, contraceptive social marketing statistics from DKT International. show a trend in recent years of increasing product sales of ECPs. To understand a more complete scope of ECP use, we use Pakistan as a case study and analyze Pakistan's Demographic Health Survey (DHS) surveys and Pakistan's Contraceptives Logistics Management Systems. Based on commodities dispensed data for ECPs in 2021, about 0.4 percent of all married women in Pakistan use ECPs. While there is currently a small proportion of women, it is growing and the use of ECPs is not zero as indicated by the DHS. Therefore, where available, countries should review their health management information systems data alongside survey data for ECP use.

A novel approach for estimating fertility rates in finite populations using count regression models

Demographic health surveys (DHS) contain in-depth information about the demographic characteristics and the factors affecting them. However, fertility rates which are the important indicators of population growth have been estimated by utilizing the design-based approaches. Model-based approach, on the other hand, facilitates efficient predictive estimates for these rates by utilizing the demographic and other family planning related characters. In this article, we first attempt to observe the effect of various socio-demographic and family planing related factors on births counts by fitting different regression models to Pakistan Demographic Health Survey 2017–2018 data under classical as well as Bayesian frameworks. The births occurred during the time periods of 1-year, 3-years and 5-years are taken as the responses and modeled using different non-linear models. The model-based approach is then used for estimation of the fertility measures including age-specific fertility rates, total fertility rate, general fertility rate, and gross reproduction rate for ever-married women in Pakistan. The performance of the model-based estimators is examined using a bootstrapped sampling algorithm. While the age-specific fertility rates are over-estimated for some age groups and under-estimated for others. The model-based fertility estimates are recommended for estimating the demographic indicators at national and sub-national levels when survey data contains incomplete or missing responses.

Assessing the relationship of maternal short stature with coexisting forms of malnutrition among neonates, infants, and young children of Pakistan.

Evidence from previous studies suggests a strong association between pediatric undernutrition and maternal stature. However, there's a scarcity of evidence regarding the relationship between maternal stature and pediatric coexisting forms of malnutrition (CFM). This study examined the prevalence and trends of CFM at the individual, household, and community levels, using data from the Demographic & Health Surveys (DHS) of Pakistan. Furthermore, this study assessed the association between pediatric CFM and short maternal stature while adjusting for multiple covariates. A panel cross-sectional analysis was conducted using data from the 2012-2013 and 2017-2018 Pakistan Demographic & Health Survey (PDHS). We included data from 6194 mother-child dyads aged 15-49 years and 0-59 months, respectively, while excluding data from pregnant mothers and dyads with incomplete anthropometric variables and anthropometric outliers. Across the two survey periods, our findings reveal a significant decline in pediatric malnutrition, including CFM, alongside a concurrent increase in maternal overweight/obesity. Three out of four households had either a malnourished mother, and/or a malnourished child, and/or both. Our study demonstrates that short maternal stature increased the odds of various forms of pediatric undernutrition by two-to-threefolds (p < .041), but we did not find an association with wasting, overweight/obesity, and nutritional paradox. This underscores the heightened vulnerability of children born to short-stature mothers to various forms of pediatric undernutrition. Addressing the high prevalence of pediatric undernutrition among children of short-stature mothers necessitates a comprehensive approach that considers an individual's nutritional status throughout their entire life cycle.

Assessment of Pregnancy Intention and Its Related Factors among Females Attending the Antenatal Clinic

Background and Objective: The intention of pregnancy is considered one of the major factors contributing to the foetal or maternal outcome. An exploration of the magnitude of this problem and its related factors can lead to improved foetal or maternal health. Thus, the objective of this study was to assess pregnancy intention and its related factors among females attending antenatal clinics of tertiary care hospitals. Methods: It is a Cross-sectional (analytical) study conducted at the Antenatal clinic, Jinnah Hospital Lahore, within the duration of January-April 2022. Two hundred and fifty(250) pregnant women aged 20 to 39 years were enrolled using non-probability convenience sampling. All the information was noted in a structured questionnaire based on study variables. The collected data was analysed using SPSS version 27.0 and frequency tables were generated. Appropriate test of significance was applied and p-value &lt; 0.05 was taken as statistically significant. Results: Among 250 pregnant females, about 195(78%) of the females reported the current pregnancy to be intentional while 55(22%) were unintentional. It was also seen that age and parity were significantly related to the intention of pregnancy p-value&lt;0.05. The main reasons behind unintentional pregnancies were; 28(51%) unaware about contraception, and 20(36.4%) contraception methods had failed. Conclusions: Approximately one-fourth of all pregnancies were unintentional which raises a concern regarding contraceptive usage and its effectiveness. The prevalence is high compared to reported by the Pakistan demographic health survey. Health education, advocacy, and health protection measures taken on all levels of health care to increase the use and access to contraceptive services are need of hour to address this unwanted situation of unwanted pregnancies.

The Role of Social Factors in Childhood Stunting in Pakistan with Special Focus on Parental Aspects

Stunting growth among children is one of the imperative health concerns for the global world. The paper measured the relationship of maternal, paternal, and communal factors with children’s stunting growth in Pakistan. The study used the Pakistan Demographic Health Survey (PDHS) and analyzed with the help of statistical packages for social sciences (SPSS Version-21). The unit of analysis was stunted children, and the sample size was (n=7448). The univariate and bivariate statistical analyses were employed by using the Chi-square test. The results of the study found that maternal, paternal, and communal factors have an association with children’s stunting growth. For example, specifically, child stunting growth is related to birth interval, low birth weight, mother education, incomplete immunization status, and poor wealth index. The study concluded that chances of child stunting increased with the help of maternal, paternal, and communal factors. The incomplete immunization status is associated with children’s stunting growth. The study recommended that the issues of birth interval, low birth weight, mother education, incomplete immunization, and poor wealth index should be the focus of the policymakers to control children’s stunting growth.

Antenatal Care - How to ensure quality!

Antenatal Care - How to ensure quality!

Studying infant mortality: A demographic analysis based on data mining models.

Child mortality, particularly among infants below 5 years, is a significant community well-being concern worldwide. The health sector's top priority in emerging states is to minimize children's death and enhance infant health. Despite a substantial decrease in worldwide deaths of children below 5 years, it remains a significant community well-being concern. Children under five years of age died at 37 per 1,000 live birth globally in 2020. However, in underdeveloped countries such as Pakistan and Ethiopia, the fatality rate of children per 1,000 live birth is 65.2 and 48.7, respectively, making it challenging to reduce. Predictive analytics approaches have become well-known for predicting future trends based on previous data and extracting meaningful patterns and connections between parameters in the healthcare industry. As a result, the objective of this study was to use data mining techniques to categorize and highlight the important causes of infant death. Datasets from the Pakistan Demographic Health Survey and the Ethiopian Demographic Health Survey revealed key characteristics in terms of factors that influence child mortality. A total of 12,654 and 12,869 records from both datasets were examined using the Bayesian network, tree (J-48), rule induction (PART), random forest, and multi-level perceptron techniques. On both datasets, various techniques were evaluated with the aforementioned classifiers. The best average accuracy of 97.8% was achieved by the best model, which forecasts the frequency of child deaths. This model can therefore estimate the mortality rates of children under five years in Ethiopia and Pakistan. Therefore, an online model to forecast child death based on our research is urgently needed and will be a useful intervention in healthcare.

Predictive analytics in smart healthcare for child mortality prediction using a machine learning approach.

In developing countries, child health and restraining under-five child mortality are one of the fundamental concerns. UNICEF adopted sustainable development goal 3 (SDG3) to reduce the under-five child mortality rate globally to 25 deaths per 1,000 live births. The under-five mortality rate is 69 deaths per 1,000 live child-births in Pakistan as reported by the Demographic and Health Survey (2018). Predictive analytics has the power to transform the healthcare industry, personalizing care for every individual. Pakistan Demographic Health Survey (2017-2018), the publicly available dataset, is used in this study and multiple imputation methods are adopted for the treatment of missing values. The information gain, a feature selection method, ranked the information-rich features and examine their impact on child mortality prediction. The synthetic minority over-sampling method (SMOTE) balanced the training dataset, and four supervised machine learning classifiers have been used, namely the decision tree classifier, random forest classifier, naive Bayes classifier, and extreme gradient boosting classifier. For comparative analysis, accuracy, precision, recall, and F1-score have been used. Eventually, a predictive analytics framework is built that predicts whether the child is alive or dead. The number under-five children in a household, preceding birth interval, family members, mother age, age of mother at first birth, antenatal care visits, breastfeeding, child size at birth, and place of delivery were found to be critical risk factors for child mortality. The random forest classifier performed efficiently and predicted under-five child mortality with accuracy (93.8%), precision (0.964), recall (0.971), and F1-score (0.967). The findings could greatly assist child health intervention programs in decision-making.

Unravelling the Impact of Food Insecurity on the Prevalence of Double Burden of Malnutrition among Children of Pakistan

Food insecurity is a major cause of double burden of malnutrition among children in developing world. Despite being self-sufficient, Pakistan contains 60% of food insecure population. Moreover, about half of under-five children are stunted and one-tenth are overweight. The coexistence of undernutrition and over nutrition among under-five children is not well investigated in the same household. This study unravels the impact of food insecurity on the prevalence of double burden of malnutrition among under-five children by employing 2018 Pakistan Demographic Health Survey data and hierarchical mixed effect logistic regression. A sample of 3,625 6-29 months old children was included. The results state that child food insecurity increases the risk of double burden (OR: 1.49, CI: 1.03-2.16) after adjusting for household and community level socioeconomic and demographic factors. Food security and nutrition programs should be targeted to prevent early childhood double burden of child malnutrition to avoid future productivity losses.

Internal migration and utilization of reproductive and maternity care among women in Pakistan: evidence from a recent National Survey.

During the last decades, migratory behavior has had a key role in population growth and redistribution in Pakistan. Migration has far-reaching socioeconomic implications for individuals and society at large that could influence the health integrity of Pakistani women. This study aimed to describe the migration patterns and drivers as well as their association with adequate access to reproductive and maternal care among married Pakistani women aged 15-49. The data from the 2017-18 Pakistan Demographic Health Survey (PDHS) was used to extract the information on the explanatory (sociodemographic and migration backgrounds) and outcome variables (unmet needs for family planning, adequate antenatal care, and delivery at health facilities). Bivariate and multivariate logistic regression analyses were employed to examine the relationship between these explanatory and outcome variables before and after adjustment for sociodemographic inequalities. In unadjusted models, the odds of having adequate ANC and delivery at health facilities were approximately 2 to 4 times higher in those living (urban non-migrant), moving to (urban to urban, rural to urban), or leaving the urban areas (rural to urban) as compared to rural non-migrants; likewise, the odds of the unmet needs for family planning was about 20-50% lower in the same migration streams compared to rural non-migrant. However, after adjustment for sociodemographic inequalities, most of these associations attenuated and only the association of urban to urban migration with unmet needs for family planning and the association of urban non-migrant with delivery at health facilities remained significant. Although the findings suggest that Internal migration flows, particularly those to urban areas (urban to urban and rural to urban), could be associated with better access to reproductive and maternity care among married Pakistani women aged 15-49 years; adjustment for sociodemographic inequalities, particularly education and wealth, nullified this association to a great extent. This has important implications for current policies and interventions in Pakistan and calls for policy reform and women's rights advocacy to enhance the literacy level of young Pakistani girls through well-tailored interventions, maintaining them at school.

Context Specific Complementary Feeding Recommendations for Children in Pakistan Based on Secondary Analysis of National Complementary Feeding Assessment and Pakistan Demographic Health Survey 2018

Background In Low Middle-Income Countries (LIMCs), malnutrition, especially undernutrition is one of the leading causes of childhood mortality and morbidity. Poor complementary feeding practices are among the most notable contributors to poor nutritional indicators in children under five. This article provides an output of secondary data analysis of the Cost of Diet (CoD) and Optifood component of National Complementary Feeding Assessment conducted by UNICEF Pakistan along with Pakistan Demographic Health Survey (PDHS) 2018. Methods For correlation of Optifood data and CoD data with PDHS data of CF, GraphPad software, MS Excel was used along with manual quantifications. The analysis of DHS-2018 data was conducted using STATA software. Univariate analysis included comparison of categorical variables i.e. various individual, household and community level parameters with that of outcome variables of minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum dietary diversity (MAD) using chi-square test. Findings The overall rate of MMF was 56.6% among children of 6-23 months of age with MDD in 18.6% and MAD in 13.8% of children. Percentage of annual cost spent on nutritious diet for MDD, MMF and MAD varies from 27.86% to 43.08% across all the provinces. Children aged 6–8 months and 9–11 months often consumed infant milk and cereals, while children aged 12–23 months often consumed eggs and grain products. Consumption of dairy products was highest in Punjab, Sindh, AJK, and Islamabad, that of grains roots and tubers was highest in KPK, FATA and GB. Conclusion Considering CF practices in Pakistan are inadequate as indicated by poor MDD, MMF, and MAD, therefore it is imperative that a holistic approach using both communication and non-communication based interventions is to be employed through active stakeholder engagement.

Association between Contraceptive Usage and Maternal Education towards Birth Spacing: Evidence from Pakistan Demographic Health Survey (PDHS) 2017–18

Association between Contraceptive Usage and Maternal Education towards Birth Spacing: Evidence from Pakistan Demographic Health Survey (PDHS) 2017–18

Women empowerment and access to maternity and reproductive healthcare in Pakistan: cross-validation of a Survey-based Index in Afghanistan (SWEI-A)

BackgroundDespite the obvious violation of women’s rights in Pakistan and the vital necessity for women empowerment, a unified country-specific index measuring women empowerment is not yet available. This study cross-validated a survey-based women empowerment index from Afghanistan to be used in Pakistan.MethodsThe data for married Pakistani women aged 15–49 in the 2017–18 Pakistan demographic health survey was used to construct the final model using the explanatory and confirmatory factor analyses. The Cronbach’s alpha test examined the internal consistency of the developed index. To assess the convergence validity of the index, the association of each emerged domain with indicators of access to reproductive and maternity care was assessed by Poisson regression analysis adjusting for wealth index.ResultsThe final index had six domains; namely, labor force participation, attitude toward violence, decision-making, access to healthcare, literacy, age at critical life events predicting women empowerment of married Pakistani women with decent reliability (Cronbach’s α = 0.70), and validity (SRSEA&SRMR < 0.05, CFI&TLI > 0.92). The emerged domains were significantly associated with at least one of four indicators for access to reproductive and maternity care; indicative of a favorable convergence validity.ConclusionPakistan and Afghanistan are associated as brother countries with shared religious and ethnocultural identities in which women are perceived inferior to men and in critical need of empowering efforts. The results of this study reflect upon this resemblance in sociocultural structure by yielding similar domains for women's empowerment in Pakistan building upon an index previously developed for Afghan women. The developed index could inform the design of future policies, interventions, and research recognizing the important indicators of women empowerment in Pakistan and could enhance the comparability of the results across future studies.

Are women with disabilities less likely to utilize essential maternal and reproductive health services?-A secondary analysis of Pakistan Demographic Health Survey.

BackgroundPeople with disabilities deal with widespread exclusion from healthcare services, including sexual and reproductive health (SRH) rights. Studies analyzing the relationship between disability and key SRH utilization outcomes have often reported mixed findings. In Pakistan, very little to no literature is available on this topic, therefore we aim to determine inequalities in the utilization of essential maternal and reproductive health services between women with and without disabilities in Pakistan.MethodsThis was a secondary analysis of Pakistan Demographic Health Survey 2017–18 performed on a weighted sample of 6,711 women aged 15–49 years with a live birth in the 5 years preceding the survey. Six types of disabilities were assessed i.e. vision, hearing, communication, cognition, walking and self-care. Utilization of essential maternal and reproductive health services was assessed through a set of four outcome variables: (i) modern contraceptive use; (ii) skilled antenatal care (ANC); (iii) skilled birth attendance (SBA); and (iv) skilled postnatal care (PNC). Multivariate Cox regression analysis was performed to determine the association between dependent and independent variables. Data were analyzed using Stata MP Version 16.0.ResultsA total of 6,711 women were included out of which 14.1% (n = 947) live with at least one form of disability. Mean age was 29.4 (S.E = 0.13) years. The most prevalent form of disability was vision (7.0%), followed by walking (4.8%), cognition (4.8%) and hearing (1.8%). Women with disabilities were comparatively less educated, belonged to older age group, and had higher parity than their non-disabled counterparts. With the exception of modern contraceptive use, which was more prevalent in the group with disabilities, women with disabilities were less likely to utilize skilled ANC, SBA and PNC in bivariate analysis. However, these associations turned insignificant in the adjusted model. Overall, no statistically significant differences were observed in the utilization of essential reproductive health services between women with and without disabilities after adjusting for important covariates.ConclusionOur analyses did not find any statistically significant differences in the utilization of essential maternal and reproductive health services between women with and without disabilities. In-depth research utilizing qualitative or mixed methods is required to understand how well the healthcare system in Pakistan is responsive to the different needs of disabled women.

Child Mortality, Fertility and Poverty: A Counterfactual Analysis

Larger sizes of households tighten the resources of families particularly those in lower wealth quintiles. Households in poorer quintiles are trapped into high child mortality. The risk of child survival leads to high fertility and little investment in children. The conditions to pull these households from this malicious trap are already absent. For instance, the indicators like, women’s low rates of education, early marriages and early pregnancies, and too little birth intervals are very discouraging in Pakistan. Unfortunately, households in poorer quintiles are the least beneficiaries from national revenues and policies in developing countries, in general, are designed for general public and benefit from those policies rarely reach to most needy households. The objectives of this paper are: (i) to emphasize the changing dynamics of fertility behavior and incidence of child mortality across the wealth distribution through an empirical investigation of five wealth quantiles, (ii) to explore the causal relationship between under 5 child mortality and fertility, and finally to examine the counter effect of a few policy instruments. For this purpose, the paper exploits the latest Pakistan Demographic Health Survey to examine few important policy variables to break the nexus between poverty, child mortality and high fertility. The counterfactual analysis suggests marginal improvement in a few variables; like female education, delay in first conception and incremental increase in birth intervals if in targeted households, will significantly change the child mortality and fertility rates. The analysis will be helpful for designing interventions. This analysis can also provide guidelines for women centered institutions like Banazir Income Support Programme, federal and provincial mother and child health departments and family planning offices.