The constraints of distance and poverty on institutional deliveries in Pakistan: evidence from georeference-linked data.

While institutional deliveries in Pakistan have risen substantially over the last few years, the change has mainly occurred among the wealthy and those with access to services in urban areas. We assess the influence of economic and geographic access to health facilities on institutional deliveries by linking household survey data and georeferenced distance to facilities equipped to provide services for obstetric care in nine districts in Pakistan. Multilevel mixed-effect logistic regression analyses show that the net effect of an increase in distance to a facility by 1 kilometer is to decrease the odds of an institutional delivery by 3 percent. In contrast, household wealth and availability of at least basic emergency care within 10 kilometers substantially increase the odds of an institutional delivery. These effects are more pronounced in rural areas than in urban areas. Disadvantages faced by poor rural women can be minimized by upgrading existing facilities at district and subdistrict levels to provide comprehensive emergency care and by facilitating transportation of poor rural women directly to these facilities when they experience life-threatening complications of childbirth.

Reducing unmet need and unwanted childbearing: evidence from a panel survey in Pakistan.

Pakistan's high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the country's expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time.

Estimating the incidence of abortion in Pakistan.

This study applies an indirect estimation method to develop comprehensive national and provincial estimates of the prevalence of abortion and abortion-related morbidity in Pakistan. Data from a health facilities survey and a health professionals survey from 2002 are analyzed to develop estimates of postabortion hospitalizations and of the abortion rate, abortion ratio, and unwanted pregnancy rate. We estimate that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1,000 women aged 15-49. The abortion rate is found to be higher in provinces where contraceptive use is lower and where unwanted childbearing is higher. The unwanted pregnancy rate is estimated at 77 per 1,000 women, or about 37 percent of all pregnancies. Abortions account for termination of one in seven pregnancies. An estimated 197,000 women are treated annually in public hospitals and private teaching hospitals for induced abortion complications, a number equivalent to an annual rate of 6.4 women hospitalized as a result of unsafe induced abortions per 1,000 women aged 15-49.