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ItemPrimary antenatal health care services, maternal health and birth outcomes in rural Pakistan( 2012)Pakistan is the world’s seventh largest nation in terms of population and is inhabited by people of diverse ethnicities and cultures. The country experiences multiple social, economic, political challenges which have consequences for its people’s lives and health, especially for women and their newborn babies. Women in the country are considered to have a lower social status, lesser economic autonomy, less role in decision making for health and healthcare seeking for themselves and their newborns. Risks of maternal (maternal duration spans over the entire pregnancy and first 6 weeks postpartum) health related complications and mortality in Pakistan are one of the highest in the world. Women are also known to commonly suffer from symptoms of common mental health problems during the maternal period. The inter-action of women’s poor health, inadequate health services and health care practices, and insufficient skilled care at birth makes the maternal period for Pakistani women one of the most dangerous and life threatening experience throughout the world. Newborns in Pakistan are at particular risk for neonatal death during the first month of life. Socio-demographic, economic and health services related aspects influence their survival and health, especially in the rural areas of the country. Female newborns are at a greater disadvantage than their male counterparts. Those living in geographically remote areas, having poorer economic conditions, uneducated mothers, and having a birth order of more than 6 have lesser likelihood of survival during the first month of life. Women’s health status may also impact adversely on the health and survival of newborns. The newborn care practices prevalent in Pakistani communities, and the traditional methods used during an episode of illness may also negatively influence the health of newborns and their survival. There has been only very limited research into the effectiveness of the primary health care system in Pakistan. The separate and/or combined effectiveness of the health system, in particular in relation to birth outcomes and neonatal health has not been investigated. There has been no systematic ascertainment of the utilization of primary antenatal health care services and of private traditional and often unskilled care in Pakistan. These gaps in knowledge mean that the contribution of the primary health care system to maternal, perinatal and neonatal mortality in the country is not known. Although some improvements in maternal health indicators have been achieved, in particular in the physical health of women and children in the country, the psychological aspects of women’s health and its impact on child health is only just beginning to be researched. Overall therefore there was a need for research which investigates the contributions of the limited primary antenatal health care; and both physical and psychological aspects of maternal health as determinants of birth weight and neonatal health. The aim of this study was to establish the separate and combined contributions of healthcare use and maternal health to birth weight and neonatal health in rural Pakistan. Ethical approval was requested and given from the Ethics Review Boards in Pakistan (National Commission for Human Development) and Australia (University of Melbourne). A prospective cohort design was adopted to consecutively enroll 624 pregnant women aged 15-49 years during second trimester (20-24 weeks pregnant, keeping in view the late registration of pregnancy with the Lady health Workers (LHWs), with women and their newborns followed till 28-30 days(to cover the neonatal period) after completion of pregnancy during July 2008 – May 2009. Information was collected through three contacts with each woman and newborn at their households by 25 community based health workers, and from primary healthcare records. Three pilot-tested study specific questionnaires, the Edinburgh Postnatal Depression Scale (EPDS) and the Self- Reported Questionnaire – 20 (SRQ-20), were used to acquire information on past obstetrical history, utilization of antenatal and postnatal care services, past and current natal experience, birth and neonatal weight and antenatal and postnatal psychological health. Research data was computerized through Epi Info 6.04 version software and descriptives (frequencies/proportions/means/standard deviations) and logistic regression analyses were conducted through SPSS version 17.0 software. Follow-up was completed for 593 women (95%) of the initially enrolled women. Birth weights and neonatal weights were completed for 467 newborns (79%) out of the total live births. More than half (56.3%) of women had some formal education, while nearly one third (35.9%) lived below the national poverty line. The public sector primary healthcare system despite identifying pregnant and postnatal women had nearly one quarter (23%) not receiving any antenatal care. Perinatal healthcare use presented a complex pattern of public sector only (25%), private sector only (41%) and public plus private sector (11%) services use across a matrix of qualified and non-qualified healthcare providers. A high proportion of poorer (46% for ANC and 36% for PNC) and less well educated (33% for ANC and 28% for PNC) women were not receiving any or less than the World Health Organization and nationally recommended schedule of of antenatal and postnatal care. One fifth (22.1%) women reported antenatal depressive symptoms (EDS cut-off point > 14) and one sixth (15.6%) of women reported the same during the postnatal period on EPDS cut-off point of > 12. About one quarter (28.4%) of women were primigravid, and 26.8% reported a history of stillbirth and/or intrauterine death. Current rate of stillbirth/intrauterine deaths (pregnancy duration of >28 weeks for stillbirth, and between 20-28 weeks for intrauterine death) was 8.0% among the pregnancy outcomes, with nearly one sixth (16.3%) live births being low-birth weight-LBW (i.e. birth weight of less than 2500 grams). More than half of the newborns (56.3%) were below normal weight-for-age at one month. A significantly (p-value < 0.05) smaller proportion of babies of low birth weight was found among women who were educated, living above poverty line, using antenatal care and able to visit a healthcare provider independently. Utilization of healthcare services during the antenatal period was predicted by higher economic status, having any formal education and lower number of pregnancies in the past. Smaller family size, longer duration of marriage, use of neonatal care for the newborn and not being able to visit a healthcare provider were the factors independently predicting use of postnatal care. Younger women, women who were older at the time of their first pregnancy, a larger family size and lower score on the postnatal EPDS predicted use of neonatal care. The adverse pregnancy outcome of stillbirth/intrauterine death was predicted by antenatal symptoms of common mental health problems, younger age at first pregnancy, and untrained attendant at the time of birth. Non-use of antenatal care services, living below the national poverty line and being unable to visit a health care provider were the independent predictors for low birth weight. Women who lived above the poverty line and whose baby had low birth weight had neonates with poorer health status. Non-use of both postnatal and neonatal care had a multiplicative affect that predisposed neonates three and half times more towards low weight-for-age against the normal health standards in the country. This research was the first prospective study of a systematically recruited cohort of women and newborns to investigate maternal and neonatal healthcare use, maternal mental and reproductive health and their separate and combined effects on birth outcomes and neonatal health in rural Pakistan. The study estimated the incidence of adverse pregnancy outcomes and symptoms of common mental health problems for women during the postnatal period and low weight births and malnutrition among neonates. Prevalence estimates for symptoms of common mental health problems during pregnancy, and maternal and neonatal healthcare utilization were also derived. Through multivariate logistic regression models, we were able to identify predictors of antenatal and postnatal healthcare use for women and neonatal healthcare use for the newborns in this setting. Risk factors for low birth weight and below normal weight-for-age among neonates were also determined. Factors that predispose women towards common mental health problems during the antenatal and postnatal periods were also investigated. Overall this research adds to the existing literature for Pakistan with reference to prevalence estimates for symptoms of common mental health problems during pregnancy, and maternal and neonatal healthcare utilization. It was the first prospective cohort study which simultaneously investigated maternal and neonatal healthcare use, maternal mental health and reproductive health in Pakistan. Furthermore this follow-up research, for the first time in the country conducted a detailed investigation about neonatal healthcare use and patterns of such services’ utilization. The present research also contributes towards establishing incidence of adverse pregnancy outcomes and symptoms of common mental health problems for women during the postnatal period and low weight births and malnutrition among neonates in Pakistan. Predictors of maternal and neonatal health services use, pregnancy outcome, birth weight, neonatal health and maternal mental health have been identified for rural Pakistani and South Asian settings through this research. This research for the first time in the country has identified mental health problems as predictors of adverse pregnancy outcomes. It also established the multiplicative interaction between postnatal and neonatal care use and health status of the neonates. It is understood that given the research findings, the present study highlights future areas of research for violence and maternal health in resource constrained settings in rural South Asia especially Pakistan.