Respectful and dignified healthcare is a fundamental right for every woman. However, many women seeking childbirth services, especially those in low-income countries such as Pakistan, are mistreated by their birth attendants. The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. The study also examined the association between demographics (socio-demographic, reproductive history and empowerment status) and mistreatment, both in general and according to birth setting (whether home- or facility-based). In phase one, we identified 24 mistreatment indicators through an extensive literature review. We then pre-tested these indicators and classified them into seven behavioural types. During phase two, the survey was conducted (April-May 2013) in 14 districts across Pakistan. A total of 1,334 women who had given birth at home or in a healthcare facility over the past 12 months were interviewed. Linear regression analysis was employed for the full data set, and for facility- and home-based births separately, using Stata version 14.1. There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%). In overall analysis, experience of mistreatment was lower among women who were unemployed (β = -1.17, 95% CI -1.81, -0.53); and higher among less empowered women (β = 0.11, 95% CI 0.06, 0.16); and those assisted by a traditional birth attendant as opposed to a general physician (β = 0.94, 95% CI 0.13, 1.75). Sub-group analyses for home-based births identified the same significant associations with mistreatment, with ethnicity included. In facility-based births, there was a significant relationship between women’s employment and empowerment status and mistreatment. Women with prior education on birth preparedness were less likely to experience mistreatment compared to those who had received no previous birth preparedness education. In order to promote care that is woman-centred and provided in a respectful and culturally appropriate manner, service providers should be cognisant of the current situation and ensure provision of quality antenatal care. At the community level, women should seek antenatal care for improved birth preparedness, while at the interpersonal level strategies should be devised to leverage women’s ability to participate in key household decisions.

Introduction: Quality antenatal care is a window of opportunity for improving maternal and neonatal outcomes. Numerous studies have shown a positive effect of women empowerment on improved coverage of maternal and reproductive health services, including antenatal care (ANC). However, there is scarce evidence on the association between women’s empowerment and improved ANC services both in terms of coverage and quality. Addressing this gap, this paper examines the relationship between multi-dimensional measures of women empowerment on utilization of quality ANC (service coverage and consultation) in Pakistan. Methods: We used Pakistan Demographic and Health Survey 2017–18 (PDHS) data which comprises of 6,602 currently married women aged between 15–49 years who had a live birth in the past five years preceding the survey. Our exposure variables were three-dimensional measures of women empowerment (social independence, decision making, and attitude towards domestic violence), and our outcome variables were quality of antenatal coverage [i.e. a composite binary measure based on skilled ANC (trained professional), timeliness (1^st ANC visit during first trimester), sufficiency of ANC visits (4 or more)] and quality of ANC consultation (i.e. receiving at least 7 or more essential antenatal components out of 8). Data were analysed in Stata 16.0 software. Descriptive statistics were used to describe sample characteristics and binary logistic regression was employed to assess the association between empowerment and quality of antenatal care. Results: We found that 41.4% of the women received quality ANC coverage and 30.6% received quality ANC consultations during pregnancy. After controlling for a number of socio-economic and demographic factors, all three measures of women’s empowerment independently showed a positive relationship with both outcomes. Women with high autonomy (i.e. strongly opposed the notion of violence) in the domain of attitude to violence are 1.66 (95% CI 1.30–2.10) and 1.45 (95% CI 1.19–1.75) and times more likely to receive antenatal coverage and quality ANC consultations respectively, compared with women who ranked low on attitude to violence. Women who enjoy high social independence had 1.87 (95% CI 1.44–2.43) and 2.78 (95% CI 2.04–3.79) higher odds of quality antenatal coverage and consultations respectively, as compared with their counterparts. Similarly, women who had high autonomy in household decision making 1.98 (95% CI 1.60–2.44) and 1.56 (95% CI 2.17–1.91) were more likely to receive quality antenatal coverage and consultation respectively, as compared to women who possess low autonomy in household decision making. Conclusion: The quality of ANC coverage and consultation with service provider is considerably low in Pakistan. Women’s empowerment related to social independence, gendered beliefs about violence, and decision-making have an independent positive association with the utilisation of quality antenatal care. Thus, efforts directed towards empowering women could be an effective strategy to improve utilisation of quality antenatal care in Pakistan.

The Method Information Index (MII) is calculated from contraceptive users’ responses to questions regarding counseling content—whether they were informed about methods other than the one they received, told about method‐specific side effects, and advised what to do if they experienced side effects. The MII is increasingly reported in national surveys and used to track program performance, but little is known about its properties. Using additional questions, we assessed the consistency between responses and the method received in a prospective, multicountry study. We employed two definitions of consistency: (1) presence of any concordant response, and (2) absence of discordant responses. Consistency was high when asking whether users were informed about other methods and what to do about side effects. Responses were least consistent when asking whether side effects were mentioned. Adjusting for inconsistency, scores were up to 50 percent and 30 percent lower in Pakistan and Uganda, respectively, compared to unadjusted MII scores. Additional questions facilitated better understanding of counseling quality.

Background Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society - Pakistan implemented an operational research project - ‘Evidence for Innovating to Save Lives’, to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. Methods We conducted a quasi-experimental (pre - and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, 1) Suraj model (meaning ‘Sun’ in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and 2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata® version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. Results The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14 % percentage points, current contraceptive use by 5 % percentage points and long term modern method - intrauterine device (IUD) use by 6 % percentage points. The CMW model significantly increased contraceptive awareness by 28 % percentage points, ever use of contraceptives by 7 % percentage points and, IUD use by 3 % percentage points. Additionally the Suraj intervention led to a 35 % greater prevalence (prevalence ratio: 1.35, 95 % CI: 1.22–1.50) of contraceptive use among MWRA. Conclusion Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Purpose: Despite a general understanding that exit interviews being conducted at service providers’ facilities may influence clients’ responses favorably to health professionals, there is very little evidence available that demonstrates the extent to which this problem exists. This study aimed at assessing and comparing clients’ perceptions of the quality of family planning services and their satisfaction levels between facility- and home-based interviews. Methods: A cross-sectional survey was conducted among clients receiving family planning services across three service delivery channels – nongovernmental organization (NGO) clinics, social franchise (SF) centers, and outreach camps. The survey took place from December 2015 to January 2016 in 70 districts across all four provinces of Pakistan. A total of 2,807 clients were interviewed, of whom 1,404 clients were interviewed at health facilities after receiving services and 1,403 were interviewed at their homes within 3 days of method uptake. Results: Overall, we found no significant differences between the characteristics of study participants interviewed at health facilities or at home. The findings suggested that experiences reported in exit surveys at facilities were strongly biased positively. This was true for both experiential (service quality) and perception-based (satisfaction) questions in the context of SF centers, while at NGO clinics the interview location only affected clients’ responses regarding service quality. However, in outreach settings, clients are more likely to share bad experiences in exit interviews than in home-based interviews on objectively asked questions (service quality). Conclusion: Our study indicates signs of courtesy bias and possibly the Hawthorne effect in exit interviews. Program implementers could opt for home-based interviews for women receiving services at NGO clinics or SF center, whereas exit interviews could be used in outreach settings.

Background: Attainment of healthcare in respectful and dignified manner is a fundamental right for every woman regardless of the individual status. However, social exclusion, poor psychosocial support, and demeaning care during childbirth at health facilities are common worldwide, particularly in low- and middle-income countries. We concurrently examined how women with varying socio-demographic characteristics are treated during childbirth, the effect of women’s empowerment on mistreatment, and health services factors that contribute to mistreatment in secondary-level public health facilities in Pakistan. Methods: A cross-sectional survey was conducted during August–November 2016 among 783 women who gave birth in six secondary-care public health facilities across four contiguous districts of southern Sindh. Women were recruited in health facilities and later interviewed at home within 42 days of postpartum using a WHO’s framework-guided 43-item structured questionnaire. Means, standard deviation, and average were used to describe characteristics of the participants. Multivariable linear regression was applied using Stata 15.1. Results: Women experiencing at least one violation of their right to care by hospital staff during intrapartum care included: ineffective communication (100%); lack of supportive care (99.7%); loss of autonomy (97.5%); failure of meeting professional clinical standards (84.4%); lack of resources (76.3%); verbal abuse (15.2%); physical abuse (14.8%); and discrimination (3.2%). Risk factors of all three dimensions showed significant association with mistreatment: socio-demographic: primigravida and poorer were more mistreated; health services: lesser-education on birth preparedness and postnatal care leads to higher mistreatment; and in terms of women’s empowerment: women who were emotionally and physically abused by family, and those with lack of social support and lesser involvement in joint household decision making with husbands are more likely to be mistreated as compared to their counterparts. The magnitude of relationship between all significant risk factors and mistreatment, in the form of β coefficients, ranged from 0.2 to 5.5 with p-values less than 0.05. Conclusion: There are glaring inequalities in terms of the way women are treated during childbirth in public health facilities. Measures of socio-demographic, health services, and women’s empowerment showed a significant independent association with mistreatment during childbirth. At the health system level, there is a need for urgent solutions for more inclusive care to ensure that all women are treated with compassion and dignity, complemented by psychosocial support for those who are emotionally disturbed and lack social support.