Trends and the Relationship between 

Maternal Health and Empowerment in 

Pakistan, 2012-2018

DHS Further Analysis Reports No. 128

March 2020

This publication was produced for review by the United States Agency for International Development. 

It was prepared by Lindsay Mallick, Rabia Zafar, Christina Juan, and Johanna Useem.

DHS Further Analysis Reports No. 128 

Trends and the Relationship between Maternal Health and 

Empowerment in Pakistan, 2012-2018 

Lindsay Mallick1

Rabia Zafar2

Christina Juan3

Johanna Useem3

ICF 

Rockville, Maryland, USA 

March 2020 

1

The DHS Program, Avenir Health 

2

National Institute of Population Studies 

3

The DHS Program, ICF 

Corresponding author: Lindsay Mallick, The DHS Program, ICF, 530 Gaither Road, Suite 500, 

Rockville, MD 20850, USA; phone: 301-572-0211; email: lindsay.mallick@icf.com 
Acknowledgments: The authors would like to thank Courtney Allen and Kerry MacQuarrie for 

conceptualization support. We are additionally grateful to Kerry MacQuarrie for her thoughtful review and 

constructive feedback on an earlier draft of this paper. We express our gratitude to Shireen Assaf for 

developing the Stata programs that were modified for this analysis and Muhammad Ali Raza for additional 

help with improving the graphics. We offer our thanks to Fernanda Ewerling, who along with her coauthors, developed the SWPER and provided additional support for our paper. Finally, we thank the 

National Institute of Population Studies of Pakistan not only for providing support for this further analysis, 

but also for collecting the data that made this analysis possible.

Editor: Diane Stoy 

Document Production: Chris Gramer 

This study presents findings from a further analysis of the follow-up to the 2017-18 Pakistan Demographic 

and Health Survey (2017-18 PDHS). This report is a publication of The DHS Program, which is designed 

to collect, analyze, and disseminate data on fertility, family planning, maternal and child health, nutrition, 

and HIV/AIDS. Funding was provided by the United States Agency for International Development 

(USAID) through the DHS Program (#AID-OAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The 2017-18 PDHS was implemented by the National Institute of Population Studies (NIPS) from 

November 22, 2017 to April 30, 2018, under the aegis of the Ministry of National Health Services, 

Regulations, and Coordination, Islamabad, Pakistan. ICF provided technical assistance through The DHS 

Program, which assists countries worldwide in the implementation of population and health surveys. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about The DHS Program can be obtained 

from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA; telephone: +1 301-407-6500, fax: 

+1 301-407-6501, email: info@DHSprogram.com, internet: www.DHSprogram.com. 

Recommended citation: 

Mallick, Lindsay, Rabia Zafar, Christina Juan, and Johanna Useem. 2020. Trends and the Relationship 

between Maternal Health and Empowerment in Pakistan, 2012-2018. DHS Further Analysis Reports No. 

128. Rockville, Maryland, USA: ICF. 
iii 

CONTENTS 

TABLES ........................................................................................................................................................ v 

FIGURES .................................................................................................................................................... vii 

ABSTRACT ................................................................................................................................................. ix 

ACRONYMS AND ABBREVIATIONS ........................................................................................................ xi 

1 INTRODUCTION .............................................................................................................................. 1 

2 DATA AND METHODS ................................................................................................................... 3 

2.1 Data ..................................................................................................................................... 3 

2.2 Methods .............................................................................................................................. 3 

2.2.1 Measures ............................................................................................................... 3 

2.2.2 Analysis .................................................................................................................. 4 

3 RESULTS ........................................................................................................................................ 7 

3.1 Trends in Maternal Health Care-Seeking and Empowerment ............................................ 8 

3.1.1 Trends in maternal health ...................................................................................... 8 

3.1.2 Trends in high empowerment ................................................................................ 8 

3.2 Trends in the Relationship between Maternal Health Care-Seeking and Women’s 

Empowerment over Time .................................................................................................. 10 

3.2.1 Four or more antenatal visits ............................................................................... 10 

3.2.2 Skilled birth attendance ........................................................................................ 13 

3.2.3 Postnatal care ...................................................................................................... 16 

3.2.4 All three critical maternal health contacts ............................................................ 20 

4 DISCUSSION AND CONCLUSION ............................................................................................... 23 

4.1 Overview and Findings in Context .................................................................................... 23 

4.2 Strengths and Limitations ................................................................................................. 24 

4.3 Recommendations ............................................................................................................ 25 

4.4 Conclusion ........................................................................................................................ 25 

REFERENCES ............................................................................................................................................ 27 

APPENDIX .................................................................................................................................................. 31 

v 

TABLES 

Table 1 Key dependent and independent variables ............................................................... 6 

Table 2 Sample of women analyzed by background characteristics, Pakistan 2012-13 

and 2017-18 ............................................................................................................... 7 

Table 3 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% 

confidence intervals (CI) of attending 4 or more antenatal care visits during 

the last pregnancy .................................................................................................... 13 

Table 4 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% 

confidence intervals (CI) of skilled attendance at birth during the last live birth ...... 16 

Table 5 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% 

confidence intervals (CI) of a postnatal check after the last live birth ..................... 19 

Table 6 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% 

confidence intervals (CI) of receipt of 3 critical maternal health services ................ 22 

Appendix Table 1 Distribution of empowerment and maternal health care-seeking indicators, 

Pakistan 2012-13 and 2017-18 ................................................................................ 31 

Appendix Table 2 Antenatal care visits (4 or more) by background characteristics for both 

surveys ..................................................................................................................... 32 

Appendix Table 3 Skilled birth attendance by background characteristics for both surveys ................ 33 

Appendix Table 4 Postnatal care by background characteristics for both surveys .............................. 34 

Appendix Table 5 Percent of women obtaining all three critical maternal health services, by 

background characteristics, Pakistan 2012-13 and 2017-18 ................................... 35 

vii 

FIGURES 

Figure 1 National trends in maternal health care-seeking in Pakistan, 2012-2018 ................. 8 

Figure 2 Trends in empowerment indicators in Pakistan, 2012-2018 ...................................... 9 

Figure 3 The percentage of women with 4 or more antenatal care visits for their last 

pregnancy resulting in a live birth, according to domains and levels of 

empowerment .......................................................................................................... 11 

Figure 4 The percentage of women reported skilled birth attendance during their last 

live birth, according to domains and levels of empowerment .................................. 14 

Figure 5 The percentage of women receiving a postnatal check within 2 days of 

delivery, according to domains and levels of empowerment ................................... 17 

Figure 6 The percentage of women receiving all three maternal care contacts and 

measures of empowerment, according to domains and levels of 

empowerment .......................................................................................................... 21 

ix 

ABSTRACT 

Background: Access to and receipt of high-quality care during pregnancy and childbirth is critical for 

preventing maternal mortality. In male-dominated societies, women’s lack of autonomy can be a barrier to 

accessing maternal health care. However, research often defines autonomy narrowly, although multiple 

components of empowerment may play a role. Our study assessed the relationship between maternal health 

care-seeking and measures of empowerment among women in Pakistan in order to identify persistent 

disparities in the utilization of maternal health services. 

Methods: We analyzed data from currently married women with a recent live birth who were interviewed 

in Demographic and Health Surveys conducted in Pakistan in 2012-13 and 2017-18. We examined trends 

in antenatal care, skilled birth attendance, postnatal care, and a composite indicator of all three. We also 

assessed trends in empowerment using the validated, survey-based Women’s emPowERment (SWPER) 

index, which included three domains: attitude to violence, social independence, and decision making. We 

included an additional empowerment measure based on women’s report of problems accessing care. We 

conducted tests of association to examine the significance of the differences in care-seeking between survey 

years, and by levels of empowerment and background characteristics. Finally, we fitted adjusted logistic 

regression models to identify the magnitude of these associations after controlling for key 

sociodemographic characteristics. 

Results: The results showed the social independence and decision-making domains of empowerment were 

each significantly and positively associated with maternal health care-seeking. However, the strength and 

magnitude of the relationship between wealth and care-seeking was greater than empowerment, with a 

nearly 15-fold increase in the odds of receiving all three maternal health care contacts if a woman was in 

the wealthiest quintile compared with the lowest wealth quintile. In addition, earlier maternal health careseeking was associated with increased odds of skilled attendance at birth and postnatal care. 

Conclusions: Although higher empowerment is independently related to increased maternal health careseeking, wealth was a stronger determinant. Because empowerment may also work through wealth, 

stakeholders should consider evidence of “pro-poor” policies, in tandem with efforts towards 

empowerment, to encourage timely use of services during pregnancy and childbirth. 

Key words: Pakistan, maternal health, care-seeking, empowerment, gender

xi 

ACRONYMS AND ABBREVIATIONS 

AJK Azad Jammu and Kashmir 

ANC antenatal care 

AOR adjusted odds ratio 

BISP Benazir Income Support Program 

CI confidence interval 

DHS Demographic and Health Survey 

FATA Federally Administered Tribal Areas 

GDI Gender Development Index 

ICT Islamabad Capital Territory 

LHW lady health worker 

MDGs Millennium Development Goals 

MNCH maternal, newborn, and child health 

NIPS National Institute of Population Studies 

PDHS Pakistan Demographic and Health Survey 

PNC postnatal care 

SBA skilled birth attendant 

SDGs Sustainable Development Goals 

SWPER Survey-based Women’s emPowERment index 

UN United Nations 

UNICEF United Nations Children Fund 

UNFPA United Nations Population Fund 

UNPD United Nations Population Division 

UOR unadjusted odds ratio 

WHO World Health Organization 

 

1 

1 INTRODUCTION 

The World Health Organization (WHO) recently reported that in 2017, approximately 300,000 women died 

of mostly preventable causes directly related to pregnancy and childbirth (WHO et al. 2019). Hence, there 

is an urgent need for the global health agenda to focus on enhancing the accessibility of health services and 

programs and improving the quality of care for mothers and their newborns. Access to quality services of 

reproductive health during pregnancy, delivery, and the postnatal period can make the difference between 

survival and death for both mother and baby (WHO 2015). 

During the past two decades, considerable progress has been made to improve the maternal health 

indicators, including maternal mortality, in Pakistan. In April 2005, the Government of Pakistan introduced 

the National Maternal, Neonatal, and Child Health (MNCH) Strategic Framework that outlined 

interventions which address the needs of mother and child health (Government of Pakistan 2010). The 

MNCH Strategic Framework also aims to meet global development targets. Pakistan’s MNCH Programme 

was launched nationally in 2007 to focus on the United Nations’ (UN) Millennium Development Goals 

(MDGs) 4: Reduce maternal mortality to 140 maternal deaths per 100,000 live births by 2015 (Planning 

Commission 2010). Pakistan has shown considerable effort, with a 51% reduction between 2000 and 2017, 

reaching 140 deaths per 100,000 live births by 2017 (WHO et al. 2019). 

Currently, Pakistan is contributing to the UN’s Sustainable Development Goals (SDGs), which replaced the 

UN’s MDGs. Pakistan is committed to achieving SDG 3: Ensure healthy lives and promote well-being for 

all at all ages and Target 3.1: Reduce the global maternal mortality ratio to less than 70 per 100,000 live 

births by 2030 (Government of Pakistan 2016). However, to reach this goal, maternal mortality will need 

to be reduced by half again in the next decade. To reach the SDGs, Pakistan’s MNCH Programme’s primary 

focuses are improving emergency obstetric services and the placement of community midwives, as well as 

promoting safe deliveries by skilled birth attendants (SBA) (Technical Resource Facility 2013). One 

initiative, entitled the Lady Health Workers (LHWs) Programme, created a cadre of female health workers 

to help address the health system’s needs, including providing MNCH services for people in rural and slum 

areas (Hafeez et al. 2011; NIPS/Pakistan and ICF 2019). The LHWs support women by improving various 

health areas including personal hygiene, sexual and reproductive health, and pregnancy care with iron 

supplementation, fetal growth monitoring, and vaccinations. 

In male-dominated societies like Pakistan (Akram 2018), women’s inequitable status in society limits their 

autonomy in decision making about health care-seeking (Osamor and Grady 2016). Thus, a focus on 

empowering girls and women is needed. Several studies have demonstrated the link between constructs of 

empowerment and maternal health care-seeking globally (Ahmed et al. 2010; Ewerling et al. 2017; Osamor 

and Grady 2016). In Pakistan, research that focused on the role of select domains of empowerment and 

health care utilization found that use of services expanded when a woman has a greater autonomy in 

decision making (Agha 2011; Hearld, Anderson, and Budhwani 2018; Hou and Ma 2012; Khan, Zaheer, 

and Shafique 2017). Many of these studies, however, both globally and within the South Asian context 

specific to Pakistan, focused on narrow definitions or limited aspects of empowerment, such as autonomy 

in decision making. 
2 

Although autonomy is often used interchangeably with the term empowerment, empowerment is a multidimensional, complex construct (Ewerling et al. 2017; Kishor and Subaiya 2008; Upadhyay and Karasek 

2012). Although many definitions exist (Do and Kurimoto 2012; Ewerling et al. 2017), seminal work by 

Kabeer defines empowerment as a process in which an individual or group transcends from a once limited 

status to a state where they can make the choices that result in their desired outcomes (Kabeer 2001). Kishor 

(2000) defines empowerment in a way that can be measured with cross-sectional data by using the concepts 

of evidence and sources. Although empowerment is conceptually a process, cross-sectional surveys such as 

the Demographic and Health Surveys (DHS) can capture the end result of the process, or evidence of 

empowerment and the access to sources that enable action on these choices (Kishor 2000). Evidence of 

empowerment in cross-sectional studies has been defined by using questions that assess autonomy in 

decision making, as well as acceptance of inequitable gender-norms, such as attitude to spousal violence 

(Do and Kurimoto 2012; Kishor and Subaiya 2008). Other research has defined empowerment in terms of 

freedom of movement (Al Riyami, Afifi, and Mabry 2004). Further, empowerment is a multidimensional 

construct that spans economic, social and cultural (including familial), legal, political, and psychological 

domains, and also exists within multiple levels of society, including the household, community, and broader 

contexts (Malhotra and Schuler 2005). 

To better capture this complex construct, researchers have developed an index that captures multiple 

dimensions of empowerment with the survey-based Women’s emPowERment (SWPER) index (Ewerling 

et al. 2017; Ewerling et al. 2019). The authors empirically identified the three most dominant dimensions 

based on 15 items captured by surveys. These dimensions reflect attitudes about gender violence, social 

independence, and household decision making. To construct the SWPER index, DHS data was used to 

identify a common set of questions across 34 African nations. This was validated with the widely-used 

Gender Development Index (GDI). The SWPER aims to quantify the state of women’s empowerment and 

allows for trends and analyses both within and across countries over time. The SWPER also provides a 

means for researchers to investigate the effect of women’s empowerment on health interventions and 

outcomes (Ewerling et al. 2017). Recently, the SWPER was validated more broadly—across 62 low and 

middle-income countries—and a global standardization of the index was developed (Ewerling et al. 2019). 

In this recent version of the index, one item related to employment was dropped, and fourteen were retained. 

Our study employs the novel, multidimensional, and validated SWPER index to examine the relationships 

between women’s empowerment and utilization of maternal health services in Pakistan over time. We also 

include a measure of autonomy that reflects women’s problems in accessing healthcare as a proxy for a 

domain not included in the index, freedom of mobility. To identify persistent, problematic disparities in 

utilization of maternal health services, we test determinants of maternal health care-seeking, including 

empowerment, as well as sociodemographic characteristics across multiple time points using the two most 

recent Pakistan DHS surveys. This study aims to provide direction, insight, and targeting for future 

interventions related to the utilization of maternal health services and women’s empowerment. 
3 

2 DATA AND METHODS 

2.1 Data 

We use publicly available data from the two most recent Pakistan DHS (PDHS) surveys collected in 2012-

13 and 2017-18 (NIPS/Pakistan and ICF 2019; NIPS/Pakistan and ICF International 2013). A two-stage 

sample design provided the framework for the sample. In the first stage, provinces (or other included 

territories or regions, as described below) were stratified by urban and rural areas. Enumeration blocks 

within each stratum were selected based on a probability proportional to their size. In the second stage, 

households were systematically selected within enumeration blocks with an equal probability of selection. 

Sampling weights were calculated for use during analysis to ensure that the sample was representative at 

the national level. 

The sampled areas varied by survey. Because this study focuses on trends, we examine only comparable 

provinces and areas. In 2012-13, four provinces of Pakistan (Punjab, Sindh, Khyber Pakhtunkhwa, and 

Balochistan), the Islamabad Capital Territory (ICT Islamabad), and the region of Gilgit Baltistan were 

covered by the survey as part of the national sample. In 2017-18, the four provinces and ICT Islamabad 

were sampled, as well as the Federally Administered Tribal Areas (FATA). National estimates were based 

on these areas. Although Gilgit Baltistan was also sampled in 2017-18, this area, along with Azad Jammu 

and Kashmir (AJK), was sampled with a different sampling frame. Thus, sampling statisticians constructed 

separate weights for these areas, and they are not included in the national estimates. 

In total, our analysis included 4,145 women in 2012-13 PDHS and 3,792 women in the 2017-18 PDHS. 

Because our outcomes of interest reflect maternal health care, this sample includes only women who had a 

live birth. We limit this sample to women who have had a live birth in the past 2 years to reduce the effects 

of recall bias. Finally, we restrict our analysis to women with sufficient data (women without “don’t know” 

or missing values) for key items included in the empowerment index used in this study, SWPER. Since the 

SWPER is based on currently married women, our study was further restricted to this population. In 

summary, our analysis includes currently married women who reside in consistently sampled and 

comparable provinces and regions over time (the four provinces and ICT Islamabad), who had a live birth 

in the past 2 years, and had sufficient data to calculate the empowerment index used in this analysis. Given 

the different sample of women analyzed in this study, the results of the study will not match the final reports 

of either survey. 

2.2 Methods 

This study utilizes several methodological approaches, described below, to understand the trends in 

maternal health care-seeking in Pakistan, trends in empowerment, and trends in the relationships between 

them. The following sections detail these steps. 

2.2.1 Measures 

This analysis includes several key measures of maternal health care and empowerment, defined in Table 1. 

Our dependent (outcome) variables include indicators of maternal health care-seeking, such as four or more 

antenatal care (ANC) contacts (4+ ANC visits), skilled attendance at birth (SBA), postnatal care (PNC)—
4 

defined as a postnatal check for the mother within 2 days of delivery—and a composite indicator of all three 

critical maternal health contacts. Although institutional delivery is a critical point of contact with the health 

system, according to both surveys, nearly all women who had an SBA delivered in a facility, and the percent 

agreement between the two is nearly perfect (over 95% in each survey). 

Our four main independent variables of interest in this analysis reflect aspects of women’s empowerment. 

We used the SWPER, and the corresponding publicly available Stata programming1

, to construct three 

domains of women’s empowerment that included attitude to violence, social independence, and women’s 

decision making (Ewerling et al. 2019). Ewerling et al. (2017) originally developed the SWPER with 

principal components analysis to first identify these three domains. They then developed separate subindices, one for each of the three domains. For each domain, all 14 items in the SWPER were assigned 

weights based on the loading of that item within the respective domain. The items that most represented 

each domain (the items with the highest PCA loadings in each component) are described in Table 1. Social 

independence is heavily weighted by women who frequently read the newspaper or magazines, as well as, 

to a lesser extent, have higher education, a later age at first birth, and smaller gaps in age and education 

between the woman and her husband. For the domain that reflected attitude to violence, women who 

reported a husband was not justified in beating his wife for instances listed in Table 1 received a higher 

empowerment score than women who reported beating was justified, while holding other items constant. 

Similarly, women who reported participating in household decisions received higher scores for the decisionmaking domain. 

In the recent SWPER adaptation, a global standardization was developed, which was applied in this study. 

The authors also provided established cut-points that roughly divided global scores into terciles, while 

accounting for either normal or multimodal distribution of the data. We applied these standard cut points to 

categorize our scores into low, medium, and high levels of empowerment according to the authors’ 

recommendation (Ewerling et al. 2019). 

We also include a measure of empowerment that is not part of the SWPER. This measurement is based on 

women’s report of problems in accessing health care, which encompass constructs of empowerment as well 

as physical and financial barriers to care (Table 1). This represents a construct not included in the SWPER 

index, freedom of movement (Al Riyami, Afifi, and Mabry 2004). If a woman has no problems (coded as 

“0”), this is considered “more empowered” than if she has at least one problem, which is coded as “1”. 

2.2.2 Analysis 

To understand how use of maternal health care and women’s empowerment has changed over time, we 

examined overall levels and trends between 2012-13 and 2017-18 for each of the four indicators of maternal 

health care-seeking (4+ ANC visits, SBA, PNC, and the composite of all three). In addition, we assessed 

and compared the four measures of empowerment. We tested the statistical significance of the difference in 

the proportions in each of the two surveys by using unadjusted logistic regression. 

1

 We slightly modified the publicly available Stata code as (at the time of this analysis) this code did not account for 

the country-specific response option about decision making solely by “family elders”, a category in the Pakistan 2012-

13 survey. Our code includes this option within the “husband or other alone” category and women selecting this 

response are assigned a score of -1 for each of the three decision-making variables. 
5 

Next, to examine disparities in maternal health care-seeking, for each maternal health outcome, we tested 

the bivariate associations with each empowerment indicator, as well as sociodemographic characteristics 

among women in each survey. We used chi-square tests of independence to assess the significance of these 

associations. The background characteristics included place of residence, region, wealth quintile, education 

(none, primary, secondary or more), age at the birth (<19, 20-34, and 35 and above), and parity (1, 2-3, 4-

5, 6 or more). To assess the significance in the change in relationship between each characteristic and 

empowerment indicators, we again conducted unadjusted logistic regressions. 

The results that show the significance of the trends in maternal health care-seeking, empowerment, and the 

bivariate relationships between these pairs of indicators are presented in figures as well as tables. In this 

report, the figures show the estimates according to each survey plotted on a graph (y-axis is time, x-axis is 

proportion), connected by either a solid line or a dotted line. A solid line between the two survey time points 

indicates that the analysis identified a significant difference (p-value<0.05), while a dotted line indicates no 

significant difference. 

Finally, we conducted multivariable logistic regression for each of the four dependent variables for each 

survey to assess the magnitude of the associations between the maternal health care-seeking dependent 

variables and key independent variables related to women’s empowerment, as well as to account and control 

for the multiple socioeconomic and demographic determinants. In addition to these characteristics, we 

included variables for earlier maternal care-seeking along the continuum of care. For the dependent variable 

SBA, we included an independent variable for 4+ ANC visits. For PNC, we included both 4+ ANC visits 

as well as SBA. We present the adjusted odds ratios (AOR), 95% confidence interval (CI), and p-values 

(categorized as less than 0.001, less than 0.01, and less than 0.05) for each independent variable. Using 

Pearson’s R correlation coefficient and a variation inflation factor, we ensured that correlation and 

multicollinearity were not problematic in the adjusted models. Education was highly correlated with wealth. 

Since education was included as a variable in the SWPER index, we did not include it in our regression 

analysis. 

We conducted all analyses using Stata 16, adjusting for the complex survey design and probability sampling 

using individual weights, primary sampling unit, and strata for each survey using the svyset command. For 

all statistical tests, we set α=0.05. 

 
6 

Table 1 Key dependent and independent variables 

Variable Definition 

Dependent variables 

Four or more antenatal care visits (ANC) Percentage of women with four or more ANC visits for their most recent pregnancy that 

resulted in a live birth in the past 2 years 

Women whose birth was assisted by a 

skilled birth attendant (SBA) 

Percentage of women whose most recent live birth in the past 2 years was assisted by 

an SBA 

Postnatal care (PNC) for the mother Percentage of women who received a postnatal check-up within 2 days of delivering their 

most recent birth in the past 2 years 

Critical maternal health care contacts Percentage of women with all three of the above maternal health care services: four or 

more ANC visits, delivery assisted by an SBA, and PNC within 2 days of delivery among 

women with a live birth in the past 2 years. 

Key independent variables 

SWPER (1): Attitudes towards violence This domain of empowerment includes all empowerment variables included in SWPER 

but is most heavily weighted by five variables that represent women’s attitude to violence. 

These include responses to the questions: 

In your opinion, is a husband justified in hitting or beating his wife in the following 

situations: 

1) If she goes out without telling him? 

2) If she neglects the children? 

3) If she argues with him? 

4) If she refuses to have sex with him? 

5) If she burns the food? 

Responses are categorized as follows: 

Justified=–1; don’t know=0; not justified=1 

SWPER (2): Social independence This domain of empowerment includes all empowerment variables included in SWPER 

but is most heavily weighted by six variables that represent social independence. These 

include: 

1) Frequency of reading newspaper or magazine 

2) Woman’s education in completed years of schooling 

3) Education difference (woman’s minus husband’s completed years of schooling) 

4) Age difference (woman’s age minus husband’s age) 

5) Age at first cohabitation 

6) Age of woman at first birth 

SWPER (3): Decision making This domain of empowerment includes all empowerment variables included in SWPER, 

but is most heavily weighted by three variables that represent women’s role in household 

decision making related to the following questions: 

1) Who usually decides on respondent’s health care? 

2) Who usually decides on large household purchases? 

3) Who usually decides on visits to family or relatives? 

Responses are coded as follows: 

joint decision or respondent alone (1) or 

husband or other (including family elder) alone (–1) 

At least one problem in accessing health 

care 

This variable was coded as (1) if the respondent said any of the following was a big 

problem in response to the questions: 

When you are sick and want to get medical advice or treatment, is each of the following a 

big problem or not? 

a) Getting permission to go to the doctor? 

b) Getting money needed for advice or treatment? 

c) The distance to the health facility? 

d) Not wanting to go alone? 

If the respondent responded no to all questions, they were coded as (0). 

SWPER = Survey-based Women’s emPowERment index 
7 

3 RESULTS 

This chapter presents the results of the study. First, we present the background characteristics of the women 

in the analysis. We then examine the overarching or national trends of maternal health care-seeking 

behavior, and trends in empowerment. 

Table 2 shows the background characteristics of the analytic sample. In both surveys, the majority of women 

lived in rural areas, with a decrease in rural residence between the two surveys from 70% in 2012-13 to 

66% in 2017-18. In 2012-13 and 2017-18, the regions where respondents lived were consistent, with the 

majority of respondents living in Punjab (58% and 54% respectively), followed by Sindh (23% and 24% 

respectively), Khyber Pakhtunkhwa (15% and 17% respectively), Balochistan (4% and 5% respectively), 

and the fewest number of respondents living in ICT Islamabad, at less than 1% each year. Respondents’ 

education improved from 2012-13 to 2017-18, with the proportion of women with no education decreasing 

(54% in 2012-13 to 46% in 2017-18), some with primary education remaining stable (17% in 2012-13 and 

16% in 2017-18), and at least some with secondary education increasing (28% in 2012-13 to 38% in 2017-

18). Age at birth remained consistent, with little change across the higher risk age at birth categories; 8% 

in 2012-13 and 9% in 2017-18 were younger than age 20, and 11% were age 35-49 in both the 2012-13 and 

2017-18 surveys. The number of children born in 2012-13 and 2017-18 was similar, with 23% and 24%, 

respectively, having one child, 38% and 40%, respectively, two to three children, 22% and 23%, 

respectively, four to five children, and 17% and 13%, respectively, having six children or more. 

Table 2 Sample of women analyzed by background characteristics, Pakistan 2012-13 and 

2017-18 

 2012-13 2017-18 

 % N % N 

Place of residence Urban 29.7 1,231 33.7 1,277 

Rural 70.3 2,914 66.3 2,516 

Region Punjab 57.7 2,392 53.8 2,038 

Sindh 22.9 949 23.7 900 

Khyber Pakhtunkhwa 14.6 607 16.6 629 

Balochistan 4.4 181 5.1 194 

ICT Islamabad 0.4 16 0.8 31 

Wealth quintile Lowest 21.9 907 20.5 776 

Second 21.2 878 18.7 711 

Middle 20.4 846 22.0 832 

Fourth 20.7 856 19.0 721 

Highest 15.9 658 19.8 752 

Education None 54.4 2,255 46.3 1,755 

Primary 17.3 715 15.9 602 

Secondary + 28.3 1,175 37.9 1,435 

Age at birth <20 8.2 340 9.0 341 

20-34 80.4 3,332 80.4 3,049 

35-49 11.4 472 10.6 402 

Parity 1 23.4 969 23.6 897 

2-3 38.2 1,582 39.7 1,504 

4-5 21.7 900 23.4 887 

6+ 16.7 694 13.3 505 

 

Total 100.0 4,145 100.0 3,792 

*Note: due to rounding, percents may not add up to 100. 
8 

3.1 Trends in Maternal Health Care-Seeking and Empowerment 

3.1.1 Trends in maternal health 

Overall, maternal health care-seeking increased between 2012-13 and 2017-18 in Pakistan, as seen in Figure 

1 with supporting information provided in Appendix Table 1. Figure 1 displays the percentage of currently 

married women age 15-49 with a recent live birth who reported maternal health care utilization with 4+ 

ANC visits, SBA, and PNC services, as well as the trends in maternal health care-seeking across all three 

types of services. For 4+ ANC visits and SBA, the increases were significant and noteworthy. The 4+ ANC 

visits increased from 38% to 53%, while SBA increased by 16 percentage points (from 58% to 74%). 

However, there was only a slight, nonsignificant increase in PNC, from 61% to 63%. Combining all three 

indicators, the percentage of women who obtained all three services significantly increased from 28% to 

40%, a total of 12 percentage points. 

Figure 1 National trends in maternal health care-seeking in Pakistan, 2012-2018 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change. ANC = antenatal care; SBA = skilled birth attendance; PNC = postnatal care. 

3.1.2 Trends in high empowerment 

Figure 2 displays the percentage of currently married women age 15-49 with a birth in the past 2 years who 

reported high empowerment in terms of no problems accessing care and high empowerment related to 

attitude to violence, social independence, and decision-making SWPER domains. Unlike trends in maternal 

health care utilization, reported levels of high empowerment among Pakistani women between 2012-13 and 
9 

2017-18 have remained unchanged, except for one domain. For social independence, there was statistical 

evidence of an increase, from 31% to 36%. 

Figure 2 Trends in empowerment indicators in Pakistan, 2012-2018 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change. 
10 

3.2 Trends in the Relationship between Maternal Health Care-Seeking 

and Women’s Empowerment over Time 

This section presents an analysis of the relationship between dependent variables that reflect maternal health 

care-seeking and key independent variables of interest including the four domains of empowerment and the 

sociodemographic variables. 

3.2.1 Four or more antenatal visits 

Figure 3 (with supporting information in Appendix Table 1) shows that, as expected, there was a positive 

relationship between increasing levels of empowerment and having 4+ ANC visits, with the exception of 

the decision-making domain. Women with medium and high levels of empowerment for decision making 

had similar levels of 4+ ANC visits in 2017-18 (59% each). In 2012-13, unexpectedly, the use of 4+ ANC 

visits was highest among the medium empowerment domain (46%); however, based on non-overlapping 

confidence intervals (Appendix Table 1), this was not a significant difference. In 2017-18, there was a 24-

percentage point disparity in the use of ANC between high empowerment related to social independence 

(73%) and medium empowerment (49%), and a 40-percentage point difference in having 4+ ANC visits 

between women in high and low empowerment categories (33%). In 2017-18, there was a higher percentage 

of women who presented for four or more ANC visits if they reported having no problems accessing care 

(66%) than for women who reported at least one problem (48%). 

The disparities in care-seeking for ANC persisted over time, and as seen among all women, ANC utilization 

among women in each category of empowerment significantly increased over time. More specifically, 

among women with the highest level of empowerment on attitude to violence, 47% reported having 4+ 

ANC visits in 2012-13 compared with 63% in 2017-18, a 16-percentage point increase between the survey 

periods (p-value <0.001). Similarly, there was a 12-percentage point difference among women with low 

empowerment in the same domain, although only 37% of women in the low empowerment domain had 4+ 

ANC visits by 2017-18. 

Appendix Table 2 provides supporting information, including estimates, 95% CI, and the significance of 

the differences between independent factors, including sociodemographic characteristics, and 4+ ANC 

visits. Within each sociodemographic characteristic, the proportion of women with 4+ ANC visits varied 

significantly, and there was evidence of significant increases within each category between the two surveys, 

with the exception of the grand multiparous women (6 or more births), where there was not sufficient 

evidence of a significant increase. 

 
11 

Figure 3 The percentage of women with 4 or more antenatal care visits for their last pregnancy resulting 

in a live birth, according to domains and levels of empowerment 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change.
12 

The logistic regressions conducted in 2012-13 and 2017-18 (Table 3) show the significance of disparities 

between low, medium, and high empowerment with four or more ANC visits. In the unadjusted models, 

women with medium and high levels of empowerment were statistically more likely to have 4+ ANC visits 

compared with women with low empowerment. However, after controlling for region, wealth, and parity, 

which were also associated with the dependent variable in the adjusted models, women with high 

empowerment in the social independence and decision-making domains strongly predicted having 4+ ANC 

visits. Thus, in both 2012-13 and 2017-18, women with high social independence empowerment had twice 

the odds of having 4+ ANC visits compared with the least empowered women in this domain (2012-13 

AOR: 2.0; 95% CI: 1.5-2.8; 2017-18 AOR: 2.0, 95% CI: 1.4-2.7). Women in the high decision-making 

domain had a 30% increase in the odds in 2012-13 and a 40% increase in the odds in 2017-18 of having 4+ 

ANC visits than women in the low category of decision-making domain (2012-13 AOR: 1.3, 95% CI: 1.0-

1.7; 2017-18 AOR: 1.4, 95% CI: 1.1-1.9). In 2017-18 only, having no problems accessing care was 

associated (p<0.05) with a 30% increase in the odds of ANC (AOR: 1.3, 95% CI: 1.0-1.6); although the 

relationship was not significant in 2012-13 after controlling for covariates. Although these relationships 

were significant in adjusted models, the strength and magnitude were much attenuated compared with the 

unadjusted models. 

The strongest predictor of 4+ ANC visits in both years was wealth. Women in higher wealth quintiles were 

substantially more likely to have 4+ ANC visits. In 2017-18, women in the highest wealth quintile had 

nearly 16 times the odds of having 4+ ANC visits compared with women in the lowest wealth quintile 

(AOR: 15.7, 95% CI: 9.5-26.0). Parity also strongly and consistently predicted 4+ ANC visits in both 

surveys. Women who were pregnant or gave birth to higher order children of any grouping (2-3, 4-5, or 6 

or more) were less likely to have 4+ ANC visits compared with women whose pregnancy resulted in their 

first live birth. In 2017-18, women with 6 or more births had 50% reduced odds of completing 4+ ANC 

visits compared with women in their first pregnancy (AOR: 0.5; 95% CI: 0.3-0.7). 

The relationship between 4+ ANC visits and empowerment, wealth, and parity remained relatively constant 

between the two surveys, although the magnitude of the relationship between lowest and each of the higher 

(second, middle, second highest, highest) wealth quintiles grew over time. However, the magnitude of 

relationship between region and 4+ ANC visits diminished over time. In 2017-18, women in Balochistan 

had a 50% reduced odds of having 4+ ANC visits compared with women in Punjab (AOR: 0.5; 95% CI: 

0.3-0.7), while women in both Sindh and ICT Islamabad had greater odds of receipt of care compared with 

women in Punjab, although the significance was marginal (p-value<0.05). 

 
13 

Table 3 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% confidence 

intervals (CI) of attending 4 or more antenatal care visits during the last pregnancy 

 2012-13 2017-18 

Variable UOR 95% CI AOR 95% CI UOR 95% CI AOR 95% CI 

Empowerment 

Problems accessing care (ref=at least one) None 1.8*** [1.4,2.2] 0.9 [0.7,1.2] 2.1*** [1.7,2.6] 1.3* [1.0,1.6] 

SWPER 

Attitude to violence (ref=low) Medium 1.7** [1.2,2.3] 1.1 [0.8,1.6] 1.6** [1.2,2.3] 1.2 [0.9,1.7] 

High 2.6*** [2.1,3.3] 1.3* [1.0,1.7] 2.9*** [2.3,3.7] 1.3 [1.0,1.7] 

Social independence (ref=low) Medium 1.6*** [1.2,2.1] 1.2 [0.9,1.6] 2.0*** [1.6,2.5] 1.2 [0.9,1.6] 

High 5.2*** [4.0,6.8] 2.0*** [1.5,2.8] 5.5*** [4.3,7.2] 2.0*** [1.4,2.7] 

Decision making (ref=low) Medium 1.7*** [1.3,2.1] 1.3 [1.0,1.7] 1.7*** [1.3,2.1] 1.4* [1.0,1.8] 

High 1.3* [1.0,1.6] 1.3* [1.0,1.7] 1.7*** [1.4,2.1] 1.4* [1.1,1.9] 

 

Background characteristics 

Place of residence (ref= rural) Urban 4.3*** [3.2,5.7] 1.2 [0.9,1.6] 3.3*** [2.5,4.4] 1.1 [0.8,1.5] 

Region (ref=Punjab) Sindh 1.1 [0.8,1.4] 1.7*** [1.3,2.2] 0.7 [0.5,1.1] 1.4* [1.0,1.9] 

Khyber Pakhtunkhwa 0.5*** [0.4,0.7] 0.8 [0.6,1.0] 0.6* [0.4,0.9] 1.2 [0.8,1.6] 

Balochistan 0.2*** [0.1,0.3] 0.4*** [0.2,0.6] 0.2*** [0.1,0.3] 0.5** [0.3,0.7] 

ICT Islamabad 6.0*** [4.0,9.0] 2.7*** [1.8,4.1] 3.1*** [1.9,5.1] 1.6* [1.0,2.4] 

Wealth quintile (ref=lowest) Second 2.0*** [1.4,2.9] 2.1*** [1.4,3.1] 2.3*** [1.6,3.2] 2.4*** [1.7,3.4] 

Middle 3.1*** [2.2,4.3] 2.7*** [1.8,4.0] 3.9*** [2.8,5.6] 3.4*** [2.3,5.1] 

Fourth 7.0*** [5.1,9.7] 5.0*** [3.3,7.6] 10.3*** [7.1,14.7] 7.2*** [4.6,11.2] 

Highest 26.1*** [17.4,39.3] 14.6*** [9.0,23.7] 27.7*** [18.1,42.4] 15.7*** [9.5,26.0] 

Age at birth (ref=20-34) <20 0.8 [0.6,1.1] 1.0 [0.6,1.5] 0.7** [0.5,0.9] 0.9 [0.6,1.3] 

35-49 0.6*** [0.5,0.8] 0.9 [0.6,1.2] 0.6** [0.4,0.8] 1.0 [0.7,1.5] 

Parity (ref=first child) 2-3 0.6*** [0.5,0.8] 0.6** [0.5,0.8] 0.7** [0.5,0.9] 0.6** [0.5,0.8] 

4-5 0.4*** [0.3,0.5] 0.5*** [0.3,0.7] 0.5*** [0.4,0.6] 0.6** [0.4,0.8] 

6+ 0.3*** [0.2,0.4] 0.6* [0.4,0.9] 0.3*** [0.2,0.3] 0.5** [0.3,0.7] 

Notes: *p<0.05, **p<0.01, ***p<0.001 

3.2.2 Skilled birth attendance 

The overall percentage of Pakistani women who experienced SBA increased as did the percentage of 

women with SBA according to each domain and category of empowerment (see Figure 4). Appendix 

Table 3 provides estimates, confidence intervals, the percentage point differences between surveys, and the 

p-values that represent the significance of the differences between characteristics and the dependent 

variable, as well as the significance of change over time. In terms of attitude toward violence, social 

independence, and problems accessing care, women with high empowerment had higher utilization of SBA 

compared with women in medium and low empowerment categories in the respective domains. The largest 

disparities, which persisted across the two surveys, were apparent within the domain of social 

independence. In 2012-13, there was a 32-percentage point gap between the highest and the lowest levels 

of empowerment (77% and 45%, respectively). This gap narrowed slightly to 27 percentage points by 2017-

18, although both categories of empowerment showed a significant increase in utilization of SBA (87% 

among the high empowerment category and 60% among low empowerment). In terms of decision making, 

while there was a similar pattern of an increase of utilization of SBA services, there was no significant 

difference between categories of empowerment in 2012-13. By 2017-18, however, this disparity widened, 
14 

in which 80% of women with high empowerment had an SBA compared with 69% of women with low 

empowerment. 

As shown in Appendix Table 3, utilization of maternal health care services rose by over 10 percentage 

points among nearly all characteristics. There was strong statistical evidence of a change in women’s SBA 

utilization in Balochistan, with the largest surge of 24 percentage points relative to observed increases in 

SBA utilization in other regions in our analysis (p<0.001). In addition, there is strong statistical evidence 

of an association (p<0.001) between SBA and wealth, education, and parity across the 5-year period. 

Figure 4 The percentage of women reported skilled birth attendance during their last live birth, according 

to domains and levels of empowerment 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change. 
15 

The differences between levels of empowerment in SBA, as seen in Figure 4, Appendix Table 3, and in the 

unadjusted logistic regression models in Table 4, were largely not significant after controlling for key 

sociodemographic variables in both surveys, except for high social independence. In 2012-13 and 2017-18, 

women with high social independence empowerment had a 70% and 60% increase in the odds of having an 

SBA compared with the women with low social independence, respectively (2012-13 AOR: 1.7, 95% CI: 

1.2-2.2; 2017-18 AOR: 1.6, 95% CI: 1.1-2.4). Similar to 4+ ANC visits, the magnitude of the association 

between higher wealth and SBA was large. In 2017-18, for example, women in the highest wealth quintile 

had eight times higher odds of having an SBA at delivery compared with women in the lowest wealth 

quintile (AOR: 8.1, 95% CI: 4.4-14.9). Unlike 4+ ANC visits, however, higher parity was not a stronger 

predictor of having an SBA, a relationship that may have been attenuated given the inclusion of earlier 

maternal care-seeking. This model also controlled for having had 4+ ANC visits in the pregnancy resulting 

in this birth. In both surveys, we found that women who had 4+ ANC visits had 3 times the odds or higher 

of delivering with an SBA compared with women who had fewer than 4 visits (2012-13 AOR: 3.0, 95% CI: 

2.4-3.8; 2017-18 AOR: 3.5, 95% CI: 2.7-4.6). 

Between the two surveys, the relationships between the independent variables and SBA did not change 

across most covariates, except for region and parity. In 2012-13, women residing in ICT Islamabad were 

significantly more likely to deliver with an SBA compared with women in Punjab (AOR: 2.1, 95% CI: 1.2-

3.5) and in 2017-18, there was no difference. Women with higher parity were significantly less likely to 

deliver with an SBA in 2012-13, while in 2017-18 the relationship trended in the same direction. The 

associations were largely not significant in the adjusted model. 

 
16 

Table 4 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% confidence 

intervals (CI) of skilled attendance at birth during the last live birth 

2012-13 2017-18 

Variable UOR 95% CI AOR 95% CI UOR 95% CI AOR 95% CI 

Empowerment 

Problems accessing care (ref=at least one) None 1.7*** [1.3,2.2] 1.1 [0.9,1.5] 1.9*** [1.4,2.7] 1.0 [0.7,1.4] 

SWPER 

Attitude to violence (ref=low) Medium 1.3 [1.0,1.8] 1.0 [0.7,1.4] 1.2 [0.9,1.7] 0.9 [0.6,1.2] 

High 2.0*** [1.6,2.5] 1.2 [1.0,1.6] 2.5*** [1.9,3.3] 1.2 [0.9,1.6] 

Social independence (ref=low) Medium 1.3* [1.1,1.7] 1.0 [0.8,1.3] 1.8*** [1.4,2.3] 1.3 [1.0,1.7] 

High 4.1*** [3.1,5.5] 1.7** [1.2,2.2] 4.4*** [3.3,5.7] 1.6* [1.1,2.4] 

Decision making (ref=low) Medium 1.4* [1.0,1.9] 1.1 [0.8,1.5] 1.5** [1.1,2.0] 1.1 [0.8,1.5] 

High 1.1 [0.9,1.4] 1.1 [0.8,1.5] 1.7*** [1.3,2.2] 1.2 [0.9,1.7] 

Earlier maternal health care-seeking 

Antenatal care, 4 visits (ref=no) Yes 5.7*** [4.5,7.3] 3.0*** [2.4,3.8] 7.0*** [5.5,9.0] 3.5*** [2.7,4.6] 

 

Background characteristics 

Place of residence (ref= rural) Urban 2.9*** [2.1,4.0] 0.7 [0.5,1.1] 3.3*** [2.4,4.7] 1.2 [0.8,1.7] 

Region (ref=Punjab) Sindh 1.3 [1.0,1.8] 2.2*** [1.5,3.3] 1.0 [0.7,1.5] 1.9** [1.2,2.8] 

Khyber Pakhtunkhwa 0.8 [0.5,1.1] 1.3 [0.9,1.8] 0.7* [0.4,1.0] 1.0 [0.7,1.6] 

Balochistan 0.2*** [0.1,0.3] 0.3*** [0.2,0.5] 0.2*** [0.1,0.3] 0.4*** [0.3,0.7] 

ICT Islamabad 5.5*** [3.3,9.4] 2.1** [1.2,3.5] 2.5** [1.3,4.7] 1.0 [0.6,1.9] 

Wealth quintile (ref=lowest) Second 1.5** [1.1,2.1] 1.5* [1.0,2.1] 1.5** [1.1,2.0] 1.5* [1.1,2.0] 

Middle 2.5*** [1.8,3.7] 2.2*** [1.5,3.3] 3.6*** [2.6,5.0] 2.9*** [2.0,4.1] 

Fourth 5.2*** [3.6,7.4] 3.7*** [2.4,5.7] 5.9*** [3.8,9.0] 3.0*** [1.8,4.8] 

Highest 14.8*** [8.9,24.8] 7.0*** [3.7,13.2] 23.0*** [13.7,38.5] 8.1*** [4.4,14.9] 

Age at birth (ref=20-34) <20 1.1 [0.8,1.5] 1.2 [0.8,1.9] 0.9 [0.6,1.3] 1.3 [0.8,2.0] 

35-49 0.6*** [0.5,0.8] 0.9 [0.7,1.2] 0.6* [0.4,0.9] 0.9 [0.6,1.4] 

Parity (ref=first child) 2-3 0.6*** [0.5,0.7] 0.7* [0.5,0.9] 0.7** [0.5,0.9] 0.8 [0.5,1.1] 

4-5 0.4*** [0.3,0.5] 0.5*** [0.4,0.7] 0.4*** [0.3,0.6] 0.6* [0.4,0.9] 

6+ 0.3*** [0.2,0.3] 0.5** [0.3,0.7] 0.3*** [0.2,0.4] 0.7 [0.4,1.1] 

Notes: *p<0.05, **p<0.01, ***p<0.001 

3.2.3 Postnatal care 

Unlike 4+ ANC visits and SBA, levels of PNC utilization within 2 days of delivery generally have not 

increased between 2012-13 and 2017-18. Overall levels of PNC, as well as levels of PNC within nearly all 

domains and levels of empowerment, remain unchanged at both time points (see Figure 5). The one 

exception was the SWPER decision-making domain. There was good evidence (p<0.01) of an 8-percentage 

point increase in PNC utilization among women with high decision-making empowerment from 2012-13 

to 2017-18, at 63% and 72%, respectively. 

As Appendix Table 4 shows, although changes over time were not significant, similar to 4+ ANC visits and 

SBA, there are significant gaps in PNC between the most and least empowered. Again, the largest disparities 

were noted in the SWPER domain of social independence, where in 2017-18, 76% of women with high 

empowerment received PNC versus 48% of women with low empowerment. Within both surveys, there 

was evidence of an association between PNC and most sociodemographic characteristics, including place 

of residence, region, wealth quintile, education, age at birth, and parity (2017-18 only). We identified 
17 

notable differences in the receipt of PNC based on earlier maternal health care-seeking behavior, including 

4+ ANC visits as well as SBA. 

Figure 5 The percentage of women receiving a postnatal check within 2 days of delivery, according to 

domains and levels of empowerment 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change. 
18 

As Table 5 shows, after controlling for a number of factors that could be associated with PNC care in logistic 

regression models, we found associations that diverted from those seen when examining 4+ ANC visits and 

SBA. For measures of empowerment, we found that decision-making empowerment was strongly 

associated with receipt of PNC within 2 days of delivery, but only in 2017-18. Women who had either 

medium or high empowerment related to decision making had a 70% increase in the odds of receiving PNC 

compared with women in the low empowerment category (both medium and high AOR: 1.7, 95% CI: 1.3-

2.3). In 2012-13, this was not significantly related in the adjusted model. Interestingly, the odds of having 

PNC were 30% lower for women who reported no problems in accessing care compared with those who 

reported having problems (AOR: 0.7, 95% CI: 0.5-0.9). The odds changed direction from the unadjusted 

model (AOR: 1.4, 95% CI: 1.1-1.9), indicating that the model includes an interaction between this variable 

and one or more covariates. 

Unlike 4+ ANC visits and SBA, however, wealth was not as strong of a predictor of receipt of PNC, 

although still significantly associated. The only quintile significantly different from the lowest quintile was 

the highest; women in the highest quintile had 3 times the odds of receiving PNC compared with women 

in the lowest (AOR: 2.9, 95% CI: 1.6-5.0). Although this is still high, the odds are lower than for other 

maternal health care services. Women in Khyber Pakhtunkhwa were more likely to receive PNC than 

women in Punjab in both years (2012-13 AOR: 0.3, 95% CI: 0.2-0.4; 2017-18 AOR: 0.5, 95% CI: 0.3-0.7). 

For these models that predict receipt of PNC, we included receipt of other maternal health care services, 

including 4+ ANC visits and SBA. Having delivered with an SBA was associated with a nearly 10-fold 

increase in the odds of receiving PNC, compared with women who delivered without an SBA in both 

surveys (2012-13 AOR: 9.4, 95% CI: 7.1-12.5; 2017-18 AOR: 9.7, 95% CI: 7.1-13.3). The large magnitude 

of this relationship likely attenuated that of the relationship between wealth and PNC. Having 4+ ANC 

visits was also significantly associated with receipt of PNC in both years as well, although not to the degree 

of having an SBA (2012-13 AOR: 1.6, 95% CI: 1.2-2.1; 2017-18 AOR: 1.5, 95% CI: 1.1-1.9). In addition 

to changes in the relationship between PNC and empowerment, the relationship between PNC and wealth 

grew stronger, which indicated growth in disparities as also seen in Figure 5. 
19 

Table 5 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% confidence 

intervals (CI) of a postnatal check after the last live birth 

2012-13 2017-18 

Variable UOR 95% CI AOR 95% CI UOR 95% CI AOR 95% CI 

Empowerment 

Problems accessing care (ref=at least one) None 1.9*** [1.5,2.3] 1.2 [1.0,1.6] 1.4** [1.1,1.9] 0.7* [0.5,0.9] 

SWPER 

Attitude to violence (ref=low) Medium 1.4* [1.0,1.8] 1.0 [0.7,1.4] 1.9*** [1.4,2.5] 1.6* [1.1,2.2] 

High 1.9*** [1.5,2.4] 1.0 [0.7,1.3] 2.7*** [2.2,3.4] 1.3 [1.0,1.7] 

Social independence (ref=low) Medium 1.1 [0.9,1.4] 0.8 [0.6,1.1] 1.6*** [1.3,2.0] 1.0 [0.7,1.3] 

High 2.6*** [2.0,3.3] 0.9 [0.7,1.3] 3.4*** [2.6,4.4] 1.2 [0.8,1.7] 

Decision making (ref=low) Medium 1.3* [1.0,1.7] 1.0 [0.7,1.3] 2.1*** [1.7,2.7] 1.7*** [1.3,2.3] 

High 1.3* [1.1,1.6] 1.1 [0.8,1.4] 2.3*** [1.8,2.9] 1.7*** [1.3,2.3] 

Earlier maternal health care-seeking 

Antenatal care, 4 visits (ref=no) Yes 3.8*** [3.1,4.6] 1.6*** [1.2,2.1] 3.9*** [3.1,4.9] 1.5** [1.1,1.9] 

Skilled attendant at birth (ref=no) Yes 10.9*** [8.4,14.0] 9.4*** [7.1,12.5] 13.7*** [10.1,18.6] 9.7*** [7.1,13.3] 

Background characteristics 

Place of residence (ref= rural) Urban 2.4*** [1.8,3.2] 1.1 [0.7,1.8] 2.5*** [1.9,3.3] 0.9 [0.7,1.3] 

Region (ref=Punjab) Sindh 1.0 [0.7,1.4] 0.9 [0.6,1.4] 1.2 [0.9,1.7] 1.6* [1.1,2.4] 

Khyber Pakhtunkhwa 0.3*** [0.2,0.4] 0.3*** [0.2,0.4] 0.4*** [0.3,0.5] 0.5** [0.3,0.7] 

Balochistan 0.3*** [0.2,0.4] 0.9 [0.5,1.5] 0.3*** [0.2,0.5] 0.9 [0.6,1.4] 

ICT Islamabad 1.8** [1.2,2.8] 0.6 [0.4,1.0] 1.9** [1.2,3.0] 0.9 [0.6,1.6] 

Wealth quintile (ref=lowest) 

Second 1.6** [1.2,2.2] 1.5* [1.1,2.1] 1.1 [0.8,1.4] 0.9 [0.6,1.3] 

Middle 1.9*** [1.4,2.6] 1.2 [0.8,1.7] 1.8** [1.3,2.6] 1.1 [0.7,1.6] 

Fourth 3.6*** [2.4,5.2] 1.4 [0.9,2.2] 3.3*** [2.2,4.8] 1.5 [1.0,2.4] 

Highest 6.2*** [4.2,9.0] 1.4 [0.8,2.4] 8.5*** [5.5,13.1] 2.9*** [1.6,5.0] 

Age at birth (ref=20-34) <20 0.9 [0.7,1.3] 0.9 [0.5,1.5] 0.6** [0.5,0.9] 0.8 [0.5,1.2] 

35-49 0.8 [0.6,1.0] 1.2 [0.8,1.7] 0.7* [0.5,0.9] 1.1 [0.7,1.6] 

Parity (ref=first child) 2-3 0.7** [0.6,0.9] 0.9 [0.7,1.1] 0.9 [0.7,1.1] 1.0 [0.7,1.4] 

4-5 0.5*** [0.4,0.7] 0.8 [0.6,1.2] 0.6** [0.5,0.8] 0.9 [0.6,1.3] 

6+ 0.5*** [0.4,0.6] 0.8 [0.5,1.3] 0.4*** [0.3,0.5] 0.6 [0.4,1.0] 

Notes: *p<0.05, **p<0.01, ***p<0.001 

 
20 

3.2.4 All three critical maternal health contacts 

Figure 6 shows that the disparities between measures of empowerment were more pronounced when 

examining our composite indicator of receipt of critical maternal health care services for 4+ ANC visits, 

SBA, and PNC. In each survey, higher levels of empowerment among the domains of attitude to violence, 

social independence, decision making, and problems accessing care show strong statistical evidence of an 

association with utilizing all four maternal health care services. For example, there was a 41-percentage 

point difference between women with high empowerment of social independence (60% had all three 

services) than women with low empowerment (19%), which was greater than the disparities seen when 

examining empowerment and any of the three services separately. Women with both medium and high 

levels of empowerment for decision making had similar attainment of all three critical maternal health care 

contacts in 2017-18, and both groups had greater attainment than women with lower decision-making 

empowerment. However, in 2012-13, medium decision making had the highest attainment (35%), though 

overlapping confidence intervals suggest the difference was not necessarily significant (Appendix Table 6). 

All sociodemographic characteristics and empowerment domains of interest were strongly associated with 

all three critical maternal health contacts. Further, we saw significant gains in the use of all three services 

over time across most characteristics and within empowerment domains. Only use among grand 

multiparous women (women with 6+ children) and women in ICT Islamabad lacked evidence of a 

significant change. Appendix Table 6 presents additional information about these characteristics. 

Combining all three critical points of service for women during pregnancy, childbirth, and the early 

postpartum period, we found amplified associations between critical maternal health care and measures of 

empowerment and wealth (Table 6). High empowerment among every SWPER domain of empowerment, 

and medium empowerment for social independence and decision making were significantly associated with 

receipt of all three services compared with low empowerment in the respective domains. For social 

independence, the odds of receiving all three services in 2017-18 were two times higher among the highly 

empowered women (AOR: 2.1, 95% CI: 1.5-2.9), compared with the least empowered women, and 40% 

higher when comparing the medium category to the lowest (AOR: 1.4, 95% CI: 1.0, 2.0). For both medium 

and high empowered women in the decision-making domain, the odds were 50% greater comparing each 

with the least empowered (medium and high AOR: 1.5, 95% CI: 1.2-2.0;). For the attitude towards violence 

as well, women in the highest empowered group had a 60% increase in the odds of having all three contacts 

compared with the lowest empowered group (AOR: 1.6, 95% CI: 1.2-2.0). The magnitude of the 

associations between higher wealth quintiles compared with the lowest quintile reference group were 

considerably large. In 2017-18, the odds of receiving all three health services were 15 times those of women 

in the lowest quintile, although less than the odds in 2012-13, where women in the wealthiest quintile had 

nearly 19 times greater odds of receiving all three services (2012-13 AOR: 18.7 95% CI: 11.1-31.5; 2017-

18 AOR: 14.9, 95% CI: 9.0-24.8). Parity and region were also significantly associated in these models in 

both years. 
21 

Figure 6 The percentage of women receiving all three maternal care contacts and measures of 

empowerment, according to domains and levels of empowerment 

Note: A solid line indicates a significant change between two surveys, while a dotted line indicates no significant 

change. 

 
22 

Table 6 Unadjusted odds ratios (UOR), adjusted odds ratios (AOR), and 95% confidence 

intervals (CI) of receipt of 3 critical maternal health services 

2012-13 2017-18 

Variable UOR 95% CI AOR 95% CI UOR 95% CI AOR 95% CI 

Empowerment 

Problems accessing care (ref=at least one) None 2.0*** [1.6,2.6] 1.0 [0.8,1.3] 2.0*** [1.6,2.5] 1.1 [0.9,1.4] 

SWPER 

Attitude to violence (ref=low) Medium 1.8** [1.3,2.6] 1.1 [0.8,1.6] 2.0*** [1.4,2.7] 1.4 [1.0,1.9] 

High 3.1*** [2.4,4.1] 1.4* [1.1,1.9] 3.8*** [3.0,4.8] 1.6** [1.2,2.0] 

Social independence (ref=low) Medium 1.5** [1.2,2.0] 1.0 [0.8,1.4] 2.6*** [1.9,3.5] 1.4* [1.0,2.0] 

High 6.1*** [4.6,8.0] 2.2*** [1.5,3.1] 6.5*** [5.0,8.4] 2.1*** [1.5,2.9] 

Decision making (ref=low) Medium 1.8*** [1.4,2.4] 1.4* [1.1,1.9] 2.0*** [1.5,2.5] 1.5** [1.2,2.0] 

High 1.3* [1.1,1.7] 1.4* [1.0,1.8] 2.0*** [1.6,2.4] 1.5** [1.2,2.0] 

 

Background characteristics 

Place of residence (ref= rural) Urban 4.4*** [3.2,5.9] 1.0 [0.7,1.3] 3.2*** [2.4,4.3] 1.0 [0.8,1.3] 

 

Region (ref=Punjab) Sindh 1.2 [0.9,1.6] 2.0*** [1.5,2.7] 0.8 [0.6,1.2] 1.6** [1.1,2.1] 

Khyber Pakhtunkhwa 0.5*** [0.3,0.6] 0.8 [0.6,1.1] 0.4*** [0.3,0.6] 0.8 [0.5,1.1] 

Balochistan 0.1*** [0.1,0.2] 0.3*** [0.2,0.5] 0.2*** [0.1,0.3] 0.4*** [0.3,0.7] 

ICT Islamabad 4.9*** [3.3,7.2] 2.0*** [1.4,2.9] 2.9*** [1.9,4.4] 1.6* [1.0,2.4] 

Wealth quintile (ref=lowest) Second 2.4*** [1.6,3.6] 2.5*** [1.6,3.8] 1.9*** [1.4,2.7] 2.1*** [1.4,3.2] 

Middle 3.6*** [2.3,5.7] 3.3*** [2.1,5.1] 3.5*** [2.4,4.9] 3.2*** [2.1,4.8] 

Fourth 9.7*** [6.4,14.8] 7.4*** [4.7,11.5] 9.5*** [6.5,13.8] 6.8*** [4.3,10.9] 

Highest 32.2*** [20.3,51.1] 18.7*** [11.1,31.5] 24.6*** [16.7,36.2] 14.9*** [9.0,24.8] 

Age at birth (ref=20-34) <20 0.7* [0.5,1.0] 0.9 [0.6,1.5] 0.6*** [0.4,0.8] 0.9 [0.6,1.3] 

35-49 0.6** [0.5,0.8] 1.0 [0.7,1.5] 0.6** [0.4,0.8] 1.0 [0.6,1.5] 

Parity (ref=first child) 2-3 0.7** [0.5,0.8] 0.7* [0.5,0.9] 0.7* [0.6,0.9] 0.7* [0.5,1.0] 

4-5 0.4*** [0.3,0.5] 0.5*** [0.3,0.7] 0.5*** [0.4,0.6] 0.6** [0.4,0.8] 

6+ 0.3*** [0.2,0.4] 0.6* [0.4,0.9] 0.2*** [0.2,0.3] 0.5** [0.3,0.7] 

Notes: *p<0.05, **p<0.01, ***p<0.001 
23 

4 DISCUSSION AND CONCLUSION 

4.1 Overview and Findings in Context 

This study examined trends in maternal health care-seeking, empowerment, and their relationships over 

time. Overall, we found maternal health care-seeking among currently married Pakistani women has 

increased between the 2012-13 and 2017-18 Pakistan DHS surveys for 4+ ANC visits and SBA, but not for 

PNC care within 2 days of delivery. We also found evidence of significant gains for the percent of women 

who obtained all three services. In contrast, evidence of women’s empowerment has not shown marked 

improvement, except for the domain of social independence, which reflects reading the newspaper or 

magazines, age at first birth, education, and age and education differentials between husband and wife. 

Further, with the exception of PNC, social independence was significantly associated with receipt of the 

maternal health care indicators examined in this study, even after controlling for sociodemographic 

characteristics. For PNC, the empowerment domain that most strongly predicted receipt of care was 

decision making. Although decision making also predicted ANC and the composite indicator of all three 

services, the magnitude and strength of the association were greater for social independence in these 

models. However, the adjusted logistic regressions revealed that the strongest predictor of receipt of care 

was wealth, where increasing wealth was associated with drastically increased odds of care-seeking. In 

addition, prior maternal health care-seeking was strongly associated with receipt of maternal care along the 

continuum of services, such as having an SBA at delivery, which was associated with much higher odds of 

receiving PNC than delivering without an SBA. Finally, women pregnant or delivering higher order 

children versus the first child were less likely to obtain care, even for PNC, and after controlling for wealth, 

previous care-seeking, and empowerment. 

Our study reaffirms similar relationships found in the literature that shows similar predictors of maternal 

health care-seeking globally and in Pakistan. The literature has established that women’s decision-making 

power is a strong predictor of care-seeking behavior among Pakistani women and has a positive relationship 

with the recommended ANC, SBA during delivery, and PNC (Agha and Carton 2011; Hou and Ma 2012). 

Hearld et al. (2018) find a positive association between empowerment, education, and maternal health 

services in Pakistan using an index of empowerment that included items related to decision making and 

whether a woman reports problems accessing care. Similar to Hearld’s 2018 study, we found that the social 

independence domain of empowerment, which reflects education, reading print media, and differentials 

between husband and wife, was associated with ANC, SBA, and the composite indicator of all three 

services. In addition, there is a well-known connection between socioeconomic status and health care 

utilization globally (Ahmed et al. 2010; Ewerling et al. 2017). Previous national and provincial level 

research studies conducted in Pakistan show that wealth inequality was a constant predictor of utilization 

of recommended ANC as well as other maternal health services (Agha and Carton 2011; Agha and Tappis 

2016; Hearld, Anderson, and Budhwani 2018; Noh et al. 2019; Sahito and Fatmi 2018). 

Definitions of empowerment imply that access to resources is a critical component of a woman’s agency to 

act upon her own choices, although Kabeer (2005) notes that programs which provide financial services for 

the poor do not guarantee women’s empowerment. However, evidence shows that wealth is a strong, 

positive predictor of empowerment (Akram 2018; Osamor and Grady 2016). Although wealth and 

empowerment are both independently associated with the outcomes, more research is necessary to 
24 

disentangle these relationships (Ewerling et al. 2017). Both factors are important in care-seeking as seen in 

our study and others (Ahmed et al. 2010; Hearld, Anderson, and Budhwani 2018), and both should be 

addressed in tandem. 

While wealth and empowerment prominently predict maternal health care-seeking, our study also supports 

previous research which highlights the importance of the entirety of the continuum of care, and the role of 

obtaining ANC in having skilled care at birth, and the importance of both in receipt of PNC (Iqbal et al. 

2017). One study conducted in Islamabad found that previous care-seeking behavior leads to better 

utilization of maternal health care services and revealed that women who had ANC were more likely to 

have PNC compared to women who had no ANC (Naseem et al. 2017). Since the time around delivery—

during and after labor—is the time when most maternal deaths disproportionately occur (Ronsmans, 

Graham, and group 2006), early and adequate ANC should also be supported as a means not only to monitor 

the pregnancy, but also to promote later care during that critical window around childbirth. Antenatal care 

is the primary, most critical component within the continuum of care for maternal health (Singh, Story, and 

Moran 2016). 

The present study found that parity is also a strong predictor of maternal health care seeking. This finding 

is also well supported by other research globally (Sonneveldt, DeCormier Plosky, and Stover 2013) and in 

Pakistan. In accordance with the literature from the region, parity is consistently associated with the usage 

of maternal health care services, including ANC (Agha and Tappis 2016; Sahito and Fatmi 2018) and 

institutional delivery (Agha 2011). This indicates that, in this resource limited setting, women with higher 

parity take advantage of their previous experience, knowledge of pregnancy and delivering, and limited 

resources to avail themselves of health care services for their subsequent pregnancies and births, especially 

if they have not faced any complications during previous pregnancies (Celik and Hotchkiss 2000; Elo 

1992). 

4.2 Strengths and Limitations 

While most studies include only one or two components of empowerment, this study uses the 

multidimensional SWPER index, as well as a fourth measure of empowerment, to examine the trends and 

the relationship between empowerment and maternal health care-seeking over time in Pakistan. After 

examining two rounds of surveys, the study provides novel evidence of limited changes in women’s 

empowerment in Pakistan. Findings from this analysis highlight the need for future research and programs 

that focus on the multiple dimensions of empowerment, and also address the economic disparities that so 

strongly predict receipt of critical maternal health services. 

This study has some limitations. First, although the Pakistan survey was designed to include a nationally 

representative sample, this study did not examine all regions that were sampled in both surveys. Given the 

focus on trends over time, we limited the study to areas that were sampled consistently between the two 

most recent surveys. Therefore, the results of our study cannot be said to represent Pakistan as a whole. In 

addition, the analysis was not all inclusive of all aspects of empowerment, especially at the community or 

societal level. For example, while community acceptability of patriarchal cultural norms may play an 

important role in women’s empowerment, our analysis was limited by the unavailability of related factors. 

Finally, our adjusted regression models did not include all potential influencing factors or barriers to care, 
25 

such as proximity to health facilities, transportation, or a history of or current complications that could 

potentially influence a woman’s care-seeking behavior. 

4.3 Recommendations 

As our findings imply, health care-seeking may be strengthened by increasing Pakistani women’s 

empowerment and economic status. Future efforts, including research, should strive to understand the effect 

of improving both simultaneously, with concentration on the social independence domain. Ahmed et al 

(2010) noted the synergistic potential of a multi-pronged approach—addressing economic security, 

education, and empowerment—on improving maternal health care utilization. Pro-poor cash transfer 

programs or voucher schemes may encourage women to utilize services and would be well-suited for 

encouraging early ANC given the link between ANC and SBA. Earlier voucher schemes were shown to 

increase the use of antenatal, delivery, and postnatal services in Pakistan (Agha 2011). An impact evaluation 

of a cash transfer program in India successfully encouraged maternal health service utilization and reduced 

perinatal and neonatal deaths. However, the authors noted the program’s difficulty reaching the poorest 

women and suggested that cultural barriers prevented women’s use of care services (Lim et al. 2010). 

It is critical that these pro-poor efforts also address empowerment, promote services among women with 

higher parity, and encourage timely use of maternal healthcare services. Ambler and De Brauw (2017) found 

that the Benazir Income Support Program (BISP), a program that provided income support for the poorest 

households, was associated with women’s empowerment, while other research by Tahir et al. (2018) cited 

the BISP program’s limited success at addressing empowerment. Both Tahir et al. and Mumtaz et al. (2014) 

note the need to address the underlying societal structures that prohibit women’s empowerment and the 

ability to obtain care. Mumtaz et al. (2014) cite the challenging dynamic of the caste structure in preventing 

the success of cash transfer programs and other community empowerment efforts, and they suggest that 

programs aimed at reducing financial barriers will not reach their full potential unless the root issues of the 

marginalized poor are addressed. 

Given the importance of earlier ANC in continued adherence to care during pregnancy and childbirth, 

stakeholders should consider investing in programs that promote women’s empowerment—including 

decision making and social independence—and economic status in targeting timely, comprehensive ANC 

as a means of also promoting SBA and PNC. Finally, since maternal mortality is due in part to lower 

maternal health care-seeking among women with higher parity (Sonneveldt, DeCormier Plosky, and Stover 

2013), efforts should incorporate focused targeting of this population as well. 

4.4 Conclusion 

This study examined the relationships between maternal health care-seeking and multiple domains of 

empowerment over time. Our analyses found that the social independence domain of empowerment, which 

reflects a women’s engagement with print media, education, and differentials in age and education between 

a woman and her husband, was strongly associated with ANC care and skilled attendance at birth, while a 

woman’s decision making empowerment was, to a lesser extent, also associated with care-seeking. 

Moreover, the magnitude and strength of the associations between wealth and each maternal health careseeking outcome was much stronger than the associations with empowerment. Parity and previous careseeking along the continuum of maternal care are also strongly linked to the receipt of maternal health care 

services. This study provides insight into specific populations to target for improving in women’s access to 
26 

care, including the poorest, least empowered women who have already experienced childbirth. The results 

further point to the need to focus on timely initiation of ANC to promote service utilization along the 

continuum of care. Nevertheless, contact with the health system alone is not enough to prevent maternal 

morbidity and mortality. Assuring that enough sufficiently trained health workers are equipped with lifesaving technologies at facilities that are accessible to women is vital to maternal health. 
27 

REFERENCES 

Agha, S. 2011. “Impact of a Maternal Health Voucher Scheme on Institutional Delivery among Low 

Income Women in Pakistan.” Reproductive Health 8(1):10. 

Agha, S., and T. W. Carton. 2011. “Determinants of Institutional Delivery in Rural Jhang, Pakistan.” 

International Journal for Equity in Health 10(1):31. 

Agha, S., and H. Tappis. 2016. “The Timing of Antenatal Care Initiation and the Content of Care in 

Sindh, Pakistan.” BMC Pregnancy and Childbirth 16(1):190. 

Ahmed, S., A. A. Creanga, D. G. Gillespie, and A. O. Tsui. 2010. “Economic Status, Education and 

Empowerment: Implications for Maternal Health Service Utilization in Developing Countries.” PLOS 

One 5(6). 

Akram, N. 2018. “Women’s Empowerment in Pakistan: Its Dimensions and Determinants.” Social 

Indicators Research 140(2):755-775. 

Al Riyami, A., M. Afifi, and R. M. Mabry. 2004. “Women's Autonomy, Education and Employment in 

Oman and Their Influence on Contraceptive Use.” Reproductive Health Matters 12(23):144-154. 

Ambler, K., and A. De Brauw. 2017. The Impacts of Cash Transfers on Women’s Empowerment: 

Learning from Pakistan’s BISP Program: World Bank. 

Celik, Y., and D. R. Hotchkiss. 2000. “The Socio-Economic Determinants of Maternal Health Care 

Utilization in Turkey.” Social Science & Medicine 50(12):1797-1806. 

Do, M., and N. Kurimoto. 2012. “Women's Empowerment and Choice of Contraceptive Methods in 

Selected African Countries.” International Perspectives on Sexual and Reproductive Health:23-33. 

Elo, I.T. 1992. “Utilization of Maternal Health-Care Services in Peru: The Role of Women's Education.” 

Health Transition Review:49-69. 

Ewerling, F., J. W. Lynch, C. G. Victora, A. van Eerdewijk, M. Tyszler, and A. J. Barros. 2017. “The 

Swper Index for Women's Empowerment in Africa: Development and Validation of an Index Based on 

Survey Data.” The Lancet Global Health 5(9):e916-e923. 

Ewerling, F., A. Raj, C. G. Victora, F. Hellwig, C. V. Coll, and A. Barros. 2019. “A Survey-Based 

Women's Empowerment Index for Low-and Middle-Income Countries: The Swper Goes Global.” 

Available at SSRN 3466986. 

Government of Pakistan. 2010. National Program for Maternal, Newborn and Child Health (2006-2012), 

Government of Pakistan’s Initiative for Millennium Developments Goals 4 and 5. Islamabad, Pakistan: 

Ministry of Health. 
28 

Government of Pakistan. 2016. National Health Vision Pakistan 2016-2025. Islamabad: Pakistan: 

Ministry of Health. 

http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/pakistan/national_he

alth_vision_2016-25_30-08-2016.pdf. 

Hafeez, A., B. K. Mohamud, M. R. Shiekh, S. A. I. Shah, and R. Jooma. 2011. “Lady Health Workers 

Programme in Pakistan: Challenges, Achievements and the Way Forward.” JPMA: Journal of the 

Pakistan Medical Association 61(3):210. 

Hearld, K. R., J. L. Anderson, and H. Budhwani. 2018. “Examining the Relationship between Individual 

Characteristics, Community-Level Traits, Multidimensional Empowerment, and Maternal Health Care 

Utilization in the Islamic Republic of Pakistan.” Maternal and Child Health Journal 22(9):1319-1326. 

Hou, X., and N. Ma. 2012. “The Effect of Women’s Decision-Making Power on Maternal Health 

Services Uptake: Evidence from Pakistan.” Health Policy and Planning 28(2):176-184. 

Iqbal, S., S. Maqsood, R. Zakar, M. Z. Zakar, and F. Fischer. 2017. “Continuum of Care in Maternal, 

Newborn and Child Health in Pakistan: Analysis of Trends and Determinants from 2006 to 2012.” BMC 

Health Services Research 17(1):189. 

Kabeer, N. 2001. “Reflections on the Measurement of Women’s Empowerment.” In Discussing Women's 

Empowerment Theory and Practice. Stockholm: SIDA: Swedish International Development Cooperation 

Agency. 

Kabeer, N. 2005. “Is Microfinance a “Magic Bullet” for Women's Empowerment? Analysis of Findings 

from South Asia.” Economic and Political weekly:4709-4718. 

Khan, M. T., S. Zaheer, and K. Shafique. 2017. “Maternal Education, Empowerment, Economic Status 

and Child Polio Vaccination Uptake in Pakistan: A Population Based Cross Sectional Study.” BMJ Open

7(3):e013853. 

Kishor, S. 2000. “Empowerment of Women in Egypt and Links to the Survival and Health of Their 

Infants.” 

Kishor, S., and L. Subaiya. 2008. Understanding Women's Empowerment: A Comparative Analysis of 

Demographic and Health Surveys (DHS) Data. DHS Comparative Reports No. 20. Calverton, Maryland, 

USA: Macro International. http://dhsprogram.com/pubs/pdf/CR20/CR20.pdf. 

Lim, S. S., L. Dandona, J. A. Hoisington, S. L. James, M. C. Hogan, and E. Gakidou. 2010. “India's 

Janani Suraksha Yojana, a Conditional Cash Transfer Programme to Increase Births in Health Facilities: 

An Impact Evaluation.” The Lancet 375(9730):2009-2023. 

Malhotra, A., and S. R. Schuler. 2005. “Women’s Empowerment as a Variable in International 

Development.” In Measuring Empowerment: Cross-Disciplinary Perspectives, edited by D. Narayan, 71-

88. Washington, DC: The World Bank 
29 

Mumtaz, Z., S. Salway, A. Bhatti, L. Shanner, S. Zaman, L. Laing, and G. T. Ellison. 2014. “Improving 

Maternal Health in Pakistan: Toward a Deeper Understanding of the Social Determinants of Poor 

Women’s Access to Maternal Health Services.” American Journal of Public Health 104(S1):S17-S24. 

Naseem, S., U. K. Khattak, H. Ghazanfar, and A. Irfan. 2017. “Maternal Health Status in Terms of 

Utilisation of Antenatal, Natal and Postnatal Services in a Periurban Setting of Islamabad: A Community 

Based Survey.” Journal of Pakistan Medical Association 67(8):1186-1191. 

NIPS/Pakistan, and ICF. 2019. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan: 

National Institute of Population Studies (NIPS)/Pakistan and ICF. Available at 

http://dhsprogram.com/pubs/pdf/FR354/FR354.pdf. 

NIPS/Pakistan, and ICF International. 2013. Pakistan Demographic and Health Survey 2012-13. 

Islamabad, Pakistan: National Institute of Population Studies - (NIPS)/Pakistan and ICF International. 

http://dhsprogram.com/pubs/pdf/FR290/FR290.pdf. 

Noh, J.-W., Y.-m. Kim, L. J. Lee, N. Akram, F. Shahid, Y. D. Kwon, and J. Stekelenburg. 2019. “Factors 

Associated with the Use of Antenatal Care in Sindh Province, Pakistan: A Population-Based Study.” 

PLOS One 14(4). 

Osamor, P. E., and C. Grady. 2016. “Women's Autonomy in Health Care Decision-Making in Developing 

Countries: A Synthesis of the Literature.” International Journal of Women's Health 8:191-202. 

Planning Commission. 2010. Pakistan Millennium Development Goals Report 2010. Islamabad, Pakistan: 

Planning Commission, Centre for Poverty Reduction and Social Policy Development. 

Ronsmans, C., W.J. Graham, and L.M.S.S.s. group. 2006. “Maternal Mortality: Who, When, Where, and 

Why.” The Lancet 368(9542):1189-1200. 

Sahito, A., and Z. Fatmi. 2018. “Inequities in Antenatal Care, and Individual and Environmental 

Determinants of Utilization at National and Sub-National Level in Pakistan: A Multilevel Analysis.” 

International Journal of Health Policy and Management 7(8):699. 

Singh, K., W. T. Story, and A. C. Moran. 2016. “Assessing the Continuum of Care Pathway for Maternal 

Health in South Asia and Sub-Saharan Africa.” Maternal and Child Health Journal 20(2):281-289. 

Sonneveldt, E., W. DeCormier Plosky, and J. Stover. 2013. “Linking High Parity and Maternal and Child 

Mortality: What Is the Impact of Lower Health Services Coverage among Higher Order Births?” BMC 

Public Health 13(3):S7. 

Technical Resource Facility. 2013. Pakistan National Maternal and Child Health Programme: Mid Term 

Evaluation Summary, April 2013. Islamabad. Pakistan: MNCH Programme. http://www.trfpakistan.org. 

Upadhyay, U. D., and D. Karasek. 2012. “Women's Empowerment and Ideal Family Size: An 

Examination of DHS Empowerment Measures in Sub-Saharan Africa.” International Perspectives on 

Sexual and Reproductive Health:78-89. 
30 

WHO. 2015. Strategies Towards Ending Preventable Maternal Mortality (Epmm). Geneva, Switzerland: 

World Health Organization. 

WHO, UNICEF, UNFPA, World Bank Group, and UN Population Division. 2019. Trends in Maternal 

Mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United 

Nations Population Division. Geneva, Switzerland: World Health Organization. 

 
31 

APPENDIX 

Appendix Table 1 Distribution of empowerment and maternal health care-seeking indicators, 

Pakistan 2012-13 and 2017-18 

2012-13 2017-18 

% N % N 

Empowerment 

Problems accessing care 

None 31.8 1,320 28.6 1,086 

At least one 68.2 2,826 71.4 2,706 

SWPER: Attitude to violence 

Low empowerment 31.8 1,317 30.1 1,142 

Medium empowerment 14.0 580 13.7 520 

High empowerment 54.2 2,249 56.2 2,130 

 

SWPER: Social independence 

Low empowerment 31.9 1,321 28.4 1,078 

Medium empowerment 37.1 1,536 35.5 1,344 

High empowerment 31.1 1,288 36.1 1,369 

 

SWPER: Decision making 

Low empowerment 47.0 1,948 46.1 1,747 

Medium empowerment 22.8 946 24.3 920 

High empowerment 30.2 1,250 29.7 1,125 

 

Maternal health care-seeking 

Antenatal care, 4 visits 

No 61.7 2,556 46.6 1,769 

Yes 38.3 1,589 53.4 2,023 

 

Skilled birth attendance 

No 42.5 1,763 25.6 972 

Yes 57.5 2,382 74.4 2,820 

 

PNC for the mother in 2 days 

No 39.2 1,626 37.5 1,420 

Yes 60.8 2,519 62.5 2,372 

All three contacts 

No 72.5 3,004 60.1 2,280 

Yes 27.5 1,141 39.9 1,513 

 

Total 100.0 4,145 100.0 3,792 

*Note: Due to rounding, percentages may not add up to 100. 

 
32 

Appendix Table 2 Antenatal visits (4 or more) by background characteristics for both surveys 

 2012-13 2017-18 Difference2 

Variable % [95% C.I.] p 2017-18 – 2012-13 1 % [95% C.I.] p1

Total 38.3 [35.5,41.3] 53.4 [49.7,57.0] 14.4*** 

Empowerment 

Problems accessing care *** *** 

None 47.6 [42.9,52.4] 66.3 [61.8,70.6] 18.6*** 

At least one 34.0 [31.0,37.2] 48.2 [44.3,52.0] 13.5*** 

SWPER 

Attitude to violence *** *** 

Low 25.2 [21.8,28.8] 36.9 [32.5,41.5] 11.1*** 

Medium 35.9 [30.0,42.2] 49.1 [42.7,55.5] 12.9** 

High 46.7 [42.8,50.6] 63.2 [58.9,67.4] 16.4*** 

Social independence *** *** 

Low 23.2 [19.6,27.1] 33.0 [29.3,37.0] 9.7*** 

Medium 32.3 [29.1,35.8] 49.5 [44.7,54.2] 16.6*** 

High 61.1 [56.7,65.3] 73.2 [68.7,77.2] 11.8*** 

Decision making *** *** 

Low 33.9 [30.7,37.1] 46.4 [42.0,50.8] 11.7*** 

Medium 45.9 [40.5,51.4] 59.2 [54.0,64.1] 13.0*** 

High 39.6 [35.6,43.8] 59.5 [54.1,64.6] 19.8*** 

 

Background characteristics 

Place of residence *** *** 

Urban 62.6 [56.8,68.1] 72.1 [67.7,76.2] 9.5** 

Rural 28.1 [25.2,31.2] 43.8 [39.2,48.5] 15.1*** 

Region *** *** 

Punjab 41.4 [37.1,45.9] 58.6 [52.8,64.2] 17.2*** 

Sindh 43.3 [38.3,48.3] 51.4 [45.0,57.7] 8.1* 

Khyber Pakhtunkhwa 25.6 [21.0,30.8] 46.8 [39.9,53.8] 21.2*** 

Balochistan 10.8 [6.9,16.4] 24.3 [18.1,31.7] 13.5** 

ICT Islamabad 81.0 [74.7,86.1] 81.3 [73.5,87.2] 0.3 

Wealth quintile *** *** 

Lowest 13.6 [10.7,17.1] 20.5 [16.6,25.0] 7.1** 

Second 24.3 [20.3,28.8] 37.0 [31.6,42.7] 11.9*** 

Middle 32.6 [28.2,37.2] 50.4 [44.8,56.0] 17.6*** 

Fourth 52.4 [47.6,57.1] 72.5 [67.2,77.3] 19.9*** 

Highest 80.4 [75.1,84.8] 87.7 [83.6,90.9] 7.3* 

Education *** *** 

None 21.7 [18.9,24.8] 31.2 [27.9,34.7] 9.3*** 

Primary 40.9 [35.3,46.8] 55.8 [49.4,62.0] 14.4*** 

Secondary + 68.7 [64.0,73.0] 79.4 [75.7,82.7] 10.7*** 

Age at birth *** ** 

<20 34.2 [27.6,41.6] 45.2 [38.1,52.5] 10.2* 

20-34 40.2 [37.1,43.3] 55.6 [51.7,59.4] 15.0*** 

35-49 28.4 [23.5,33.9] 43.4 [36.0,51.1] 13.9** 

Parity *** *** 

1 52.3 [47.5,57.0] 65.7 [60.7,70.3] 12.7*** 

2-3 40.5 [36.8,44.4] 56.4 [51.6,61.0] 15.3*** 

4-5 29.4 [24.1,35.3] 47.6 [43.0,52.3] 17.6*** 

6+ 25.5 [20.9,30.7] 32.6 [27.5,38.2] 7.1 

Notes: 

1 p-value significance of the covariate in each survey, *p<0.05, **p<0.01, ***p<0.001 

2 Difference between the two surveys with the p-value of the difference 

 
33 

Appendix Table 3 Skilled birth attendance by background characteristics for both surveys 

2012-13 2017-18 Difference2

 

Variable % [95% C.I.] p 2017-18 – 2012-13 1 % [95% C.I.] p1

Total 57.5 [53.8,61.1] 74.4 [70.9,77.6] 16.6*** 

Empowerment 

Problems accessing care *** *** 

None 66.1 [61.3,70.6] 82.5 [77.7,86.5] 16.4*** 

At least one 53.4 [49.1,57.8] 71.1 [67.0,74.9] 17.3*** 

SWPER 

Attitude to violence *** *** 

Low 47.4 [42.7,52.3] 63.6 [58.2,68.8] 16.0*** 

Medium 54.0 [47.6,60.2] 68.6 [62.3,74.3] 14.5** 

High 64.2 [59.5,68.7] 81.5 [77.9,84.7] 17.2*** 

Social independence *** *** 

Low 44.8 [39.2,50.7] 60.0 [55.4,64.4] 15.2*** 

Medium 51.9 [47.7,56.0] 73.3 [68.3,77.8] 21.0*** 

High 77.1 [73.1,80.6] 86.7 [83.7,89.2] 9.5*** 

Decision making *** 

Low 55.2 [49.8,60.5] 69.5 [64.8,73.8] 14.0*** 

Medium 62.8 [57.6,67.7] 77.2 [72.7,81.1] 14.4*** 

High 57.0 [52.2,61.6] 79.6 [74.9,83.6] 22.5*** 

Earlier maternal health care-seeking 

Antenatal care, 4 visits *** *** 

No 42.8 [39.0,46.6] 56.4 [51.6,61.1] 13.4*** 

Yes 81.1 [77.1,84.5] 90.1 [88.0,91.9] 8.9*** 

 

Background characteristics 

Place of residence *** *** 

Urban 74.4 [68.6,79.4] 87.4 [84.1,90.1] 13.1*** 

Rural 50.3 [45.8,54.8] 67.7 [63.1,72.0] 17.1*** 

Region *** *** 

Punjab 58.6 [52.8,64.1] 77.5 [71.5,82.5] 18.9*** 

Sindh 65.1 [59.8,70.0] 77.5 [72.0,82.2] 12.4** 

Khyber Pakhtunkhwa 52.2 [45.2,59.2] 69.2 [62.9,74.8] 17.0*** 

Balochistan 17.6 [11.7,25.4] 41.6 [32.8,50.9] 24.0*** 

ICT Islamabad 88.7 [82.8,92.7] 89.4 [82.7,93.8] 0.8 

Wealth quintile *** *** 

Lowest 34.0 [27.9,40.7] 50.6 [44.2,57.0] 16.8*** 

Second 44.3 [38.8,50.0] 60.9 [54.9,66.5] 16.3*** 

Middle 56.6 [50.7,62.3] 78.6 [74.2,82.5] 21.8*** 

Fourth 72.8 [68.2,77.0] 85.8 [81.2,89.4] 13.0*** 

Highest 88.4 [83.2,92.2] 95.9 [93.7,97.4] 7.5*** 

Education *** *** 

None 43.1 [38.8,47.5] 60.2 [55.6,64.7] 17.0*** 

Primary 60.5 [55.0,65.8] 77.4 [71.0,82.7] 16.7*** 

Secondary + 83.1 [79.0,86.5] 90.4 [87.7,92.5] 7.3*** 

Age at birth *** * 

<20 61.6 [54.0,68.7] 73.3 [66.5,79.2] 11.2* 

20-34 58.7 [54.8,62.4] 75.6 [71.8,79.0] 16.7*** 

35-49 46.0 [39.9,52.2] 66.0 [57.7,73.4] 19.4*** 

Parity *** *** 

1 72.5 [68.1,76.5] 83.4 [79.3,86.9] 10.6*** 

2-3 60.5 [56.0,64.8] 77.4 [73.4,80.9] 16.5*** 

4-5 48.7 [42.9,54.7] 68.7 [63.5,73.5] 19.7*** 

6+ 40.8 [34.8,47.1] 59.2 [53.0,65.1] 18.2*** 

Notes: 

1 p-value significance of the covariate in each survey, *p<0.05, **p<0.01, ***p<0.001 

2 Difference between the two surveys with the p-value of the difference 

 

 
34 

Appendix Table 4 Postnatal care by background characteristics for both surveys 

 2012-13 2017-18 Difference2

 

Variable % [95% C.I.] p 2017-18 – 2012-13 1 % [95% C.I.] p1

Total 60.8 [57.4,64.0] 62.5 [59.0,66.0] 1.4 

Empowerment 

Problems accessing care *** ** 

None 70.7 [66.8,74.3] 68.6 [63.5,73.3] -2.0 

At least one 56.1 [52.4,59.8] 60.1 [56.0,64.1] 3.5 

SWPER 

Attitude to violence *** *** 

Low 51.1 [46.6,55.6] 47.1 [42.2,52.1] -4.4 

Medium 58.8 [52.5,64.8] 62.4 [55.8,68.6] 3.6 

High 67.0 [62.6,71.1] 70.9 [66.9,74.5] 3.9 

Social independence *** *** 

Low 53.1 [48.2,57.9] 48.4 [43.1,53.6] -5.1 

Medium 55.9 [51.6,60.0] 60.0 [55.2,64.7] 3.9 

High 74.5 [70.7,78.0] 76.2 [72.6,79.4] 1.6 

Decision making * *** 

Low 57.3 [52.9,61.6] 52.5 [47.9,57.2] -5.3 

Medium 64.4 [59.2,69.2] 70.1 [65.6,74.1] 5.8 

High 63.5 [59.2,67.5] 71.9 [67.2,76.2] 8.6** 

Earlier maternal health care-seeking 

Antenatal care, 4 visits *** *** 

No 49.5 [45.8,53.3] 46.1 [41.4,50.9] -4.1 

Yes 78.8 [75.4,81.9] 76.9 [73.9,79.6] -1.8 

Skilled birth attendance *** *** 

No 30.8 [26.2,35.9] 19.8 [15.6,24.9] -11.5*** 

Yes 82.9 [80.4,85.2] 77.3 [74.6,79.7] -5.8** 

 

Background characteristics 

Place of residence *** *** 

Urban 74.7 [70.3,78.6] 76.2 [72.6,79.4] 1.6 

Rural 54.9 [50.9,58.8] 55.6 [50.9,60.3] 0.3 

Region *** *** 

Punjab 66.0 [60.7,70.9] 66.9 [60.8,72.5] 0.9 

Sindh 66.3 [61.1,71.1] 71.0 [66.1,75.4] 4.7 

Khyber Pakhtunkhwa 38.2 [32.7,43.9] 42.9 [36.5,49.7] 4.8 

Balochistan 37.6 [31.5,44.0] 38.4 [31.6,45.6] 0.8 

ICT Islamabad 78.0 [71.0,83.7] 79.3 [72.4,84.9] 1.3 

Wealth quintile *** *** 

Lowest 42.6 [36.5,49.0] 45.5 [38.3,52.8] 2.3 

Second 54.5 [49.4,59.5] 46.8 [41.2,52.6] -7.9* 

Middle 58.1 [52.9,63.2] 60.0 [54.1,65.5] 1.8 

Fourth 72.6 [66.6,77.8] 73.2 [67.9,78.0] 0.6 

Highest 82.1 [77.5,86.0] 87.6 [83.9,90.6] 5.5* 

Education *** *** 

None 52.1 [48.0,56.3] 48.8 [44.0,53.6] -3.8 

Primary 59.0 [53.4,64.5] 61.6 [55.7,67.2] 2.6 

Secondary + 78.4 [74.7,81.7] 79.7 [76.4,82.7] 1.5 

Age at birth ** 

<20 59.7 [51.9,67.1] 53.9 [46.5,61.1] -6.4 

20-34 61.6 [58.3,64.9] 64.5 [60.7,68.1] 2.5 

35-49 55.4 [48.7,61.9] 55.2 [47.5,62.6] -0.8 

Parity *** *** 

1 70.0 [65.5,74.0] 69.2 [63.9,74.1] -1.3 

2-3 62.4 [58.5,66.1] 66.6 [62.5,70.5] 4.0 

4-5 54.5 [48.8,60.2] 58.9 [53.7,64.0] 4.0 

6+ 52.4 [46.4,58.3] 44.9 [38.9,51.0] -7.8 

Notes: 

1 p-value significance of the covariate in each survey, *p<0.05, **p<0.01, ***p<0.001 2 Difference between the two surveys with the p-value of the difference 

 
35 

Appendix Table 5 Percent of women obtaining all three critical maternal health services, by 

background characteristics, Pakistan 2012-13 and 2017-18 

 2012-13 2017-18 

Variable % [95% C.I.] p1 % [95% C.I.] p1

Difference2

 

2017-18 – 2012-13 

Total 27.5 [24.8,30.5] 39.9 [36.4,43.5] 12.0*** 

Empowerment 

Problems accessing care *** *** 

None 37.4 [32.9,42.1] 52.2 [47.4,56.9] 14.8*** 

At least one 22.9 [20.0,26.1] 34.9 [31.4,38.7] 11.6*** 

SWPER 

Attitude to violence *** *** 

Low 15.1 [12.5,18.1] 21.5 [18.1,25.4] 6.3** 

Medium 24.4 [19.3,30.3] 35.0 [29.3,41.3] 10.5* 

High 35.6 [31.6,39.9] 50.9 [46.8,55.0] 15.2*** 

Social independence *** *** 

Low 14.2 [11.6,17.3] 18.6 [15.5,22.0] 4.5* 

Medium 20.1 [17.3,23.2] 37.0 [32.3,41.9] 16.5*** 

High 50.1 [45.6,54.6] 59.5 [55.4,63.6] 9.3** 

Decision making *** *** 

Low 23.1 [20.0,26.4] 31.4 [27.4,35.6] 7.8** 

Medium 35.3 [30.0,41.0] 47.1 [42.2,52.1] 11.8** 

High 28.6 [24.9,32.6] 47.2 [42.2,52.3] 18.6*** 

 

Background characteristics 

Place of residence *** *** 

Urban 49.5 [43.7,55.3] 58.6 [53.8,63.2] 9.1* 

Rural 18.3 [15.6,21.3] 30.4 [26.2,34.9] 11.8*** 

Region *** *** 

Punjab 29.6 [25.3,34.3] 45.8 [40.2,51.5] 16.2*** 

Sindh 33.4 [28.8,38.3] 40.7 [34.5,47.3] 7.3 

Khyber Pakhtunkhwa 16.0 [12.4,20.3] 26.0 [20.6,32.4] 10.1** 

Balochistan 5.1 [3.0,8.5] 14.0 [10.1,19.1] 8.8** 

ICT Islamabad 67.2 [59.7,74.0] 70.8 [62.4,78.0] 3.6 

 

Wealth quintile *** *** 

Lowest 6.4 [4.5,9.0] 12.3 [9.6,15.6] 6.1** 

Second 13.8 [10.9,17.5] 21.3 [17.1,26.3] 7.4** 

Middle 19.9 [16.2,24.2] 32.7 [28.0,37.7] 12.7*** 

Fourth 39.9 [35.1,44.9] 57.0 [51.1,62.8] 16.9*** 

Highest 68.7 [62.5,74.3] 77.5 [72.5,81.8] 8.8* 

Education *** *** 

None 12.6 [10.5,15.1] 19.0 [16.2,22.2] 6.4*** 

Primary 25.0 [20.4,30.3] 39.1 [33.3,45.3] 13.9*** 

Secondary + 57.7 [52.8,62.4] 65.8 [61.6,69.7] 8.2* 

Age at birth ** *** 

<20 22.0 [16.5,28.7] 29.1 [22.9,36.1] 6.7 

20-34 29.2 [26.1,32.5] 42.4 [38.7,46.2] 12.9*** 

35-49 20.0 [15.8,24.9] 29.6 [22.6,37.7] 9.0* 

Parity *** *** 

1 39.1 [34.5,44.0] 51.2 [45.9,56.5] 11.6** 

2-3 30.2 [26.7,34.0] 43.9 [39.3,48.7] 13.4*** 

4-5 19.7 [14.9,25.4] 33.4 [28.9,38.3] 13.4*** 

6+ 15.4 [11.8,19.9] 19.1 [14.6,24.6] 3.7 

Notes: 

1 p-value significance of the covariate in each survey, *p<0.05, **p<0.01, ***p<0.001 2 Difference between the two surveys with the p-value of the difference