UTILIZATION OF SKILLED BIRTH ATTENDANT SERVICES AND ASSOCIATED FACTORS IN TEHSIL SALARZAI BAJAUR AGENCY

UTILIZATION OF SKILLED BIRTH ATTENDANT SERVICES AND ASSOCIATED FACTORS IN TEHSIL SALARZAI BAJAUR AGENCY, PAKISTAN
Sahib Rahman
Master in Public Health (Session 2014-2016)
Khyber Medical University Peshawar
Supervisor
Assistant Professor Dr. Ayesha Imtiaz
Institute of Public Health & Social Sciences
Khyber Medical University, Peshawar

SUPERVISOR CERTIFICATE
Supervisor Name: Dr. Ayesha Imtiaz
Designation: Assistant Professor
Signature: _________________
Submitted by: Sahib Rahman
Master in Public Health (Session 2014-2016)
Institute of Public Health & Social Sciences
Khyber Medical University, Peshawar
Submitted on: _________________________

Submitted to: Institute of Public Health & Social Sciences
Khyber Medical University, Peshawar
ACKNOWLEDGMENT
In the name of almighty ALLAH, the most beneficent and merciful, all praises are for him, to who belongs whatsoever is in the earths and in the skies, who granted me the courage and strength to successfully accomplish the very difficult course and the ability to write the dissertation “Utilization of skilled birth attendant Services and associated factors in tehsil salarzai Bajaur agency, Pakistan” has been prepared under the supervision of assistant Professor, Dr. Ayesh Imtiaz, Institute of Public Health and Social Sciences Khyber Medical University (KMU), Peshawar. I am thankful to him for his unrelenting, valuable and crucial support and guidance.

Efforts of functional area experts, Dr. Muhammad Naseem assistant Professor and Dr. Hamid Husain, associate Professor, Institute of Public Health and Social Sciences, Khyber Medical University Peshawar are also acknowledged and appreciated.

I also take note of and appreciate the contribution of Mr. Muhammad Asif, male nurse in Ayub Teaching Hospital abbottabad for their role and contribution toward my project.

I would like special thanks to Institute of Public Health & Social Sciences, Khyber Medical
University for giving me the opportunity to build my skills and knowledge.
Last but not the least I would not forget to mention my parents and whole family, as without his support and assistance I would not be able to complete my project.

TABLE OF CONTENTS
TOC o “1-3” h z u LIST OF TABLES PAGEREF _Toc521071695 h 6LIST OF FIGURES: PAGEREF _Toc521071696 h 7ACRONYMS PAGEREF _Toc521071697 h 8ABSTRACT PAGEREF _Toc521071698 h 10CHAPTER 1 PAGEREF _Toc521071699 h 12INTRODUCTION AND LITERATURE REVIEW PAGEREF _Toc521071700 h 121.1: INTRODUCTION: PAGEREF _Toc521071701 h 121.2: LITERATURE REVIEW: PAGEREF _Toc521071702 h 161.2.1 HOISTORICAL BACKGROUND OF BAJAUR AGENCY PAGEREF _Toc521071703 h 161.2.2: GLOBAL BURDEN OF MATERNAL MORTALITY: PAGEREF _Toc521071704 h 181.2.3: BURDEN OF MATERNAL MORTALITY IN PAKISTAN: PAGEREF _Toc521071705 h 201.2.4: IMPROVING MATERNAL AND CHILD HEALTH PAGEREF _Toc521071706 h 211.2.5: ROLE OF SKILLED BIRTH ATTENDANTS IN MATERNAL MORTALITY: PAGEREF _Toc521071708 h 221.2.6: GLOBAL PREVALENCE OF UTILIZATION OF SBAs SERVICES: PAGEREF _Toc521071709 h 231.2.7: PREVALENCE OF UTILIZATION OF SBAs SERVICES IN PAKISTAN: PAGEREF _Toc521071710 h 231.2.8: TYPES OF SKILLED BIRTH ATTENDANTS: PAGEREF _Toc521071711 h 251.2.9: FACTORS AFFECTING UPTAKE OF SBAs: PAGEREF _Toc521071712 h 251.2.10: CONCLUSION: PAGEREF _Toc521071713 h 28CHAPTER 2 PAGEREF _Toc521071714 h 30METHODS AND MATERIALS PAGEREF _Toc521071715 h 302.1: STUDY DESIGN: PAGEREF _Toc521071716 h 302.2: STUDY DURATION: PAGEREF _Toc521071717 h 302.3: STUDY SETTING: PAGEREF _Toc521071718 h 302.4: STUDY POPULATION PAGEREF _Toc521071719 h 302.5: INCLUSION CRITERIA& EXCLUSION CRITERIA: PAGEREF _Toc521071720 h 30INCLUSION CRITERIA: PAGEREF _Toc521071721 h 30EXCLUSION CRITERIA: PAGEREF _Toc521071722 h 302.6: SAMPLING PAGEREF _Toc521071723 h 30SAMPLE SIZE: PAGEREF _Toc521071724 h 30SAMPLE TECHNIQUE: PAGEREF _Toc521071725 h 302.7: ETHICAL CONSIDERATION: PAGEREF _Toc521071726 h 312.8: DATA COLLECTION PROCEDURE: PAGEREF _Toc521071727 h 312.9: DATA ANALYSIS: PAGEREF _Toc521071728 h 33CHAPTER 3 PAGEREF _Toc521071729 h 34RESULTS AND DISCUSSION PAGEREF _Toc521071730 h 343.1: RESULTS PAGEREF _Toc521071731 h 343.1.1: DESCRIPTIVE ANALYSIS PAGEREF _Toc521071732 h 343.1.2: ASSOCIATION OF SOCIAL AND DEMOGRAPHIC, OBSTETRIC AND RECENT DELIVERY CHARACTERISTICS WITH SBAs PAGEREF _Toc521071738 h 383.1.3: LOGISTIC REGRESSION ANALYSIS: PAGEREF _Toc521071742 h 433.1.4: FIGURES: PAGEREF _Toc521071746 h 453.2: DISCUSSION PAGEREF _Toc521071747 h 493.2.1: KEY FINDINGS: PAGEREF _Toc521071748 h 493.2.2: DISCUSSION AND COMPARISON WITH OTHER STUDIES: PAGEREF _Toc521071749 h 503.3: STRENGTH AND LIMITATIONS: PAGEREF _Toc521071750 h 573.4: CONCLUSION AND RECOMMENDATION: PAGEREF _Toc521071751 h 58CHAPTER 4 PAGEREF _Toc521071752 h 59REFERENCES PAGEREF _Toc521071753 h 59ANNEXURES: PAGEREF _Toc521071756 h 63ANNEXURE I: INFORMED CONSENT FORM PAGEREF _Toc521071757 h 63ANNEXURE II: QUESTIONNAIRE PAGEREF _Toc521071758 h 64ANNEXURE III: STUDY PLAN (GANTT CHART) PAGEREF _Toc521071759 h 67ANNEXURE IV: STUDY BUDGET PAGEREF _Toc521071760 h 68
LIST OF TABLES1.1: Situation of indicators MDG-5……………………………………………………………… 22
3.1: Descriptive Analysis of Characteristics of Study Participants………………………………34
3.2: Descriptive analysis of social demographic characteristics of the study participants………. 35
3.3: Descriptive analysis of obstetric characteristics of the study participants…………………. 36
3.4: Descriptive analysis of recent delivery characters of the study participants……………….. 37
3:5 Descriptive analysis of choices for next delivery of study participants…………………….. 38
3.6: Descriptive analysis of social demographic characteristics associated with birth
attendant’s services………………………………………………………………………… 40
3.7: Descriptive Analysis of obstetric characteristics associated with birth attendant’s
services………………………………………………………………………………………41
3.8: Descriptive analysis of recent delivery characteristics associated with birth attendant’s
Services………………………………………………………………………………………42
3.9: Univariate and multivariate analysis of social demographic characteristics associated with
skilled birth attendant’s services……………………………………………………………44
3.10: Univariate and multivariate analysis of obstetric characteristics associated with
skilled birth attendant’s services……………………………………………………………45
3.11: Univariate and multivariate analysis of recent delivery characteristics associated with
skilled birth attendant’s services……………………………………………………………45
LIST OF FIGURES:1.1: Map of Bajaur Agency……………………………………………………………………….17
1.2: Targets and achievements – Maternal Mortality Ratio……………………………………….20
1.3: Targets and achievements – Birth Attendanted by Skilled Birth attendant (%)……………..24
3.1: Distribution of occupation of husbands……………………………………………………..46
3.2: Reasons for not receiving antenatal care by the participants……………………………………46
3.3: Distribution of maternal health problems in participant’s community………………………47
3.4: Reasons for recent delivery at home among participants…………………………………….47
3.5: Reasons for recent delivery at health facility among participants…………………………..48
3.6: Reasons for health facility is better place for delivery among participants…………………48
3.7: Reasons for home is better place for delivery among participants………………………….49
ACRONYMSMMR………………………………………………….Maternal mortality ratio
MMRate……………………………………………Maternal mortality rate
MM………………………………………………Maternal mortality
SBA……………………………………………..Skilled birth attendant
CBA……………………………………………..Child bearing age
WHO…………………………………………………World health organization
MDGs…………………..…………………………Millennium development goals
SDG……………………………………………..Sustainable development goal
UNICEF…………………………………………United nation international children fund
UNPF..……………………………………………….United nations population fund
SSA…………………………………………………Sub-Saharan Africa
FATA………………………………………………. Federally administered tribal area
FR………………………………………………….Frontier region
KP……………………………………………………Khyber Pakhtunkhawa
SPSS…………………………………………………Statistical package for the social science
ANC…………………………………………………Antenatal care
PDHS……………………………………………Pakistan demographic health survey
LHV……………………………………………….Lady health visitor
LHW…………………………………………….Lady health worker
UNPD …………………………………………….United nations population division
ICF International………………………………….Inner city fund international
MICS…………………………………………….Multiple indicators cluster survey
PKR…………………………………………….Pakistani rupee
BHU……………………………………………Basic health unit
RHC……………………………………………..Rural health center
CHC……………………………………………..Community health center
PHC…………………………………………….Primary health center
EmOC……………………………………………..Emergency obstetric care
EmONC………………………………………….Emergency obstetric and neonatal care
EPI…………………………………….….………Expended program on immunization
TBA…………………………………….…………Traditional birth attendant
APA…………………………………….…………Assistant political agent
GB………………………………………………Gilgit Baltistan
FANC……………………………………..……..Focused antenatal care
GDG………………………………………………Guideline development group
AJ;K……………………………………………Azad Jammu and Kashmir
MNCH…………………………………………….Maternal, Neonatal and child health
CPR……………………………………………… Contraceptive prevalence rate
TFR………………………………………………Total fertility rate
CHW…………………………………..…………Community Health Worker
FP………………………………………………….Family Planning
AS;RB…………………………….…..…………Advanced Study and Research Board
MTDF……………………………………………Medium Term Development Framework
ABSTRACTBACKGROUND: Low utilization of skilled birth attendant services maintained high maternal mortality and disability.2 Maternal mortality ratio in developing countries was 239 per 100,000 live births while 12 per 100,000 in developed countries in 2015.4 The maternal mortality ratio in Pakistan was 178 per 100,000 in 2015.3 According to Pakistan demographic health survey 2012-2013 about 52 percent deliveries assisted by skilled birth attendants in Pakistan while in Khyber Pakhtunkhawa about 48 percent deliveries assisted by skilled birth attendants.5 Skilled birth attendant can play a major role in improving birth outcome. This study assessed the utilization of skilled birth attendant services and associated factors in Tehsil Salarzai Bajaur Agency.

OBJECTIVE: To determine the utilization of skilled birth attendant services in Tehsil Salarzai, Bajaur agency.

To determine the factors associated with utilization of skilled birth attendant services in Tehsil Salarzai, Bajaur agency.

METHODOLOGY: A cross sectional study was conducted from November 2015 to March 2016 at tehsil salarzai Bajaur agency. 730 participants were included who had deliveries the recent babies in last one year. Multiple stage random sampling technique was used for data collection. Two sectors (lower amadak and upper amadak) were selected randomly from four sectors in Tehsil Salarzai. Total 15 villages were selected randomly from these two sectors. 10 villages from lower amadak and the remaining 5 villages from upper amadak proportionate to their population. Data was collected by direct interviewing the participants used a pretested modified standard questionnaire. Descriptive and logistic regression analysis was done to determine the utilization of skilled birth attendant and associated factors.
RESULT: Total 730 participants were included in the study. 45% participants were utilized skilled birth attendant services. 43.6% participants were delivered the recent baby at health facility. 57.9% participants were received antenatal care. Age of about 60% participants was between 20-30 years and about 98% were housewives and 97.7% were uneducated. Age of participants between 20-30 years (Adjusted OR 1.861, P =.028), availability of health facility in participants sectors (Adjusted OR 6.051, P = .019), availability lady health visitor in participants sectors (Adjusted OR .082, P = .052), antenatal care received for recent pregnancy (Adjusted OR .187, P = ;.001) and history of complication of recent delivery (Adjusted OR 1.543, P = .049), were found to be significantly associated with utilization of skilled birth attendant services. Family monthly income and number of children of participant’s socio-demographic characteristics and still birth of o participant’s obstetric characteristics were not found to be associated with utilization of skilled birth attendant services.
CONCLUSION: Low utilization skilled birth attendant services was mainly due to easy labor in the home, privacy problem did not want to exposed to stringer, illiteracy of participants and their spouses, low socio economic status, unavailability of health facilities, health care worker equipments and medicines. Cultural tradition and unempowerment of participants were also the main reasons of low utilization skilled birth attendant services. However in our study the family monthly income was not found to be significantly associated with utilization of skilled birth attendant services.
CHAPTER 1INTRODUCTION AND LITERATURE REVIEW1.1: INTRODUCTION:Pregnancy and child birth complications are a leading cause of death and disability among women of reproductive age in the developing countries of the world.1 Globally 830 women died every day from complications of pregnancy and childbirth in 2015. Maternal mortality ratio (MMR) was about 216 per 100,000 live births during pregnancy, child birth and after soon the termination of pregnancy in 2015.2-4 Globally MMR reduced nearly 44 percent over the last 25 years, to an estimated 216 per 100,000 live births of maternal deaths in 2015, from MMR of 385 in 1990. The annual number of maternal deaths decreased by 43% from approximately 532 000 in 1990 to an estimated 303 000 in 2015. Almost 99 percent maternal death occurred in developing countries in 2015. Only Sub-Saharan Africa (SSA) and south Asia accounts for 88 percent of all of the maternal deaths in the world.2-4 The Approximate MMR in developing countries was 239 per 100,000 live births which was roughly 20 times higher than that of developed countries, where it was just 12 per 100,000 in 2015.2, 4 The approximate global lifetime risk of a maternal death reduced from 1 in 73 in 1990 to 1 in 180 in 2015.2 The estimated lifetime risk of maternal death in developing countries was 1 in 150 while in developed countries was 1 in 4900 in 2015.2, 4 The risk of woman dying from maternal cause is 33 times higher in developing country than in developed country. Maternal mortality (MM) is one of the health indicators which indicate a wide difference between rich and poor, urban and rural and both between the countries and within them.3
Many researchers recognized that more than three fourths of maternal deaths are related to direct obstetric causes, such as hemorrhage, sepsis, abortion, ruptured uterus, and hypertensive diseases of pregnancy which are easily preventable and treatable and 77 percent of deaths occur during or soon after childbirth (within 24 hours). 88 to 98 percent of these problems are estimated to be avoidable, although over 99 percent of maternal deaths in SSA could not be prevented.1, 5, 6 MM in Ethiopia was found to be highest in the world with an estimated MMR of 676 deaths per 100,000 live births in 2011 which slightly increased from the 2005 MMR level of 673 deaths per 100,000 live births.5
According to the latest estimate of World Health Organization (WHO), United Nations Children Fund (UNICEF), United Nations Population Fund (UNFPA), World Bank and United Nations Population Division (UNPD), the MMR in Pakistan reduced to 178 per 100,000 in 2015 from 211 per 100,000 live births in 2010. Pakistan making progress and was on track but still far behind from the proposed 140 target of MDG-5 for 2015, so Pakistan failed to achieve MDG-5 target.2 According to PDHS 2006-07 MMR was different in rural and urban areas of Pakistan. In rural areas it was about 319 and urban areas was 175 per 100,000 live births so it was about double in rural areas than urban areas. Similarly MMR was different in the different regions of Pakistan. In KP MMR was found about 275 per 100,000 live births whereas in Baluchistan it was 785 per 100,000 live births. In Punjab and Sindh the MMR was about 227 and 314 per 100,000 live births respectively. In Pakistan the MMR was found highest in Baluchistan and lowest in Punjab.7 MMR in FATA was about 380 in 2007 which was significantly decreased up to 290 per 100,000 live birth whereas in Gilgit Baltistan (GB) it was about 450 per 100,000 live birth in 2011-2012.8, 9
56197515120620The estimated lifetime risk of a maternal death in Pakistan is 1 in 140 in 2105.2 The main factors which have observed to contributed in MMR are include poverty, lack of education, lack of empowerment, gender inequalities, early marriage, cultural restrictions, unavailability of health facilities, poor reproductive health services, lack of SBAs.10
The study’s results from Ethiopia, Malawi, and Tanzania showed that socioeconomic status, availability of facility, short labor duration, staff attitudes, lack of privacy, reproductive behavior, cultural traditions and the patterns of decision making power within household are mainly responsible factors for low utilization of SBAs.5 The maternal health services found to be effective in reducing maternal mortality these services include family planning, antenatal care, safe delivery and emergency obstetric care.11 SBAs can play a major role to improve outcome during delivery and postpartum by detecting and managing early complications of pregnancy and delivery.12 Utilization of SBAs during pregnancy, labor and delivery during the postpartum period could prevent many instances of maternal morbidity and mortality but unfortunately qualified midwives, nurses and doctors are often not available in the rural areas of many developing countries where most women are delivered.1
Studies from both developed and developing countries indicated that maternal mortality has been generally low when a higher proportion of deliveries are attended by SBAs.5 WHO recommends that delivery be attended by SBAs to reduce delivery related complications and improve the maternal and newborn health and survival. The WHO also strongly advocates for skilled care at every birth to reduce the global burden of 536, 000 maternal deaths every year.1, 12 It is estimated that SBAs presence at delivery could prevent about 16 percent to 33 percent of maternal deaths and SBAs presence at delivery may impact on the rates of stillbirths and neonatal mortality.13 Around the world, one third of births take place at home without the assistance of a skilled attendant.1 In developing countries the proportion of SBAs was about 61 percent in 2007.1, 13 According to PDHS 2012-2013 it is estimated that about more than half of deliveries (52 percent) take place at home whereas less than half (48 percent) take place at health facility. It has been estimated that approximately 52 percent deliveries were attended by SBAs in Pakistan. In urban areas of Pakistan about 71 percent and rural areas about 44.4 percent deliveries were attended by SBAs.14 Similarly deliveries attended by SBAs have found to be different among the different regions of Pakistan. In KP and Baluchistan nearly 48 percent and18 percent of deliverers were attended by SBAs respectively. Similarly in Punjab and Sindh 52 percent and 60 percent of deliveries were attended by SBAs respectively. In Islamabad 88 percent of deliveries attended by SBAs which is higher than other regions of Pakistan and in GB about 44 percent deliveries were attended by SBAs.14
The WHO defines a skilled birth attendant (SBA) “as an accredited health professional such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”.15
Federally administered tribal areas (FATA) is the special region of Pakistan consists of seven political agencies namely Bajaur, Mohmand, Khyber, Kurum, Orakzai, South Waziristan, North Wazirisatn and six smaller zones called Frontier regions (FRs) with the districts of Peshawar, Kohat, Bunnu, Dera Ismail Khan, Lakki Marwat and Tank.8 According to the Multiple Cluster Survey (MICS) FATA 2009, sex ratio in FATA was 108.7 males rounded to 109 per 100 females which was similar to 1998 censes. FATA has a low literacy rate lack of maternal and child health care facilities and services. It was estimated that literacy rate for the age of 10 years and above was found to be 21.4 percent and overall adult literacy rate (15 years and above) was about 22 percent. Female literacy rate of this age group was about 6.7 percent and 35.8 percent males.

Youth literacy rate (15-24 years of age) was 30.7 percent and female youth literacy rate was 12.4 percent.8
MMR in FATA have found 290 per 100,000 live births in 2011-2012.9 According to the MICS survey 2007, FATA has a high maternal mortality rate of 380 per 100,000 live births which was high than the national level MMR of 276 and KP MMR of 275 per 100,000 live births. The under-5 mortality rate in FATA was 104 per 1,000 live births, while infant mortality rate was 86 per 1000 births. The mortality rate for males was higher than that of females in the case of both infants as well as under-5 year children. Both infant and under-5 child mortality rates for males are higher in FATA when compared to national levels. Prevalence of ANC in FATA was roughly 25.8 percent and majority of deliveries (72.7 percent) took place in home while more than quarter (27.3 percent) took place in health faculty. The prevalence of skilled attendant at delivery was about 25.4 percent.8
Many studies acknowledged that use of SBAs services at every delivery is the best process indicator that correlate the maternal mortality, morbidity and poor delivery outcome. Despite the fact that utilization of SBAs is essential for further improvement of maternal and child health little is known about the current magnitude of use and factors influence the use of SBAs services in Pakistan. Therefore this study aims to determine the utilization of SBAs services and efforts to investigate the factors that are consider being barriers to the utilization of SBAs services. Many studies from different developing countries have attributed the low utilization of SBAs services to low socioeconomic status (family monthly income, education and occupation status of participants and their husbands) and not availability of proper health facility, no health care provider, tradition and custom of family and patterns of decision making power within household. All these indicators are mostly found in the developing countries which are matched with our cross sectional study for low utilization of SBAs services. This study helped to understand the relation between the utilization of SBAs services and associated factors especially in context of developing countries like Pakistan. Pakistan is a developing country with poor Maternal, Neonatal and Child Health (MNCH) indicators, limited resources and poor infrastructure of health system especially in primary health system. So evidence based policies are required to make best use of limited available resources and to develop possible health resources as well to focus on key issues which contributing to poor utilization of SBAs services and develop more effective interventions for improving utilization of SABs services.
1.2: LITERATURE REVIEW:1.2.1 HOISTORICAL BACKGROUND OF BAJAUR AGENCYFATA along with border of Afghanistan, covering an area of 27,220 km2 (10,507 square miles). The north and east, the tribal area are bounded by the KP while on the south it is bounded by province of Baluchistan. In the south-east, FATA joins the Punjab province. The Durand Line, which separates Pakistan from Afghanistan, forms the western border of FATA.8 According to the MICS FATA, approximately 3.341 million (33, 41000) people are living in this area under their own century old rules and regulations whereas in 1998 census 3.176 million (31, 76331) people was living in FATA.8, 16 According to the MICS, sex ratio in FATA was 108.7 males rounded to 109 per 100 females which was similar to 1998 censes. FATA has a low literacy rate lack of maternal and child health care facilities and services. It was estimated that literacy rate for the age of 10 years and above was found to be 21.4 percent and overall adult literacy rate (15 years and above) was about 22 percent. Female literacy rate of this age group was about 6.7 percent and 35.8 percent males. Youth literacy rate (15-24 years of age) was 30.7 percent and female youth literacy rate was 12.4 percent.8
Bajaur is one of the seven agencies of FATA, and was declared a FATA in December 1973. Prior to I960, Bajaur Agency remained a semi-independent territory and was considered as an unreachable area. In 1960, Bajaur was declared as a subdivision of Malakand Agency and an Assistant Political Agent (APA) was appointed with his headquarters at Munda. The estimated population in 2104 was 1.173 million (117, 3000) whereas according to 1998 census the population was 0.595 million (595, 227).16, 17 Total covered area is 1290 square kilometers and annual average growth rate from 1998 – 2014 was 4.24 percent with population density of 909 persons per square kilometer. Average household size was 9 individuals.17 According to FATA MICS 2009 sex ratio was 114 males and in 1998 census it was 105 males per 100 females.8 Administratively Bajaur is divided into Khar and Nawagi subdivisions. Khar subdivision include three Tehsils namely Salarzai, Khar, Utmankhel whereas Nawagi division include four Tehsils namely Mamund, Nawagi, Barang, Chamerkand as shown in the map of bajaur.16, 17
Moreover Tehsil Salarzai further consists of four sectors namely upper amadak, lower amadak, upper saddin and lower saddin. So this study was mainly conducted in upper amadak and lower amadak of Tehsil Salarzai. Bajaur have low literacy rate, lack of maternal and child health care facilities and services and also a conflict zone since seven years. According to MICS 2007 literacy rate for the age of 10 and above years was found to be 15.8 percent and adult literacy rate (15 and above years) was 16.5 percent while youth literacy rate (15-24 years) was 25 percent.8, 18 In other hand there two hospital, eight dispensaries, two Rural Health Clinics (RHC), twenty basic health units (BHU), three Tuberculosis (TB) clinic, seven Community Health Center (CHC) and no maternal and child health center. Moreover total 134 Doctors, 20 Nurses and 366 Paramedics were available in 2012-2013 for a huge population.16, 17 Women cannot avail skilled and safe delivery services easily and are highly vulnerable to delivery related morbidity and mortality. This aim of this study was to determine the utilization of skilled birth attendant services and associated factors in general population of the tehsil salarzai and come up with recommendation to improve the utilization of SBAs services and associated factors in the area to decrease MMR burden and save precious lives of women.

42862589535FIGURE: 1.1 Map of Bajaur agency

Source: Development profile of Bajaur Agency
1.2.2: GLOBAL BURDEN OF MATERNAL MORTALITY:According to WHO, “A maternal mortality defined as a death of a woman while pregnant or within 42 days of the end of the pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes”.2
“Pregnancy-related death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death”.

“Late maternal death is defined as the death of a woman from direct or indirect obstetric causes, more than 42 days, but less than one year after termination of pregnancy”.2
Worldwide 830 women died every day from complications of pregnancy and childbirth in 2015. Out of 830 daily maternal deaths, 550 occurred in SSA and 180 in southern Asia, compared to 5 in developed countries.2-4 As estimated globally 13.6 million women died in 25 years between 1990 and 2015 due to the maternal causes. The number of women dying due to complications during pregnancy and childbirth has decreased by 44 percent from 385 in 1990 to 216 in 2015. This translate to a decrease of over 43 percent in the estimated annual number of maternal deaths from 532,000 in 1990 to 303,000 in 2015, and a more than halving of the approximate global lifetime risk of a maternal death from 1 in 73 to 1 in 180. The growth was prominent, but the annual rate of decline was less than 75 percent which was needed to achieve the MDG-5 target 1990 and 2015, which would require an annual decline of 5.5 percent. The 44 percent decline since 1990 translates into an average annual decline of just 2.3 percent. Between 1990 and 2000, the global maternal mortality ratio decreased by 1.2 percent per year, while from 2000 to 2015 progress accelerated to a 3.0 percent decline per year. 2-4 One target under Sustainable Development Goal 3 (SDG) is to reduce the global MMR to less than 70 per 100,000 births, with no country having MMR of more than twice the global average. It is possible to accelerate the decline. Countries have now united behind a new target to reduce MM even further.4
Globally MMR was about 216 per 100,000 live births during pregnancy, child birth and after soon the termination of pregnancy in 2015.2 Majority of these deaths occurred in low resources countries. MM is higher in women living in rural areas and among poorer communities. The Approximate MMR in developing countries was 239 per 100,000 live births which was roughly 20 times higher than that of developed countries, where it was just 12 per 100,000 in 2015.2, 4 MM in Ethiopia was found to be highest in the world with an estimated MMR of 676 deaths per 100,000 live births in 2011 which slightly increased from the 2005 MMR level of 673 deaths per 100,000 live births.5
Extremely high MMR is considered to be ? 1000, very high MMR is 500–999, high MMR is 300–499, moderate MMR is 100–299, and low MMR is < 100.2 The main causes of maternal deaths are hemorrhage, hypertension, infections, obstructed labor, unsafe abortion and indirect causes mostly due to interaction between pre-existing medical conditions and pregnancy.1-4 80 percent of maternal death occur due to hemorrhage, hypertension, infections, obstructed labor, unsafe abortion.6 The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. There are large disparities between countries, but also within countries, and between women with high and low income and those women living in rural versus urban areas.3, 4
“Maternal mortality ratio (MMR) is defined as the number of maternal deaths during a given time period per 100 000 live births during the same time period”.
“Maternal mortality rate (MMRate) is defined as the number of maternal deaths divided by person-years lived by women of reproductive age (or woman-years lived at ages 15–49 years)”.2 The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in pregnancy and childbirth is a leading cause of death among adolescent girls in developing countries. Women in developing countries have more pregnancies as compare to women in developed countries, and their lifetime risk of death due to pregnancy is higher.4 A woman’s lifetime risk of maternal death is 1 in 4900 in developed countries, than 1 in 150 in developing countries. In countries designated as fragile states, the lifetime risk is 1 in 54 showing the consequences from breakdowns in health systems.2, 4
“Adult lifetime risk of maternal death is defined as the probability that a 15-year-old woman will die eventually from a maternal cause”.2, 4 The risk of woman dying from maternal cause is 33 times higher in developing country than in developed country in 2015.2, 3 The study of Nesfin Nigussie et al conducted in 2002 mentioned that lifetime risk of maternal death is forty times higher in developing countries than in developed countries.6 The estimated lifetime risk of a maternal death in Pakistan is 1 in 140 in 2105.2 Two countries in the word with the highest estimated lifetime risk of maternal mortality are Sierra Leone with an approximate risk of 1 in 17, and Chad with an approximate risk of 1 in 18.

1.2.3: BURDEN OF MATERNAL MORTALITY IN PAKISTAN:
Situation of MM has improved during the last few years in Pakistan.18 According to the latest estimate of WHO, UNICEF, UNFPA, World Bank and UNPD, the MMR in Pakistan reduced to 178 per 100,000 in 2015 from 211 per 100,000 live births in 2010 but still far behind from the proposed 140 target of MDG-5 for 2015, so Pakistan failed to achieve MDG target. Pakistan is fifty-third highest number of maternal death (9700) in the world in 2015, following Tanzania (8200), Kenya (8000), Indonesia (6400), Uganda (5700), and Bangladesh (5500).2 According to PDHS 2006-07 MMR was different in rural and urban areas of Pakistan. In rural areas it was about 319 and urban areas was 175 per 100,000 live births so it was about double in rural areas than urban areas. Similarly MMR was different in the different regions of Pakistan. In KP MMR was found about 275 per 100,000 live births whereas in Baluchistan it was 785 per 100,000 live births. In Punjab and Sindh the MMR was about 227 and 314 per 100,000 live births respectively. In Pakistan the MMR was found highest in Baluchistan and lowest in Punjab.7 MMR in FATA was about 380 in 2007 which was significantly decreased up to 290 per 100,000 live birth whereas in GB it was about 450 per 100,000 live birth in 2011-2012.8, 9 21T
Figure1.2 Targets and Achievements – Maternal Mortality Ratio

f
Source: Pakistan Millennium Development Goals Report, 2013
1.2.4: IMPROVING MATERNAL AND CHILD HEALTHPOLICIES AND PROGRAMS IN PAKISTAN:
Maternal and child health remains the focus of policies and programs in Pakistan. Since 2005, efforts to improve child and maternal heal h outcomes in the country have been guided by the policy frameworks i.e. Poverty Reduction Strategy Paper (PRSP) II 2007-09, Health Policy 2009, and the Medium Term Development Framework (MTDF) 2005-10. Some of the major measures undertaken by the government to improve t maternal and child health include:
Expanded Program on Immunization (EPI): aims at protecting children by immunizing them against nine infectious diseases of children and also their mothers against Tetanus.
LHWs Program: Role of LHWs have expanded to identifying pregnant women, providing them with multivitamin supplements, referring them to antenatal care services at BHUs/RHCs and participating in immunization days, in addition to their basic functions of providing family planning services along with basic health care.
Maternal, Neonatal and Child Health (MNCH): It aims to improve MNCH services and provide better access to high quality MNCH ; Family Planning (FP) services. Provide comprehensive Emergency Obstetric and Neonatal Care (EmONC) services in 275 hospitals and health facilities and FP services in all health facilities. Moreover train 10,000 Community Health Worker (CHW) and nutrition worker.
Micro Nutrient Deficiency Control Program: Under the guidance of the Nutrition through Primary Health Care (PHC) program, micronutrient supplementation for anemia control, vitamin A supplementation to children under five years of age, micro nutrients to women of child bearing age, growth monitoring, counseling on breast feeding and weaning practices and awareness are being provided through LHWs. The basic objective of various policies (MDTF, PRSP II and Health Policy 2009) in context of maternal health includes reducing the widespread of communicable diseases, addressing inequalities in primary and secondary health care facilities, correcting urban biases, bridging the basic nutritional gaps and improving the drug sector to ensure the availability, affordability and quality of drugs.18

GLOBAL ACTION
Pakistan was a signatory to the Millennium Declaration and was committed to achieve theMDGs.7 Under MDG 5, Pakistan aims to reduce MMR by three-quarters and ensure universal access to reproductive health. Improvement on MDG 5 was measured against five indicators: MMR, proportion of births attended by SBAs, contraceptive prevalence rate (CPR), total fertility rate (TFR), and proportion of women aged 15-49 years who gave birth in the last three years who had at least one antenatal consultation. In 2006-07 the MMR was 276 per 100,000 live births whereas in 2012-13 proportion of births attended by SBAs was 52 percent, CPR was 35 percent and TFR was 3.8. Similarly proportion of women aged 15-49 years who gave birth in the last three years who had at least one antenatal consultation was 68 percent in 2011-12. Pakistan has shown progress on all indicators for their MDG 5, but despite this, it was off track on all indicators and therefore unlikely to achieve MDG 5.9 (Table 1.1)4195445-20472405103495-20364453284220-2040890
-66675314325Table 1.1 Situation of indicators MDG-5 Table 1.1 Status of Indicators- MDG –
Source: Pakistan Millennium Development Goals Report, 2013
1.2.5: ROLE OF SKILLED BIRTH ATTENDANTS IN MATERNAL MORTALITY:WHO defines a skilled birth attendant (SBA) “as an accredited health professional such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”.15
SBAs can play an important role to minimize maternal morbidity and mortality.1 WHO also recommends that every woman be attended by SBAs during delivery to improve maternal and newborn health and survival, and the rate of deliveries attended by SBAs was considered a measure of progress towards achieving the millennium development goal of reducing maternal and neonatal mortality.12 WHO recommends that delivery be attended by SBAs to reduce delivery related complications and improve the maternal and newborn health and survival. The WHO also strongly advocates for skilled care at every birth to reduce the global burden of 536, 000 maternal deaths every year.1, 12 The proportion of births attended by SBAs directly impacts on the MMR.9 It is estimated that SBAs presence at delivery could prevent about 16 percent to 33 percent of maternal deaths and SBAs presence at delivery may impact on the rates of stillbirths and neonatal mortality.13 Globally more than 80 percent of maternal deaths is due to five direct obstetric causes, hemorrhage, sepsis, unsafe abortion, obstructed labor and hypertensive diseases. Most of these deaths can be preventable and treatable if women have access to essential obstetric care during pregnancy.1
1.2.6: GLOBAL PREVALENCE OF UTILIZATION OF SBAs SERVICES:The SBAs was one of the indicators of MDG-5 to improve maternal health. The global target was more than 90 percent SBAs in delivery for 2015.9 Overall the proportion of deliveries attended by SBA in developing regions increased from 53 percent in 1990 to 61 percent in 2007, still in South Asia and SSA it was remained less than 50 percent. It is also estimated that the proportion of SBAs births in these regions is significantly lower in rural areas than in urban areas.13
1.2.7: PREVALENCE OF UTILIZATION OF SBAs SERVICES IN PAKISTAN:Pakistan is sixth most populous country in the world, having a population of 184.5 million. Population growth rate is 2 and average fertility rate is 3.8.14 Pakistan also has fifth largest youth population with 53 percent of population under 19 years of age.19 Two-third of the population is rural and forty nine percent population is estimated to belong to the low socioeconomic group, mostly in the rural areas.20 In Pakistan approximately more than half of birth (52 percent) take place in home without the assistance of SBAs except 4.4 percent whereas less than half (48 percent) take place in health facility. In Pakistan the prevalence of SBAs increased from 18 per 100 child birth in 1990-1991 to 52 per 100 child birth in 2012-2013 but still lag behind the proposed target of more than 90 percent and the Pakistan was off track in this indicator.9 However the proportion of SBAs in rural areas were less than urban areas. In urban areas about 71 percent deliveries were attended by SBAs whereas in rural areas about 44.4 percent were attended by SBAs in 2012-2013.14 Similarly the proportion of SBAs is vary in different regions of Pakistan. The province of Sindh has best performed in this indicator among all provinces of Pakistan with a reported value of 60.5 percent in 2012-2013. Punjab has lagged behind Sindh, with SBAs at 52.5 percent which hover around the national average of 52 percent in the same years. The proportion of SBAs in KP and Baluchistan were found to be 48 percent and 18 percent in KP and Baluchistan respectively. Baluchistan was found to be lowest among the regions of Pakistan which had reached the peak of 45 in 2010-2011. In Islamabad 9 in 10 (88 percent) have attended by SBAs as compare 43.7 percent in GB. In Azad Jammu and Kashmir (AJ&K) and FATA the proportion of SBAs was 47 percent and 55 percent respectively in 2011-2012.14, 9
-28575370205Figure 1.3 Targets and Achievements – Birth Attendanted by Skilled Birth attendant (%)
Source: Pakistan Millennium Development Goals Report, 2013
1.2.8: TYPES OF SKILLED BIRTH ATTENDANTS:The main types of SBAs which found in many countries include:
Midwife: Person who regularly admitted to an educational program duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.

Nurse with midwifery skills: Nurse who has acquired midwifery knowledge and skills either as a result of midwifery being part of their nursing curricula or through special post basic training in midwifery.

Doctor with midwifery skills: Medical doctor who have acquired competency in midwifery skills through specialist education and training, either during their pre-service education or as part of a post-basic program of studies.

Obstetricians: Medical doctor who have specialized in the medical management andcare of pregnancy and childbirth and in pregnancy-related complications, but not usually complications of the newly born infant. They have usually undergone additional education and clinical training to acquire these additional skills and have been certified or accredited in obstetrics.15
1.2.9: FACTORS AFFECTING UPTAKE OF SBAs:Many studies have mentioned that many factors have observed to contributed in uptake of SBAs are include poverty, lack of education, gender inequality, cultural restrictions, unavailability of health facilities, place of residence, poor reproductive health services, lack of SBAs.1, 10, 21
POVERTY:
Poverty is the major factor for utilization of health care services. In generally the participants with low income status are less likely to utilize and access to modern health facilities and services, whereas participants with higher income status take the initiative in seeking care for themselves and for their children.1 Low economic status in our country is increasing the frequency of unsafe abortions and huge economic burden exert a important reduction in providing the basic health care facilities to the people of our society.10
LACK OF EDUCATION:
Education is another important factor contributing the utilization of SBAs services. Low literacy rate of participants associated with low utilization of SBAs as compare to literate participants.1, 10 literacy rates in Pakistan especially in rural areas of Pakistan is one of the lowest in the world that keeps the participants ignorant and uninformed about their reproductive health. Low literacy also keeps the participants unaware about their rights and facilities provided. Improving literacy rate in participants can reduces the prevalence of abortions and can improve the utilization of SBAs services.10
GENDER INEQUALITY:
It is widely accepted that increased gender equality is prerequisite for obtaining enhancement in maternal health and child health.1 Gender inequality is widely exists in many developing countries mostly in South Asia. Gender inequality is found to have destructive effect and associated with maternal and child health. Gender inequality enable participants to have little empowerment to make decision about their own reproductive health choices. Participants have no right to decide when to have delivery.10
CULTURAL RESTRICTIONS:
Culture restrictions include male dominance, not availability of males, absence of husbands from home, devaluing of female, family traditions of not seeking of health care facilities and hesitancy on their own to go to health facility without the head of the family.8 These cultural restrictions in developing countries especially in remote and rural areas prevent the participants from accessing and utilizing essential health care services during pregnancy, childbirth and postpartum period. So cultural restrictions negatively impact the utilization of SBAs services.1
UNAVAILABILITY OF HEALTH FACILITIES:
In developing countries like Pakistan, Nepal and Ethiopia low utilization of SBAs services is not only caused by economic, educational, cultural and religious reasons but also the unavailability of health facilities.1 Participants living in the rural and remote areas cannot access to adequate health care facility for maternal care due to unavailability of health care facility.10 Unavailability of health facility is one of the important reasons behind the physical delay in arrival to an appropriate health facility.10
PLACE OF RESIDENCE:
Around the world maternal health care different within and between developing countries. A systematic review of inequalities in the use of maternal health care in developing countries mentioned that within countries, women living in urban areas were more likely to deliver with the help of SBAs than the women living in rural areas.1 Like other developing countries in Pakistan the institutional deliveries is highest (68 percent) in urban areas as compare to (40 percent) in rural areas. The urban-rural difference in institutional deliveries within regions was highest in Sindh (78 percent and 47 percent, respectively). In KP, the corresponding proportions were 63 percent in urban areas and 36 percent in rural areas.14 This is due to the majority of women living in rural areas and do not have access to receive adequate antenatal, intra natal and post natal care because of unavailability of adequate health care facility to provide the care during pregnancy.10
POOR REPRODUCTIVE HEALTH SERVICES:
In developing countries, like Pakistan and Nepal, low use of SBAs during pregnancy and child birth is not only caused by economic, geographic, cultural and religious reasons but also by institutional problems.1 Inadequate and insufficient maternal health services leads to delay in getting the maternal services.10 Pakistan has a good healthcare system which encompasses a Basic Health Unit (BHU), a Rural Health Center (RHC) and a tertiary unit. The available reproductive healthcare services are free of charge. However, BHU and RHC services are underutilized due to inaccessibility, poor referral system and unavailability of working ambulances. In most rural areas, broken roads and unavailability of proper ambulance services hinder the timely transfer of women to health facility. A cross-sectional survey on EmOC services revealed that in Pakistan more than 50 percent of public health facilities lacked female physicians to provide EmOC services; this shortcoming acted as a barrier to using reproductive healthcare services by women.13
LACK OF SKILLED BIRTH ATTENDANTS:
Human resources are an important factor in health care. The evidence suggests that maternal mortality is responsive to the availability of skilled health workers. As in many developing countries, rural health services are facing numerous problems, lack of SBAs is one of them that affect the utilization of SBAs services.1 SBAs are considered important in reducing maternal and neonatal mortalities. Unfortunately most of the deliveries in rural areas of Pakistan take place at home by untrained health personnel such as traditional birth attendants (TBAs) and dais due to lack of SBAs.10 In Pakistan 52 percent delivery have attended by SBAs in 2012-2013. The utilization of SBAs in urban areas was more (71 percent) than rural areas (44 percent). The main reason is lack of SBAs in rural areas of Pakistan.14
The high number of maternal deaths in some areas of Pakistan reflects inequities in access to health services, and highlights the gap between rich and poor. There are large disparities within country and between women with high and low income and those women living in rural versus urban areas. Disparities in the distribution of resources are the more common issue of Pakistan especially in marginalized areas. So need and evidence based policies are required to make best use of limited available resources and to develop possible health resources as well to focus on key issues which contributing to poor utilization of SBAs services and develop more effective interventions for improving utilization of SBAs services especially in rural areas of Pakistan. Strengthen the available health facilities by provision of human resources, equipments and other necessary resources. Strengthen the professional capacity of the available health care providers and other staff. For the creation of general awareness, health and related problems and utilization the health services for these problems the education should common in general population. High cost of health services utilization is the most common hurdle in the utilization of any health services in Pakistan like other developing countries so special health policies for the poor community of Pakistan, like health insurance, health cards and other health programs should launch to provide low cost health services for improvement of utilization of SBAs services as well as other health services. Change the policies for distribution of the basic resources like education, health facility, health care provider and other necessity. The result of the study is very important for policy makers as documented in the reproductive health road map to improve maternal health in general and increase the utilization of SBAs services by promoting quality antenatal care, make mother have skilled assistance during their delivery and developed a force to perform EmOC.
1.2.10: CONCLUSION:
Globally 830 women died every day from complications of pregnancy and childbirth in 2015. Maternal mortality ratio (MMR) was about 216 per 100,000 live births during pregnancy, child birth and after soon the termination of pregnancy in 2015. Almost 99 percent maternal death occurred in developing countries.2-4 Pregnancy and child birth complications are a leading cause of death and disability among women of reproductive age in the developing countries of the world.1 The approximate global lifetime risk of a maternal death reduced from 1 in 73 in 1990 to 1 in 180 in 2015.2 The estimated lifetime risk of maternal death in developing countries was 1 in 150 while in developed countries was 1 in 4900 in 2015.2, 4 According to the latest estimate of the MMR in Pakistan reduced to 178 per 100,000 in 2015 from 211 per 100,000 live births in 2010. The estimated lifetime risk of a maternal death in Pakistan is 1 in 140 in 2105.2 The main factors which have observed to contributed in MMR are include poverty, lack of education, lack of empowerment, gender inequalities, early marriage, cultural restrictions, unavailability of health facilities, poor reproductive health services, lack of SBAs.10 SBAs can play a major role to improve outcome during delivery and postpartum by detecting and managing early complications of pregnancy and delivery.12 The WHO also strongly advocates for skilled care at every birth to reduce the global burden of 536, 000 maternal deaths every year.1
Thus it is compulsory to do more quantities research to address the issues and problems for developing appropriate health care services for utilization of SBAs services for delivery.
CHAPTER 2METHODS AND MATERIALS2.1: STUDY DESIGN: Community base cross sectional study.

2.2: STUDY DURATION: This study was from November 2015 to April 2016 so the duration of study was 6 months.

2.3: STUDY SETTING: This study was conducted in Tehsil Salarzai Bajaur Agency
2.4: STUDY POPULATION: All participants having delivery in last one year
2.5: INCLUSION CRITERIA& EXCLUSION CRITERIA:INCLUSION CRITERIA: Women having Delivery in last one year were included in the study.

EXCLUSION CRITERIA: Participants not willing to participate were not included in the study.

2.6: SAMPLINGSAMPLE SIZE: Sample size was calculated through “open source epidemiologic statistics of public health (openEpi)”.

n = DEFF*Np(1-p)/ (d2/Z21-?/2*(N-1)+p*(1-p)
n= sample size
N= target population size =9002
P= anticipated prevalence =48%
DEFF= Design effect (for cluster survey) = 1.8
d= margin of error = 5%
Z= standard normal deviation which is usually see at 1.96 which correspond to 95% confidence interval.

10% non-responded added to the sample size then final sample size was 730.

SAMPLE TECHNIQUE:Multi stages stratified clusters sampling technique was used to collect the data of a required sample size which was 730. There were four sectors in Tehsil Salarzai. Two sectors out of these four sectors were selected randomly that were Lower amadak (Lar amadak) and Upper amadak (Bar amadak). The houses were selected randomly from these two sectors through polio campaign micro plan. Total 15 villages were selected randomly from these two sectors. Out of 15 10 villages from Lar amadak and 5 villages from Bar amadak which was proportionate to their population. From each village of Lar amadak 53 women were selected so total 530 women selected from Lar amadak and 40 women were selected per village of Bar amadaks so 200 women were selected from Bar amadak.

From each house only one woman was selected which have delivery more recently. If more than one eligible participant were available in the house then participant was selected having delivery more recently.

2.7: ETHICAL CONSIDERATION:Ethical approval was obtained from ethical board of KMU. Permission was obtained from local administration of Bajaur agency and from local leaders and houses elders.

Informed consent (verbal/written) was obtained from the participants.

2.8: DATA COLLECTION PROCEDURE:This questionnaire based cross sectional study was conducted in Tehsil Salarzai of Bajaur Agency. Approval was obtained from AS&RB, and ethical approval from ethical board of KMU, Peshawar. Permission was obtained from local administration of Bajaur Agency and from local leaders and houses elders.

Standard modified questionnaire was used for data collection. For making it easy for participants the questionnaire was first translated in local language that is Urdu and Pashto. For its reliability it was pilot tested on a sample of 36 (5% of total sample size). Questionnaire consists of three parts. The first part includes social and demographic data, the second part includes obstetric history and third part includes history of recent delivery. Before enrollment in study, the purpose of the study was explained to participants and Informed consent (Verbal/written) was obtained. Data was collected through LHV and Nurse. Sessions were arranged to discuss the proposal and questionnaire with data collectors and how use the questionnaire and collect data. The data was collected through face to face interview technique from participants in their houses using pilot tested standard modified questionnaire.
A sample of 730 participants living in Lar amadak and Bar amadak, fulfilling the inclusion and exclusion criteria was obtained using consecutive sample technique. From each house only one woman was selected. If more than one eligible participant were available in the house then participant was selected having delivery more recently. Participation enrolled in study was totally voluntary and some participants having fulfilling the inclusion criteria but didn’t want to participant due to unknown reasons. Data was collected for socio and demographic like age of participants, education status of participants and their spouse, family monthly income, availability of health facility and health care provider in the sector of participants, obstetric characteristics like parity, ANC received for recent delivery, total number of ANC visits, gestational age of first ANC, received advise for delivery during ANC, recent delivery characteristics like place of recent delivery, received SBAs services, type of birth attendant, decision maker, history and type of complication and choices for next delivery like preferred place and birth attendants of participant and their spouse.
Age of participants was record as continuous variable as completed in years at the time of interview and verified from her national identity cared if available and participants her family member and relative like husband, mother and father. For analysis the age was categorized in three categories that are < 20 years, 21 – 30 years and > 30 years. Education status was assessed on the bases of two categories, uneducated and educated whereas the education status of their spouses was assessed in three categories, uneducated, educated up to matric and above matric. Family monthly income was categorized in < 10,000, 11,000 – 20,000, 21,000 – 30,000 and > 31,000 in PKR. Information was obtained about availability of health facility and their distance from home in km. Similarly information was also obtained about availability of health care provider and their type. ANC visits during recent pregnancy was categorized as < 4 visits and > 4 visits, base on the WHO criteria that the women have minimum of four ANC visits during pregnancy.14, 22 Information was also obtained about parity, place of delivery, type of birth attendant, decision maker and history of complication of recent delivery. Some information was obtained about next delivery like preferred place, preferred assistant of participant and husband preferred place for next delivery.

There are four sectors namely Lar amadak, Bar amadak, Lar sadin and Bar sadin in Tehsil Salarzai of Bajaur Agency. Two sectors i.e Lar amadak and Bar amadak were selected randomly out of four. Total 15 villages were selected randomly from these two sectors. Out of 15 villages 10 villages from Lara madak and 5 villages from bar amadak which was proportionate to their population were selected randomly. From each village of lar amadak 53 women were selected so total 530 women selected from Lar amadak and 40 women were selected per village of bar amadak, so 200 women were selected from bar amadak, fulfilling the inclusion and exclusion criteria of recent delivery.

2.9: DATA ANALYSIS:
Data was entered and analyzed by using Statistical Package for Social Science (SPSS) version 22. Mean and standard deviation were calculated for continuous variables such as age, family monthly income, number of antenatal care visits, number of pregnancies and number of live birth. Frequency and proportion were calculated for categorical variables such as occupation of respondent, level of education, antenatal care receive, types of skilled birth attendants, place of delivery. Cross tabulations was done to determine the independent variables across the categories of outcome variables (Skilled delivery, and unskilled delivery). For these, results were compared by using Chi-square test for categorical variables and p < 0.05 was considered significant. Method of Logistic regression was performed to calculate odds ratio for determining the likelihood of delivery with SBAs for continuous and categorical variables. Univariate analysis was performed to determine association of SBAs services utilization and risk factors. Odds ratio and p-value were calculated for the attributes. P-value of 0.05 was taken as significant for the univariate analysis. Multiple logistic regression analysis was done to eliminate the confounders as well identifying the individual effects of the factors. Multivariate analysis was done on variables, found significant on univariate analysis (P ? 0.25). Adjusted Odds ratio was calculated, after adjusting for confounding variables. A cut off of P < 0.05 is taken as significant for the logistic regression.

CHAPTER 3RESULTS AND DISCUSSION3.1: RESULTSTotal of 730 participants were included in the study. Data was collected about social demographic, obstetric history and history of the recent delivery characteristics of study participants.
3.1.1: DESCRIPTIVE ANALYSISOverall characteristics of study participants (women)
Table 3.1 shows Mean ± Standard deviation for participant characteristics. There were 730 participants in the study. Mean age of participant were 26.3 ± 5.954 and mean monthly income of family was 23243.15 ± 12988.551 Pakistani rupees (PKR). Mean distance of the health facility from residence was 5.48 ± 4.46 Km. The first antenatal visit was made at mean gestational age of 16.93 ± 7.79 and the average number of antenatal care visits were 3.28 ± 1.206.
Table 3.1: Descriptive analysis of characteristics of study participants (Women) N = 730
Characteristics Mean ± Standard deviation
Age of Participant (years) 26.30 ± 5.95
Family monthly income (PKR) 23243.15 ± 12988.55
Average distance of nearest health facility from home (Km) 5.48 ± 4.46
Total number of pregnancies 3.71 ± 2.11
Total number of children 3.61 ± 2.1
Total number of stillbirths 1.35 ± 0.71
Gestational age of first antenatal care visit (weeks) 16.93 ± 7.79
Total number of antenatal care visits 3.28 ± 1.20
Table 3.2 shows the social & demographic characteristics of the participants. Information was obtained about participant’s age, occupation and education level. Occupation, education Level of husband, family monthly income was also inquired about. 437 (59.9%) participants were between 21 and 30 years of age while 158 (21.6%) participants age was > 30 years. 715 (97.9%) participants were housewives and 713 (97.7) participants were uneducated. Husbands of 583 (79.9%) participants were daily laborers, 47 (6.4%) were merchants (Figure 3.1). 519 (71.1%) husbands of participants were uneducated and 183 (25.1%) had up to secondary school education. Monthly income of 375 (51.4%) participants was in the range of 11,000 – 20,000 PKR, while 149 (20.4%) participants monthly income was ? 31,000 PKR. Data was also collection about the presence of health facilities in the participant sector. Health facilities were available in their sectors as reported by 610 (83.6%) participants. Similarly nearest heath facilities from homes were at the distance of ? 5 km as reported by 610 (83.6%) participants. 58% participants reported that there is no health care provider in their sectors, whereas about 34% participants stated that health care provider were available in their sectors. About 96% participants stated that LHVs were available in their sectors.
Table 3.2: Descriptive analysis of social demographic characteristics of the study participantsCharacteristics N = 730 Percent (%)
Age of participant (years):
? 20 135 18.5
21 – 30 437 59.9
> 30 158 21.6
Education status of participant:
Uneducated 713 97.7
Educated 17 2.3
Education level of husband:
Uneducated 519 71.1
? Matric 183 25.1
> Matric 28 3.8
Family monthly income (PKR):
? 10,000 93 27.7
11,000 – 20,000 375 51.4
21,000 – 30,000 113 15.5
? 31,000 149 20.4
Availability of health facility in participant sector:
Yes 610 83.6
No 120 16.4
Nearest health facility from participant home:
? 5 Km 610 83.6
11–15 Km 120 16.4
Availability of health care worker in participant sector:
Yes 249 34.1
No 424 58.1
Don’t know 57 7.8
Type of health care worker in participant sector:
Nurse 134 18.4
LHV 106 14.5
TBA 9 1.2
Table 3.3 shows the descriptive analysis of obstetric characteristics of the participant. Information about maternal health problems in the community, parity, history of still birth, antenatal care visits made during recent pregnancy, total number of antenatal care visits, gestational age at first antenatal care visit, reasons for receiving/not receiving antenatal care and any advice received about where to deliver, during antenatal care. 460 (63.0%) participants were multipara and 142 (19.5%) participants were grand multipara. 52 (7.1%) participants had history of stillbirth. 423 (57.9%) participants received ANC during the last pregnancy and out of 423 (57.9%) participants, 165 (39%) women have made ? 4 ANC visits. 212 (50.1%) participants made their first ANC visit at < 12 weeks of gestation and 133 (31.4%) participants between 13–24 weeks of gestation. Among the participants who received ANC, 331 (78.2%) participants received due to their sickness. 233 (55.1%) participants received advice about “where to deliver” during ANC. Reasons stated for not attending ANC included lack of awareness about the importance of ANC 92 (30%) and afraid of user fee 52 (16.9%) (Figure 3.2). Maternal health problems in the community as reported by the study participants mainly included pregnancy related problems 245 (33.6%), far of health facility 131 (17.9%) and inadequate health care 102 (14%) (Figure 3.3).

Table 3.3: Descriptive analysis of obstetric characteristics of the study participantsCharacteristics N = 730 Percent (%)
Parity:
Primipara 128 17.5
Multipara 456 62.5
Grand multipara 146 20.0
Antenatal care received for recent pregnancy:
Yes 423 57.9
No 307 42.1
Total number of antenatal care visits:
< 4 Visits 258 61.0
? 4 Visits 165 39.0
Gestational age of first antenatal care visit (weeks):
? 12 weeks 212 50.1
13–24 weeks 133 31.4
> 24 weeks 78 18.4
Received advice for delivery during antenatal care:
Yes 233 55.1
No 190 44.9
Table 3.4 shows the information about the recent delivery of participant. 412 (56.4%) participants had home deliveries in last pregnancies, 329 (45%) participants were assisted by SBAs in their deliveries. Deliveries of 283 (56.4%) participants were attended by mother in laws and 247 (33.8%) by LHVs. The main reasons given for home delivery were easy labor 182 (44.2%) and afraid of user fee 130 (31.6%) (Figure 3.4). Sickness was most stated reason for having delivery at health facility 269 (84.6%) (Figure 3.5). Decision for selecting the place of delivery was made by the 172 (23.6%) participants themselves, in 314 (43%) cases decision was made by both husbands and wives together while in 227 (31.3%) cases place of delivery was decided by mother in laws alone. Almost all participants 727 (99.6%) reported that there is a difference in delivery at home and health facility. 475 (65.1%) and 116 (15.9%) respectively stated that delivery at health facility is better because the lives of mother and child can be saved (Figure 3.6). 333 (45.6%) participants favored home due to privacy and 272 (37.3%) due to no cost (Figure 3.7). 589 (80.7%) participants were history of complication in the recent delivery. The common complications that participants experienced during recent delivery included difficult labor 293 (40.1%), hemorrhage 188 (25.8) and prolonged labor 76 (10.4%).
Table 3.4: Descriptive analysis of recent delivery characters of the study participants
Characteristics N = 730 Percent (%)
Place of delivery in recent/last pregnancy:
Home 412 56.4
Health Facility 318 43.6
Received skilled birth attendant services:
Yes 329 45
No 401 55
Type of birth attendant for recent delivery:
Mother in law 283 38.8
LHV 247 33.8
Relative 82 11.2
Obstetrician 34 4.7
Neighbor 28 3.8
TBA 8 1.1
More than one 48 6.6
Decision maker for recent delivery:
Both of us 314 43.0
Mother in law 227 31.1
Myself 172 23.6
My husband 11 1.5
Father in law 6 0.8
History of complication of recent delivery:
Yes 589 80.7
No 141 19.3
Type of complication of recent delivery:
Difficult labor 293 40.1
Hemorrhage 188 25.8
Prolonged labor 76 10.4
Retain placenta 15 2.1
Stillbirth 9 1.2
Mal presentation 7 1
Table 3.5 shows the information about choices for next delivery of participant. Home was preferred place for next delivery both by the participants 621 (85.1%) and their husbands 617 (84.5%) while 503 (68.9%) participant preferred mother in law as birth attendant for the next delivery and 112 (15.3%) preferred doctor.

Table 3.5: Descriptive analysis of choices for next delivery of study participantsCharacteristics N = 730 Percent (%)
Preferred place for participant next delivery:
Home 621 85.1
Health facility 109 14.9
Preferred assistant for participant next delivery:
Mother in law 503 68.9
Doctor 112 15.3
Relative 90 12.3
Neighbor 20 2.7
TBA 5 0.7
Husband preference place for participant next delivery:
Home 617 84.5
Health facility 113 15.5
3.1.2: ASSOCIATION OF SOCIAL AND DEMOGRAPHIC, OBSTETRIC AND RECENT DELIVERY CHARACTERISTICS WITH SBAs
Table 3.6 shows the association of social and demographic characteristics of participants with their utilization of SBAs. Age of participants was significantly associated with SBAs services utilization (P = 0.002). Women below 20 years of age showed preference for skilled delivery (23.4% vs 14.5%) as compare to women above 30 years of age (17.6% vs 24.9%). Housewives didn’t utilize the services of SBAs for their delivery. Education level of participants was found to be associated with utilization of SBAs services (P = 0.002) as education participants had more skilled deliveries (4.3% vs 0.7%). The occupation (P = 0.027) and education level of husbands (P = 0.004) were found to have significant association with selection of type of birth attendant. Participants whose husbands were daily laborer (79.9% vs 89%) had more deliveries with non SBAs. Similarly participants whose husbands were uneducated also had more deliveries with non SBAs (69% vs 72.8%). Utilization of the services of skilled birth attendant for delivery was not influenced by monthly income of the family (P = 0.677). Availability of health facility in the participants sector was found to be significantly associated with utilization of the services of SBAs (P = < 0.001). Participants preferred skilled delivery, where the health facility is available in their sector Similarly distance of the nearest health facility from home in the participants sector was also found to be significantly associated with skilled delivery (P = < 0.001). Participants who resided within a distance of < 5 Km from health facility showed interest in skilled delivery (72.2% vs 88.8%). Availability of health care provider in the participants sector was found to be significant association with utilization of SBAs services (P = < 0.010). Participants who reported that health care provider were not available in their sector have preferred skilled delivery (63.2% vs 53.8%) than the participants who reported that health care provider were available in their sector (31.6% vs 36.2%). However, type of heath care provider was not significantly associated with SBAs services (P = 0.592).
Table 3.6: Descriptive analysis of social and demographic characteristics associated with birth attendant services
Characteristics Birth attendant
Skilled Unskilled Total
N (%) P-Value
N (%)
329 (45) N (%)
401 (55) Age of participant (years):
? 20 77 (23.4) 58 (14.5) 135 (18.5) 0.002
21 –30 194 (59.0) 243 (60.6) 437 (59.9) > 30 58 (17.6) 100 (24.9) 158 (21.6) Education status of participant:
Uneducated 315 (95.7) 398 (99.3) 713 (97.7) 0.002
Educated 14 (4.3) 3 (0.7) 17 (2.3) Occupation of husband:
Daily laborer 253 (79.9) 330 (82.3) 583 (79.9) 0.027
Merchant 21 (6.4) 26 (6.5) 47 (6.4) Farmer 5 (1.5) 2 (0.5) 7 (1.0) Government employee 6 (1.8) 0 (0.0) 6 (0.8) Other 44 (13.4) 43 (10.7) 87 (11.9) Education level of husband:
Uneducated 227 (69.0) 292 (72.8) 519 (71.1) 0.004
? matric 84 (25.5) 99 (24.7) (25.1) > Matric 10 (2.5) 18 (5.5) 28 (3.8) Family monthly income (PKR):
? 10,000 40 (12.2) 53 (13.2) 93 (12.7) 0.677
11,000 – 20,000 172 (52.3) 203 (50.6) 375 (51.4) 21,000 – 30,000 46 (14.0) 67 (16.7) 113 (15.5) ? 31,000 71 (21.6) 78 (19.5) 149 (20.4) Availability of health facility in participant sector:
Yes 254 (77.2) 356 (88.8) 610 (83.6) < 0.001
No 75 (22.8) 45 (11.2) 120 (16.4) Nearest health facility from participant home:
? 5 Km 254 (77.2) 356 (88.8) 610 (83.6) < 0.001
11–15 Km 75 (22.8) 45 (11.2) 120 (16.4) Availability of health care provider in participant sector:
Yes 104 (31.6) 145 (36.2) 249 (34.1) 0.010
No 208 (63.2) 216 (53.9) 424 (58.1) Don’t know 17 (5.2) 40 (10.0) 57 (7.8) Type of health care provider in participant sector:
Nurse 52 (15.8) 82 (20.4) 134 (18.4) 0.592
LHV 44 (13.4) 62 (15.5) 106 (14.5) TBA 5 (1.5) 4 (1.0) 9 (1.2) Table 3.7 shows the association of obstetric characteristics of participants with utilization of skilled birth attendant services. Maternal health problems in participant’s community was found to be significantly associated with utilization of SBA services (P = < 0.001). Participants who reported pregnancy related problems (32.2% vs 34.7%), far of health facility (28.6% vs 9.2%) and inadequate health care (13.7% vs 14.2%) have preferred more skilled delivery as compare to the participants who reported nutritional (5.2% vs 8.2%), and frequent pregnancy problems (2.4% vs 7.7%). Parity was significantly associated with utilization of SBAs services (P = .016). Primipara (21.9% vs 14.0%) and multipara (60.2% vs 64.3%) showed preference for skilled delivery. Participants who had the history of still birth were less likely to utilize s services for delivery (6.7% vs 7.5%). However this association was not significant (P = 0.678). Antenatal care received for recent pregnancy had significant associated with utilization of SBAs services (P = < 0.001). Those Participants who received antenatal care for recent pregnancy have preferred skilled delivery (77.8% vs 41.6%) as compare to the participants who did not received antenatal care (22.2% vs 58.4%). However the participants who received < 4 ANC visits have utilized the SBAs services (44.4% vs 27.9%) as compare to the participants who received ? 4 ANC visits (33.4% vs 13.7%). Number of ANC visits was found to be significantly associated with utilization of SBAs services (P = 0.039). The trend of utilization of SBAs services was almost similar between the participants who received advice for delivery during ANC (39.2% vs 25.9%) and the participants who did not receive (38.6% vs 15.7%). However the receiving advice during ANC for delivery was significantly associated with utilization of SBAs services (P = 0.016)
Table 3.7: Descriptive analysis of obstetric characteristics associated with birth attendants services
Characteristics Birth attendant
Skilled Unskilled Total
N (%) P-Value
N (%)
329 (45) N (%)
401 (55) Maternal health problem in participant community:
Pregnancy related problem 106 (32.2) 139 (34.7) 245 (33.6) < 0.001
Far of health facility 94 (28.6) 37 (9.2) 131 (17.9) Inadequate health care 45 (13.7) 57 (14.2) 102 (14.0) Nutritional problem 17 (5.2) 33 (8.2) 50 (6.8) Frequent pregnancy 8 (2.4) 31 (7.7) 39 (5.3) Don’t know 59 (17.9) 104 (25.5) 163 (22.3) Parity:
Primipara 72 (21.9) 56 (14.0) 128 (17.5) 0.016
Multipara 198 (60.2) 258 (64.3) 456 (62.5) Grand multipara 59 (17.9) 87 (21.7) 146 (20.0) Antenatal care received for recent pregnancy:
Yes 256 (77.8) 167 (41.6) 423 (57.9) < 0.001
No 73 (22.2) 234 (58.4) 307 (42.1) Total number of antenatal care visits:
< 4 Visits 146 (44.4) 112 (27.9) 258 (61.0) 0.039
? 4 Visits 110 (33.4) 55 (13.7) 165 (39.0) Received advice for delivery during antenatal care:
Yes 129 (39.2) 104 (25.9) 233 (55.1) 0.016
No 127 (38.6) 63 (15.7) 190 (44.9) Tale 3.8 shows the association of recent delivery characteristics of participants with utilization of skilled birth attendant services. Place of delivery in recent pregnancy had significant association with utilization of SBAs services (P = < 0.001). 401 women had home deliveries and 401 of these participants didn’t utilize the services of SBAs. Decision maker for recent delivery was not association with utilization the services of SBAs (P = 0.778). However the participants have preferred unskilled delivery when the decision was made by mother in law (28.9% vs 32.9%). More participants developed complications in the recent delivery who utilized unskilled birth attendant services (75.1% vs 85.3%). Similarly all types of complications were found to less in the participants who utilized SBAs services. However history of complication and type of complication in recent delivery were found to be significantly associated with utilization of SBAs services (P = 0.001) and (P = 0.004) respectively.

Table 3.8: Descriptive analysis of recent delivery characteristics associated with birth attendants services
Characteristics Birth attendant
Skilled Unskilled Total
N % P-Value
N %
329 (45) N %
401 (55) Place of delivery in recent/last pregnancy:
Home 11 (3.3) 401 (100) 412 (56.4) < 0.001
Health Facility 318 (96.7) 0 (0.0) 318 (43.6) Decision maker for recent delivery:
Both of us 144 (43.8) 170 (42.4) 314 (78.3) 0.778
Mother in law 95 (28.9) 132 (32.9) 227 (31.1) Myself 81 (24.6) 91 (22.7) 172 (23.6) My husband 6 (1.8) 5 (1.2) 11 (2.7) Father in law 3 (0.9) 3 (0.7) 6 (0.8) History of complication of recent delivery:
Yes 243 (75.1) 345 (85.3) 588 (80.7) 0.001
No 82 (24.9) 59 (14.7) 141 (19.3) Type of complication of recent delivery:
Difficult labor 120 (36.4) 173 (43.6) 293 (40.1) 0.004
Hemorrhage 79 (24.0) 109 (27.2) 188 (25.8) Prolonged labor 32 (9.7) 44 (11.0) 76 (10.4) Retain placenta 2 (0.6) 13 (3.2) 15 (2.1) Stillbirth 3 (0.9) 6 (1.5) 9 (1.2) Mal presentation 7 (2.1) 0 (0.0) 7 (1.0) 3.1.3: LOGISTIC REGRESSION ANALYSIS:Logistic regression analysis was made to determine the utilization of skilled birth attendant services in association with social and demographic characteristics, obstetric characteristics and recent delivery characteristics. Univariate and multivariate analysis were done to calculate unadjusted and adjusted odds ratio and p value for the attributes. Multivariate analysis was done for the variables that were found to be significant on univariate analysis (P ? 0.25).
Table 3.9 shows univriate and multivariate analysis of social demographic characteristics associated with skilled birth attendant services utilization. The participant’s characteristics found to be associated with outcome variable on univriate analysis include participant’s age of 21–30 years (OR 2.289, P = 0.001), availability of health facility in the area (OR 3.951, P < 0.001), availability of health care provider (OR 2.226, P = 0.007) and availability of LHV in participant sector (OR 0.083, P = 0.020). The lack of education among participants (OR 0.170, P = 0.006) and their husbands (OR 0.432, P = 0.038) had negative effect on utilization of SBA services. Similarly the participants characteristics found to be associated with outcome variable on multivariate include participants age of 21–30 years (OR 2.017, P = 0.026), availability of health facility (OR 3.094, P < 0.001), availability of health care provider in participant sector (OR 2.965, P = 0.003)
Table 3.9: Univariate and multivariate analysis of social and demographic characteristics associated with skilled birth attendant’s servicesCharacteristics Univariate Multivariate
Odds ratio (95%CI) P-value Odds ratio (95%CI) P-value
Age of participant (years):
21–30 2.289 (1.43–3.662) 0.001 2.017 (1.086–3.748) 0.026
> 30 1.376 (0.946–2.002) 0.094 1.295 (0.792–2.117) 0.303
Education status of participant:
Uneducated 0.170 (0.048–.595) 0.006 0.340 (0.088–1.312) 0.117
Education level of husband:
Uneducated 0.432 (0.196–.954) 0.038 0.497 (0.184–1.341) 0.167
? Matric 0.471 (0.47–1.077) 0.074 0.537 (0.191–1.508) 0.238
Availability of health facility in participant sector:
Yes 3.951 (2.789–5.596) < 0.001 3.094 (1.809–5.293) < 0.001
Availability of health care worker in participant sector:
Yes 2.266 (1.245–4.123) 0.007 2.965 (1.434– 6.129) 0.003
No 1.688 (0.907–3.140) 0.099 3.111 (1.461– 6.624) 0.003
Table 3.10 shows univariate and multivariate analysis of obstetric characteristics associated with utilization of SBA services. The participant’s characteristics which were found to be associated with outcome variable on univariate include ANC received for recent pregnancy (OR 0.204, P < 0.001) and number of < 4 ANC visits received (OR 0.652, P = 0.039). Similarly ANC received for recent pregnancy (OR 0.182, P < 0.001) and number of < 4 ANC visits received (OR 0.395, P = 0.016) were also found to be associated with outcome variable on multivariate analysis.

Table 3.10: Univariate and multivariate analysis of obstetric characteristics associated with skilled birth attendant’s servicesCharacteristics Univariate Multivariate
Odds ratio (95%CI) P-value Odds ratio (95%CI) P-value
Antenatal care received for recent pregnancy:
Yes 0.204 (0.147–0.282) < 0.001 0.182 (0.121–0.275) < 0.001
Total number antenatal care visits:
< 4 Visits 0.652 (0.434–1.979) 0.039 0.395 (0.186–0.841) 0.016
Table 3.11 shows univariate and multivariate analysis of recent delivery characteristics associated with utilization of SBA services. The participant’s characteristics which have found to be associated with outcome variable include history of complication in recent delivery (OR 1.924, P = 0.001), and type of complication of recent delivery that is difficult labor (OR 4.509, P = 0.050), bleeding (OR 4.711, P = 0.045), prolonged labor (OR 4.727, P = 0.051). Similarly type of complication in recent delivery that is difficult labor (OR 5.309, P = 0.045), bleeding (OR 4.923, P = 0.058), prolonged labor (OR 5.267, P = 0.055) were also found to be associated with outcome variable on multivariate analysis.

Table 3.11: Univariate and multivariate analysis of recent delivery characteristics associated with skilled birth attendant’s services
Characteristics Univariate Multivariate
Odds ratio (95%CI) P-value Odds ratio (95%CI) P-value
History of complication of recent delivery:
Yes 1.924 (1.326–2.793) 0.001 1.112 (.447–2.766) 0.819
Type of complication of recent delivery:
Difficult labor 4.509 (0.999–20.344) 0.050 5.309 (1.037–27.183) 0.045
Hemorrhage 4.711 (1.034–21.467) 0.045 4.923 (0.948–25.557) 0.058
Prolonged labor 4.727 (0.997–22.424) 0.051 5.267 (0.967–28.680) 0.055
Other 5.600(4.018–197.453) 0.001 31.949(3.666–278.394) 0.002
3.1.4: FIGURES:
Figure 3.1: Distribution of occupation of husbands

Figure 3.2: Reasons for not receiving antenatal care by the participants

Figure 3.3: Distribution of maternal health problems in participant’s community

Figure 3.4: Reason for recent delivery at home among participants

Figure 3.5: Reasons for recent delivery at health facility among participants

Figure 3.6: Reasons for health facility is better place for delivery among participants

Figure 3.7: Reasons for home is better place for delivery among participants
3.2: DISCUSSION3.2.1: KEY FINDINGS:Community based case control study was conducted to determine the utilization of SBAs services and associated factors. Total of 730 participants were included in the study. Socio-demographic characteristics of participants in our study showed the mean age of participants was almost twenty six years and mean monthly income of family was 23243 PKR. Almost ninety eight percent participants were housewives and uneducated. Approximately eighty nine percent husbands of participants were daily laborers and seventy one percent were uneducated.
Obstetric characteristics showed that almost three fifth of the participants received ANC for recent pregnancy and out of them more than three fifth of the participants received less than four ANC visits. Similarly more than half of the participants received advice for delivery during ANC.

Recent delivery characteristics showed that more than fifty six percent of participants preferred home delivery whereas about forty five percent of participants preferred the utilization of SBAs services. In homes based deliveries almost two fifth of the participants were attended by mother in laws whereas in health facilities based deliveries one third of the participants were attended by LHVs. Participants who delivered at home reported the reason of easy labor and afraid of user fee. Approximately in two fifth cases the decision for selecting the place of delivery was made by both husbands and wives together and about one third cases mother in laws alone whereas about one fourth cases wives themselves were made the decision for selecting the place of delivery. Health facility was preferred for delivery to save the lives of mother and child. Home was said to be a better place for delivery because of privacy and no cost. Choices for next delivery shows that majority of participants and their husbands preferred home for next delivery with assistance of mother in laws. Three fifth of the participants of age 20-30 years have preferred the utilization of SBAs services. Similarly three forth of the participants who received ANC have preferred the utilization of SBAs services. Association of utilization of SBAs services with socio-demographic, obstetrics and recent delivery characteristics was determined.
After controlling a confounding variables age of participants between 20-30 years, availability of health facility in participant sector, availability of health care provider in participant sector, not availability of health care provider in participant sector, ANC received for recent, total number of ANC visit, and type of complication include difficult labor hemorrhage, prolonged were found to be significantly associated with utilization of SBAs services.
3.2.2: DISCUSSION AND COMPARISON WITH OTHER STUDIES:Place of delivery is an important factors influencing the choice of birth attendant. The difference by place of birth was found to be significantly associated with utilization of SBAs services. In our study 43.6 percent of the participants delivered their recent babies at health facility whereas less than half (45 percent) of the participants have utilized SBAs services. Of these 3.3 percent were home deliveries. The study of Rose NM Mpembeni in Southern Tanzania also supported our study finding showing that less half (46.7 percent) of participants delivered their recent babies at health facility whereas skilled delivery was reported by only 44.5 percent of the participants and of these only 3.6 percent were home deliveries.23
Finding of our study regarding utilization of SBAs services also supported by PDHS 2012-2013 showing that coverage of SBAs in KP is about 48.3 percent while in Punjab and Sindh are 52.5 percent and 60.5 percent respectively. Similarly in Baluchistan the SBAs coverage is 17.8 percent which is very less than other regions of Pakistan. Approximately 48 percent of births in Pakistan take place in a health facility and 52 percent deliveries take place at home. In KP nearly 59 percent of deliveries take place at home.14
The study of Jerome K. Kabakyenga et al in South-Western Uganda also reveals the similar finding that 68.7 percent of the participants were utilized SBAs services. Of these 67 percent of the participants delivered their recent babies at health facility under the assistance of SBAs.24 Contrary to our finding the study of Mulunesh Alemayehu and Wubegzier Kekkonen in Ankasha Guagusa Woreda Ethiopia indicated that 20.9 percent of the participants delivered their last babies at health facility whereas only 18.8 percent of them attended by SBAs.5 Similar finding from the study of Harun Kimani et al in Makueni County Kenya also found that 46 percent of total participants delivered their last babies at home under the assistance of un SBAs while 54 percent of participants were delivered at health facility under the assistance of SBAs.12
The study of Nesfin Nigussie et al in north Gondar zone, northwest Ethiopia also indicated that 13.5 percent of total study participants gave birth at health facility under the assistance of SBAs while 86.5 percent of participants gave birth at home under the assistance of un SBAs.6
In our study three forth of the participants who received SBAs services were 21-30 years old and the association of age with utilization of SBAs services was significant. The study of Negalign Berhanu Bayou et al in Ethiopia about utilization of clean and safe delivery services also shows that those who used clean and safe delivery services were 20-34 years old however the differences by age groups were not significant association with utilization of SBAs services.25 The study of Mary Amoakoh-Coleman et al in Ghana also reveal similar finding.26 The PDHS 2006-2007 also indicted that majority of participants who utilized SBAs services were 20-34 years old.7
In our study almost all of participants were housewives and a very few working women including government employees and some other occupations. All government employees had skilled delivery while housewives showed preference for unskilled birth attendants for their delivery. In the study of Mulunesh Alemayehu and Wubegzier Kekkonen in Ankasha Guagusa Woreda Ethiopia majority of study participants were housewives and showed preference for un SBAs for their delivery.5 Another study of Nesfin Nigussie et al in north Gondar zone, northwest Ethiopia also indicated that majority of study participants were housewives and have preferred the utilization of un SBAs for their last delivery.6
Almost all participants in our study were uneducated. Among the educated participants there was preference for skilled delivery. This finding was in line with other studies conducted in Ethiopia and other developing countries. The study of Mulunesh Alemayehu and Wubegzier Kekkonen in Ankasha Guagusa Woreda Ethiopia indicated that Participants who had attained secondary and above educational level were more likely to utilize SBAs services than uneducated. This could be due to the fact that educated participants might have more awareness about and access to health services. Moreover education empowers participants, increasing their autonomy and self confidence to make decision for their better reproductive health needs.5 Occupation of participant’s husbands was associated with SBAs services uptake. Participants whose husbands were daily laborers had more deliveries with unSBAs whereas all participants who husbands were government employees have preferred skilled delivery. Similar finding were also from the study of Harun Kimani et al in Makueni County Kenya indicating that husbands education level and employment status were significantly associated with SBAs uptake. This suggests that there is a role of men in improving maternal and reproductive health outcomes and that promoting male involvement may be an important intervention.12
Majority of participant’s husbands were found to be uneducated in our study. It was observed that utilization of SBAs services was low in the participants who husbands were uneducated. However the preference for skilled delivery was also low among the participants whose husbands were secondary school and above education. Contrary to our finding the study of Harun Kimani et al in Makueni County Kenya revealed that husband’s education above secondary school was associated with a two fold increase in the delivery by SBAs.12 Our study finding shows that majority of participants have preferred the utilization of SBAs services due to sickness during pregnancy and delivery. So in our study the utilization SBAs services were found to be significant associated with condition of participant’s health during pregnancy and delivery. In our study the family income was not found to be associated with the utilization of SBAs service. The study of Baral YR et al in Nepal showed that in participants with low socioeconomic statuses are less likely to utilize health facility whereas high socioeconomic statuses take initiative in seeking care for themselves and for their children.1 Contrary to our finding another study in Ghana also support this statement that wealthier participants as well as those with health insurance coverage are more likely to have skilled delivery compared to poor participants.26
In primary health care level public health facilities were available in both sectors whereas private health facilities were available in only lower amadak. However public health facilities were not provided proper maternal health care. The availability of health facility in the participants sector was significantly associated with utilization of SBAs services. Those participants who reported that health facility was available in their sectors have preferred the utilization of SBAs services. Similarly participants have shown interest in skilled delivery where health facility was available in distance of ? 5 Km from home as compare to the participants where health facility was available in distance of 11-15 Km. Similar to our finding the study of Jerome K. Kabakyenga et al in Uganda indicated that participants who live in rural areas were less likely to be assisted by SBAs as compare to those who living in urban areas. This could be possibly due to lack of easy access to health facilities due to distance and transport problems both in terms of availability and financial ability to pay for transport.24 Another study also indicated that participants who resided in urban areas were more likely to utilize SBAs services as compare to rural areas because of unavailability of health facilities and transports in rural areas.5
Moreover the study of Baral YR et al in Nepal indicated that studies from developing countries like Afghanistan, Bangladesh, Malawi and Nepal have shown that participants living on a distance of one hour travel away from health facility increase the chance of home delivery without the assistance of SBAs as compare to participants living on a distance of less than one hour from health facility. Distance from health facility increase the financial burden on family through transport charges and also time spent.1 In our study majority of participants stated that there were no health care provider available in their sector. Availability of health care provider and type of health care provider in the participants sectors were found to have association with utilization of SBAs services. Baral YR et al indicated that human resources are in important factors in health care. The evidence suggests that maternal mortality is responsive to the availability of skilled health workers. Moreover the author indicated that the participants from an urban of Nepal six times more likely to delivered with help of SBAs as compare to the participants from rural area. This is due to qualified staff are often based on urban areas and hospitals.1
Birth order was found to be significantly affecting the utilization of SBAs services. Primipara and grand multipara did not preference for utilization of SBAs services whereas the multipara gave preference for skilled delivery. The study of Nesfin Nigussie et al has showed that probability of giving birth at health facilities decreased in grand multipara as compare to primipara and multipara. Many studies reported that primiparas and grand multiparas are at high risk of maternal mortality and morbidity as well as poor delivery outcome.6 A cross sectional study of Mary Amoakoh-Coleman et al have also shown that skilled delivery in the of grand multipara decreased as compare to primipraa and multipara. As the birth order increased the trend and chance of skilled delivery and skilled care decreased among the participants.26 Similar to our study the parity was found to be significantly associated with utilization of SBAs services.26, 6 The study of Negalign Berhanu Bayou et al in Ethiopia mentioned in their study that utilization of clean and sale services package was more in primiparas as compare to multipara and grand multipara but the association was no significant.25
Our study findings showed that approximately two third of the participants have received ANC for recent pregnancy and about two fifth of the participants who received ANC make four and more than four ANC visits during their pregnancy. According to Pakistan demographic health survey (PDHS) 2012-2013 statistics also supported this finding showing that approximately one third of the participants make four or more than four ANC visits for their pregnancy. Antenatal care is more beneficial in preventing adverse pregnancy outcomes when it is sought early in the pregnancy and is continued through delivery.

WHO also recommends a minimum of four ANC visits to provide sufficient antenatal care and avoid pregnancy complications.14 The guideline development group (GDG), related group of WHO, stresses that four visit focused ANC (FANC) model does not present women sufficient contact with health care practitioners and is no longer recommended. Therefore WHO recommended the new model called “the 2016 WHO ANC model” which change the previous four visits FANC. This ANC model consists of minimum eight ANC visits to decrease perinatal mortality and improve women’s experience of care.27 Participants who received ANC in this study have preferred for utilization of SBAs services as compare to those participants who did not received ANC. Similarly the participants who received four and more than four ANC visits have delivered under the assistance SBAs as compare to the participants who received less than four ANC visits. In our study receiving of ANC for pregnancy as well as number of ANC visits have found to significantly associate with utilization of SBAs services. It could be due to the fact that ANC expose the participants to more health education and counseling both of which are likely to increase utilization of SBAs services. It has also mentioned by the study of Negalign Berhanu Bayou et al in Ethiopia and other studies.25 ANC receiving is one of the factors which were identified in the study of Jerome K. Kabakyenga et al in South-Western Uganda to be significantly associated with utilization of SBAs assistance. Antenatal care visits provide an opportunity for expectant mothers to be assessed for possible risks and also provide an opportunity for women to be educated on use of maternal health care services.24
This finding was consistent with the studies done in developing countries including Ethiopia, Nepal, Tanzania and Cambodia. It could be due to the fact that as the number of ANC visits increase the participants will be aware with basic information of pregnancy and delivery related risks which required SBAs services.5
Gestational age at first ANC visit of majority of participants was ? 12 weeks and 13-24 weeks. Mean gestational age at first ANC visit was about 16.93 ± 7.79 weeks. This indicated that participants in study area started receiving ANC relatively late in pregnancy. The study of Nesfin Nigussie et al in north Gondar zone, northwest Ethiopia also indicated the same finding that mean gestation age at first ANC visit was 5.2 ±1.6 months. This also indicated that participants start ANC visit late in pregnancy.6
Those participants who received ANC for their recent pregnancy majority of them have reported the reason of sickness and some participants reported the reason to know the fetus status and to know their health status. In our study more than half of the participants received advice about “where to deliver” during ANC and two fifth of them have preferred the utilization of SBAs services. Advising participants for delivery during ANC was significantly associated with utilization of SBAs services for delivery. Study conducted by Rose NM Mpembeni et al in Southern Tanzania mentioned the similar finding that those participants whose advised during ANC by health care provider to deliver at health facility had a higher proportion delivering with a SBAs compared to participants who didn’t advise.23 The study of Negalign Berhanu Bayou et al in Ethiopia also showed that participants who were advised about danger signs of pregnancy and labor, during ANC were more likely to use the services SBAs than those who were not advised.25
In our study 38.8 percent of unskilled deliveries were attended by mother in laws, 11.2 percent were attended by relatives, 3.8 percent were attended by neighbors and only 1.1 percent were attended by TBAs. Among the deliveries attended by SBAs, 33.8 percent were attended by LHVs, 4.7 percent were attended by obstetricians and only 6.6 percent were attended by more than one SBAs that were LHV, nurse and gynecologist. The study of Mulunesh Alemayehu and Wubegzier Kekkonen in Ankasha Guagusa Woreda Ethiopia also mentioned 58.7 percent were assisted by family members and relatives, 16.1 percent were assisted by health extension workers (which do not have training and education in obstetric skill) 3.2 percent were assisted by TBAs and 3.2 percent were assisted by themselves without any assistance.5 The study of Mary Amoakoh-Coleman et al in Ghana also indicated that prevalence of skilled attendance at delivery was 60.5 percent. In skilled deliverers majority of participants about 45.4 percent were delivered under the assistance of midwives and nurses and only 9 percent participants were assisted by doctors.26 The study of Rose NM Mpembeni in Southern Tanzania revealed that about 12.5 percent of all deliveries were assisted by nurse midwives, 1.9 percent were assisted by skilled midwives, 3 percent were assisted by doctors and about 27 percent were assisted by other skilled personnel. Similarly about 24.7 percent were assisted by TBAs, 26.7 percent were assisted by relatives and friends, bout 4.3 percent were assisted by other unskilled attendants.23
In our study the main reasons stated for home delivery included easy labor, afraid of user fee, far of health facility and transport problems while few participants stated the reason of feel sham, sickness, husband refused and don’t know importance of delivery at health facility. The study conducted in Ethiopia by Mulunesh Alemayehu and Wubegzier Mekonnen reported the most stated reasons as more comfortable the home delivery, no problem during home delivery as it is natural, far of health facility and parents preferred place of delivery.5 According to the study of Yalem Tsegay Assfaw in Ethiopia these reasons for home delivery were economic, transport problems, social and cultural believes, far of health facility, poor quality of services, decision making power, sudden onset of delivery, poor access to health facility due to which participants gave birth at home.11
Similarly the participants who delivered at health facility also gave a variety of reasons for delivery at health facility. The main reason was sickness in the time of delivery which was stated by most of the participants while few participants were mentioned the reasons of save mother and child lives and received health education during ANC. For majority of participants the place of birth and birth attendant was decided by participants themselves, or both husband and wife together, or mother in law whereas for a few participants the decision was made by husband and father in law alone. The participants who made joint decision with husbands were more likely to deliver under the assistance of SBAs as compare to alone decision of participants, husbands, mother in law and other relatives or friends. However decision maker was not found to be associated with utilization of SBAs services. The study of Jerome K. Kabakyenga et al in South-Western Uganda also indicated the same finding that final decision about location of delivery and assistance by SBAs for the majority was made by wife and husband together and participants themselves whereas for a few participants the final decision was made by relatives/friends. Participants who made joint decision with husbands, relatives or friends were more likely to deliver under the assistance of SBAs as compare to participants who made final decision alone. However contrary to our finding this study showed that decision maker was significantly associated with utilization of SBAs services.24
Another study conducted in southern Tanzania also mention that participants who ever jointly decided with husbands or partners on where to go for delivery had found to higher proportion delivered under the assistance of SBAs as compare to those who didn’t jointly decided with their husbands or partners. In this study the association between decision maker and assistance of SBAs was also found to be significant.23
The reason for health facility is better place for delivery was found to be significantly associated with utilization of SBAs services. In our study more than 80 percent participants developed complications in the recent delivery. The participants who developed complications during delivery preferred the utilization of SBAs services. It indicated that participants who developed complications decided to give birth in health facilities and require assistance of SBAs and when repeated trials at home failed. The common complications that participants experienced during recent delivery include difficult labor, hemorrhage, prolonged labor whereas some participants were also experienced of retain placenta, stillbirth and mal presentations. In all types of complications the participants were less likely to utilize of SBAs services except mal presentation in which all participants shows preference for utilization of SBAs services. However history of complication and type of complication of recent delivery were found to be associated with utilization of SBAs services. Similar finding was also reported by the study conducted in Ethiopia that study participants who didn’t face any complications during recent delivery were 98 percent less likely to utilize SBAs services as compare to the participants faced complications during recent delivery. Similar finding were also documented by other studies done in Sekela, north Shewa, Agemssa, Wollega and Metekel zone of ethiopoia.5 The study of Nesfin nagussie et al also reported some complications which were developed by the participants during recent delivery including hemorrhage, prolonged labor, retain placenta and some others complications.6
In our study about six seventh of the participants preferred home for their next delivery. Those participants who preferred home for their next delivery have preferred unskilled delivery in the recent delivery whereas the participants who preferred health facility for their next delivery have preferred skilled delivery in the recent delivery. Preferred place for next delivery of participants was significantly associated with utilization of SBAs services. In our study the participants have preferred different of birth assistants for their next delivery. Most of them were preferred mother in law, doctor and relatives whereas some participants were preferred neighbor and TBAs.
Similarly six seventh of the participants husbands have preferred home for the next delivery of their spouses and some of the participants husbands have preferred health facility. Participants whose husbands have preferred home for their next delivery have preferred unskilled delivery whereas the participants whose husbands have preferred health facility for their next delivery have preferred skilled delivery. Husbands preference place for participant next delivery were found to be significantly associated with utilization of SBAs services.
3.3: STRENGTH AND LIMITATIONS:
It is important to be familiar with the strength and limitations of this study. To reduce recall and reporting biases we select participant having delivery in last one year. For collection of standard data we adopt standard modified questionnaire and translated into local language that is Urdu and Pashto. For its reliability it was pilot tested. For more validity of data we conducted face to face interview technique from participants in their houses. In order to control the effect of confounding variables multiple logistic regressions was used. It was the first study conducted in Bajaur Agency as well as in FATA.
Our study has its limitations. Firstly, it was a community base cross sectional study and generated evidence to measure the utilization of SBAs services may not be strong enough. Secondly, the data collected was based on information provided by the study participants, which are subject to recall and reporting biases. Thirdly, cultural restriction was the main hurdle in data collection so some participants may not be provided the reliable information. Fourthly, this study was limited in only two of four sectors of the Tehsil Salarzai.
3.4: CONCLUSION AND RECOMMENDATION:
Pregnancy and child birth complications are a leading cause of death and disability among women of reproductive age in the developing countries of the world. In our study low utilization of SBAs services was associated with a high number of deliveries being attended by unskilled birth attendants at home due to easiness. Many of risk factors in our study also suggested by literature to be associated with low utilization of SBAs services including low literacy rate of participants and their spouses, unavailability of health facilities, distance of health facility from home, unavailability of health care worker, parity, ANC for recent delivery, place of delivery and complications of recent delivery, our study were established their associations. However further research is required for identifying the risk factors associated with low utilization of SBAs services. Similar type of study with a large sample size is required to establish more authentic associations of different risk factors with utilization of SBAs services.