ดูโค้ด

Journal of Applied Medical Sciences, vol. 1, no.1, 2012, 93-116  
ISSN: 2241-2328 (print version), 2241-2336 (online) 
Scienpress Ltd, 2012 
 
Provision and Utilization of Routine Antenatal 
Care in Rural Balochistan Province, Pakistan:  
a Survey of Knowledge, Attitudes, and  
Practices of Pregnant Women 
Abdul Ghaffar, Sathirakorn Pongpanich, Robert S. Chapman,  
Alessio Panza, Sheh Mureed1
 and Najma Ghaffar
2
 
 
 
Abstract 
Maternal health services are provided in Pakistan through primary, secondary and 
tertiary care facilities and utilization for  at least one visit is up to 61% in some 
areas. In most rural areas, however, antenatal coverage is closer to 10% and most 
of Balochistan Province is rural. This study assesses the provision and utilization 
of antenatal care (ANC) services and identifies barriers that limit utilization of the 
Government’s routine ANC services in a tribal community in Jhal Magsi District 
of Balochistan Province, Pakistan. 
The study was conducted in the Pattri Union Council of Jhal Magsi District with 
both qualitative and quantitative methodologies. Eight focus groups were 
                                                             
1
  College of Public Health Sciences, Chulalongkorn University , Bangkok, Thailand 
   e-mail: abdulghaffarlashari@gmail.com 
2
 Department of Obstetrics and Gynecology, Bolan Medical College Quetta, Pakistan 
 
Article Info: Received : July 21, 2012. Revised : August 31, 2012 
                    Published online : September 6, 2012  
 94                                                  Provision and Utilization of Routine Antenatal Care …  
 
conducted among married women and men separately in the villages of Pattri 
Union Council and a cross-sectional quantitative survey  was conducted among 
513 pregnant women aged 18 to 40 years.  
Only 14.4% of the study respondents ever had received ANC services at a 
government health facility. Short distance  from residence to health facility, high 
income, less number of parity, any education, any perceived pregnancy related 
problem and knowledge about ANC were positively associated with ANC 
(p<0.001) utilization. However attitude toward government health facility showed 
negative association with such ANC. A multivariable logistic model also showed 
significant positive association of family income, education, parity, and distance 
from residence to health facility with accessing ANC services. Attitude showed a 
negative association.  (Knowledge could not be assessed with logistic regression.) 
Qualitative data also supported quantitative results as most of the male and female 
respondents revealed low knowledge and  negative attitudes towards the ANC 
services provided at the government health facilities. 
Comprehensive health promotion and access to health services in the tribal 
community for routine ANC should be increased and implementation should be 
more targeted to increase the uptake of routine ANC services. This study suggests 
that, at the policy level, participation of women and their husbands in maternal 
health promotion programs that increase awareness will have long-term positive 
effects on ANC utilization in the Baloch community. 
 
Keywords: Antnatal care, service provision, utilization, rural, Balochistan 
 
 
1  Introduction 
Routine antenatal care includes medical interventions and advice that a 
woman receives during pregnancy and is a key entry point for pregnant women to A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          95 
receive a broad range of health promotion and preventive health services [1], 
including knowledge about healthy practices during pregnancy, nutritional 
support, prevention and treatment of anemia, diagnosis and treatment of other 
diseases and tetanus toxoid immunization [2-4]. In addition, routine ANC can be 
provided at both the household and primary health care level and helps to assure a 
link to higher levels of care when needed[5, 6]. The World Health Organization 
recommends that a woman without complications should have at least four ANC 
visits starting from the first trimester to get sufficient prenatal care to minimize 
pregnancy-related complications [7, 8]. 
The availability and accessibility of modern health services in developing and 
low income countries have increased  over the past decades[14]. While the 
effectiveness in curing diseases may lead  to greater utilization of modern health 
services compared to traditional practices, their utilization is likely to be higher 
among urban dwellers and those with higher socioeconomic status than by rural 
residents and groups with a lower socioeconomic status in developing countries 
[9].  
The predictors of the utilization of ANC services in most developing countries 
include socio-demographic factors, availability and access to the health facilities, 
the educational level of the women and  their husbands, perceptions of women 
regarding ANC and their knowledge of the importance of ANC services [10, 11]. 
Demographic factors such as the number of previous pregnancies, the number of 
children, maternal age, and marital duration also are reported to have an influence 
on the utilization of antenatal care [12]. 
“Attitude” is a state of readiness or tendency to respond in a certain manner 
when confronted with certain stimuli, is mostly dormant and is expressed in 
speech or behavior only when the object or situation is encountered[13]. Studies 
have reported negative attitudes as  a major barrier to ANC utilization [14]. 
Previous studies in rural areas of the developing world have shown an association 
of specific attitudes with utilization of and access to health services. In addition, 96                                                  Provision and Utilization of Routine Antenatal Care …  
 
socioeconomic factors contribute to inequalities in health status. Consequently, 
poor women are disadvantaged in accessing ANC, like many other aspects of their 
lives [14, 16]. 
Pakistan is one of the 11 countries that accounted for 65% of global maternal 
mortality in 2008. These countries, which also included India and Bangladesh, had 
a major share in maternal deaths worldwide [17]. In Pakistan, the maternal 
mortality ratio (MMR) is highest in rural areas and in less developed 
provinces[18, 19]. The situation in Balochistan Province is especially severe. In 
Balochistan, the MMR stands at 750 maternal deaths per 100,000 live births [19], 
as compared with 227, 314, and 275 in  the other provinces of Punjab, Sindh and 
Khayber Pakhtoon Khwa, respectively [19-22]. 
Utilization of routine antenatal care at government health facilities in Pakistan 
generally is low. According to World Health Statistics and the Pakistan 
Demographic Health Survey of 2007 (PDHS) only 61% of women had at least one 
visit and the proportion further drops to 26% for 4 visits[24]. ANC services 
utilization in rural areas is lower at about 10% [18]. The District Health 
Information System in Balochistan Province reported only 15% of pregnant 
women registered for ANC in 2010-11 [25].  
The Government of Pakistan has been providing maternal health services 
during the last two decades through primary, secondary, and tertiary health 
facilities, augmented by the Lady Health Workers (LHW) Program [25]. About 
100,000 LHWs are the backbone of the primary health care system. A number of 
maternal health projects have been launched with the cooperation of international 
donor agencies since the Alma-Ata Declaration in 1978 made a commitment to 
provide primary healthcare, including “safe motherhood”, women’s health 
projects, lady health worker projects,  maternal and child health projects and 
maternal and neonatal child health projects [26]. A literature review by the authors 
indicates that government services are utilized less than private health facilities in 
Pakistan. The Government is providing  health services to only 30% of the A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          97 
population while the remaining 70% are receiving services through the private 
health sector[25]. 
Balochistan is the least developed province in Pakistan and its urbanization 
rate has been slow relative to other  provinces during the  sixty years since 
annexation with Pakistan in 1948. The literacy rate is low, people are still living in 
their traditional commune system and their conservative values have great cultural 
influence on the community even in this modern world. Animal husbandry, 
agriculture and government  jobs are the main occupations for males. Men are 
dominant in Baloch communities in every aspect of life. Women and girls are 
highly dependent on the decisions of men for their everyday activities and their 
mobility is also limited unless a male accompanies them. The Baloch tribal system 
has a marriage system based on polygyny and exchange of women for marriages. 
Feudal anarchies among clans and sub-clans limit mobility of men, leading to 
increased immobility and suffering of women.  
 The Jhal Magsi (JM) District, Balochistan, was selected for this study 
because it is one of the most underdeveloped districts in Pakistan. Only 10% of 
pregnant women in JM have one or more antenatal visits[21]. Very little research 
has been conducted in the rural areas of Balochistan  Province to influence the 
policy makers by understanding the behaviors of the population. Therefore, this 
study assesses the provision and utilization of ANC services and to identifies 
barriers to greater utilization of the Government’s routine ANC services in a tribal 
community of the Jhal Magsi District in Balochistan Province, Pakistan. 
 
 
2  Methods 
This study was a community-based quantitative and qualitative survey 
conducted in August–December 2011 at the Pattri Union Council, Gandawa 
Tehsil, Jhal Magsi District, and Balochistan Province, Pakistan. Gandawa Tehsil 98                                                  Provision and Utilization of Routine Antenatal Care …  
 
has a district headquarters hospital, while in Pattri Union Council primary health 
services, including maternal health services, are provided through one basic health 
unit (BHU) and a civil dispensary (CD).  The majority of the Gandawa Tehsil 
residents are Baloch and about 90% of the population in the Pattri Union Council 
belongs to the Lashari clan of the Baloch tribes. 
The qualitative research was conducted  at several levels of the community. 
This research included eight focus group discussions (FGDs) conducted in the 
villages of Pattri UC. The purpose of these FGDs was to gather background 
information to assist in developing  a substantively appropriate, clearly 
understandable questionnaire for the  quantitative study. Four FGDs were 
conducted among pregnant married women who had experienced at least one live 
birth. Four FGDs were also conducted among married men. One male and one 
female respondent were invited randomly from each sub-clan and 5-6 people took 
part in each FGD.  
Due to cultural norms, the first author (AG) could not conduct FGDs with 
females. An all-female research team was assembled, under the supervision of co-
author NG, to moderate the FGDS. Notes were taken; audiotapes and photographs 
were not allowed. All the FGDs were conducted in the Balochi language. 
Transcripts of FGD proceedings were written and analyzed in Urdu.  The first 
author with the help of two male research assistants moderated male FGDs, at 
which audio recording and photographs were taken.  
Different guidelines were used for the male and female FGDs, and different 
male/female sets of five question guidelines were generated from the literature 
review and from the discussion with senior teachers at Chulalongkorn University 
in Bangkok and Balon Medical complex hospital in Quetta,  Balochistan. The 
guidelines for female FGDs were based on the importance of ANC, when and 
where they to go for ANC in complicated or uncomplicated pregnancies. Male 
FGDs guidelines were about health concerns of women during pregnancy and 
perceptions about public health facilities. A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          99 
The qualitative data were  analyzed through content  analysis with inductive 
coding and the grounded theory approach. In this report, qualitative study results 
are presented only as they bear on the content of the quantitative portion of the 
research. Other aspects of the qualitative research will be presented separately. 
The quantitative research was a cross-sectional study, using a standardized 
questionnaire in face-to-face interviews. A three-stage sampling process selected 
participants. In the first stage, one of two tehsils (Gandawa) in JM District was 
randomly selected. In the second stage, one of four union councils (UC) in 
Gandawa was selected randomly. In the third stage, subjects in UC Pattri were 
identified using the Expanded Program on Immunization (EPI) lists. According to 
the EPI list of 2011, Pattri had a total population of 17,375 and about 712 women 
became pregnant every year. Women who participated in FGDs were not included 
in the quantitative survey. Overall the refusal rate observed was low (5%), as 
female research assistants approached subjects at their homes or work places (e.g., 
agricultural fields etc.) in accordance with cultural norms. Most refusals occurred 
among very religious families and some families with feudal anarchies (armed 
conflicts between clans and sub clans). In the area studied almost all births take 
place at home, and detailed information is not available about  characteristics of 
the births. However, according to the Pakistan Demographic Survey in 2008 [19] 
Pakistani women typically reach a parity of 6.3 children per woman at the end of 
their childbearing age. The fertility rate in Balochistan of 4.1 is similar to the 
national rate[19].  
The main outcome variable was routine antenatal care (at least one visit) 
during any uncomplicated pregnancy, including the current pregnancy, in a 
government facility.  This facility could be at a secondary or primary care level, 
through health personnel including doctors, midwives  and lady health workers. 
Visits for complications or problems that need hospitalization or referrals during 
pregnancy were not included. The study did not include ANC at private facilities, 
as ANC services are free in government facilities. Furthermore, considering the 100                                                  Provision and Utilization of Routine Antenatal Care …  
 
low utilization of ANC in the study area the number of visits was set at one or 
more visits. 
The questionnaire was developed through a literature review and was finalized 
after FGDs and a pretest for clarity in another tehsil. The questionnaire was 
administrated to the subjects through female and male research assistants. The 
questionnaire included questions about  socio-demographics, (age, education, 
income and distance etc) knowledge about the schedule, the benefits of ANC, and 
attitudes toward ANC at government health facilities. The questionnaire was 
translated into Urdu (the Pakistani national language), and was translated verbally 
in the Balochi language (mother tongue of Baloch tribe) during interviews by 
trained Female research assistants for quantitative surveys. 
The sample size was calculated using OpenEPI online[27], with the 
assumption that 60% of women would be using antenatal care [19]. Keeping the 
population size at 20,000 in the Pattri Union Council, the sample size was 363 
with a 95% confidence level. We increased the size to cover all the villages of 
Pattri UC to further increase the generalizability of the study. Thus, a total of 513 
subjects, aged 18-40 years, participated in the study. 
Descriptive statistical tests were  used to measure socio-demographic 
characteristics of the respondents, with  continuous variables presented as mean 
and standard deviations (SD); categorical data were presented as numbers, and 
percentages. In a bivariate analysis, chi-square tests were used to characterize the 
associations between the dependent variables (ANC at a government facility 
during any pregnancy) and independent variables (socio-demographics, 
knowledge, attitude and any perceived problems). Independent variables for which 
p<0.05 were included in the model for multivariate logistic regression analysis. 
The analysis was calculated through odds ratios (OR) and 95% confidence 
intervals (CI) to reveal the strength of associations between dependent and 
independent variables. A p-value <0.05 was considered statistically significant. A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          101 
Data were analyzed using the Statistical Package for Social Sciences (SPSS) for 
Windows, version 16. 
The Ethics Review Committee for Research Involving Human Research 
Subjects, Health Sciences Group, Chulalongkorn University, Bangkok, Thailand, 
granted ethical approval in 2011. Permission to conduct research in the Jhal Magsi 
District was obtained from the District Health Officer and the Provincial Secretary 
of the Health Department, Government of Balochistan. 
 
 
3  Results 
3.1 Qualitative results 
There are many cultural healers in the study area. These include family 
healers, midwives, herbalists, hakims, and religious healers. Modern allopathic 
modes of treatment were also available in the community and mostly unregistered 
practitioners provided these services to the pregnant women. Both Government 
hospital and private health clinics were also available in the district headquarters. 
Most of the male and female participants in the FGDs complained about 
distance from services and pregnant women complained about their lack of 
autonomy to travel alone to health facilities. For example, one woman said, “I 
never see a hospital in my life if my husband or brother doesn’t go with me how I 
can go to hospital”  
Male participants tended to have the same view about distance. A 40 year-old 
man said, “If we need to go hospital we must start our journey at 5 AM, early in 
the morning” 
Qualitative queries also revealed that low family income was also an 
important barrier for the utilization of ANC services, “Most of the time the reason 
why we don’t use the health facility is because of our financial problems” said a 
man of about 40 years of age. 102                                                  Provision and Utilization of Routine Antenatal Care …  
 
During FGDs the participants also showed negative attitudes that seemed to 
be the result of many factors. A female living in the village that had a basic health 
unit noted that, “When we go there we don’t find any lady who we talk and listen 
and make us understand and my husband not allow me to go there for any 
pregnancy related matter.” 
Behavior of staff and the availability of drugs and other facilities also had an 
effect on the negative attitude of people in the community, A male school teacher 
noted that, “we not have good experiences with government facilities, some time 
they don’t have staff, some time they don’t have medicine, even they don’t talk 
well with us properly” 
Past experience was one of the major  factors influencing the decision on 
whether or not to visit government facilities for maternal health. Most of the 
people who visited didn’t have good experiences during their last visit for multiple 
reasons. Some never visited health facilities because of negative past experiences 
learned from others. 
Most of the male participants had  a negative impression about government 
health facilities. They stated that most of the health staff there were unfriendly.   
One of the men expressed his feelings by saying that, “last time my mother 
was sick and we went to DHQ for treatment, nobody was friendly and my mother 
was not happy.”  
Women also had the same opinion that when they go to government health 
facilities they don’t get proper treatment and the staff of the hospital makes them 
spend money unnecessarily. These experiences leave a bad impression on their 
decision makers. 
A mother of four stated that,  “Last year I had severe problems after an 
abortion and I remained sick for one week at my home so we went to the hospital 
(BHU) in the nearest village, but didn’t find any body in the hospital. We waited a 
lot but nobody come to treat me, and then in the afternoon we left for the hospital 
in Gandawa. Even there we didn’t find anybody”  A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          103 
A 40 year old man noted that,  “In my view, the medicines they prescribed 
were a lot and most were unnecessary”  
People also avoided visiting health centers/hospitals because of the attitude of 
the staff. Most of them said the hospital staffs are not friendly, but medical staff 
behaved well in the private  clinics. Patients did not know about the jobs of the 
staff and who is supposed to take care of them for maternal health services. 
The results of the qualitative study revealed that the majority of the pregnant 
women and men don’t had proper awareness about ANC and most of the 
respondents had negative attitudes toward government health facilities that 
affected the utilization of the services at primary and secondary level. 
 
 
3.2 Quantitative results 
The minimum age of the respondents was 18 and maximum was 35. The 
largest group (49.1 %) of subjects were aged 21 to 25, and the mean age was 
24.67 years. The number of children was  1 to 11 with a mean of 4.86. Health 
facilities were located 5-35 kilometer (km) from the respondent’s living place with 
a mean distance of 17.7 km. The family income of 91% of respondents was under 
10000 Pakistan rupees (PKR) per month, with a minimum of 1500 to 25000 and 
the mean was  ± 6548 PKR (< 75 US $ / month). About 92% of the respondents 
had not received any formal education,  and about 98% of the respondents were 
housewives or were engaged in agriculture along with their families.  
Four hundred and thirty  nine (85.6%) never had antenatal care during their 
current pregnancy or previous pregnancies and only 14.4% of them had had at 
least one antenatal visit. About 66.7%  of the respondents had some perceived 
pregnancy-related problem like weakness, vomiting, and convulsions. 
Table 1 shows the levels of knowledge and attitude. 408 (79.5%) respondents 
had low knowledge and scores and 105 (20.5%) had good knowledge. The attitude 104                                                  Provision and Utilization of Routine Antenatal Care …  
 
towards ANC at government health facilities was mostly negative 296 (57.7), but 
217 (42.3) had a positive attitude. 
 
                   Table 1: Knowledge and attitude of the pregnant women 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2 shows the bivariate analysis showing association of independent factors 
with antenatal care. It shows that fewer children (p<0.001), family income (p< 
0.001), education (p<0.001) and occupation (p=0.001) were associated with 
increased rate of ANC at government facilities. The table also reveals that 
perceived complications (p<0.001) are associated with less antenatal care 
utilization at a government facility. Distance also showed significant association 
(p<0.001) with ANC. However age was not significantly associated (p=0.807) 
with antenatal care utilization at a health facility. Knowledge levels were 
positively and significantly associated (p<0.001) with high utilization of antenatal 
ANC. It also shows that no women with  low knowledge utilized antenatal care 
(complete nesting of knowledge level with antenatal care utilization). Thus, 
knowledge level could not be included as an independent variable in multivariable 
logistic regression analysis. The attitude towards ANC at government health 
Knowledge (Min= 0 Max= 14)  Number Percentage   
Lower knowledge (0-7)  408  79.5 
Higher knowledge (8-14)  105  20.5 
Mean ± SD = 4.29 ± 3.50 
Attitude (Min= 10 Max= 30) 
  
Positive attitude (24-27)  217  42.3 
Negative attitude (18-23)  296  57.7 
Mean ± SD = 22.93 ± 1.98     A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          105 
facilities was significantly  (p=0.009) associated negatively with ANC and shows 
low utilization of ANC. 
 
Table 2 : Associations between independent variables and history of any antenatal    
                care at a government facility among pregnant ladies 
Antenatal care Practice  p-value  Factors 
  No= 437 (85.6%)  Yes= 74 (14.4%)   
N= 513  N  %  N  %   
Age         0.807 
≤20 69 82.1 15 17.9  
21-25 217 86.1 35 13.9  
26-30 107 86.3 17 13.7  
>30 46 86.8 7 13.2  
Parity           <0 .001 
≤3 57 68.7 26 31.3  
≥4 382 88.8 48 11.2  
Distance of residence 
from health facility (km) 
      <0.001 
≤15 262 84.0 50 16.0  
16-20 42 70.0 18 30.0  
≥20 135 95.7 6 14.4  
Family Income (per 
month) PKR (92 
PKR=$1 US)* 
      <0 .001 
≤10, 000  414  88.7  53  11.3   
≥11, 000  25  54.3  21  45.7   
Education           <0 .001 
No formal education  423  89.4  50  10.6   
Any years of education  16  40.0  24  60.0   
Occupation     0.001 
House wife  434  86.3  69  13.7   
Government servant  5  50.0  5  50.0   
Any perceived 
pregnancy-related 
problem or complication 
      <0.001 
No 107 62.2 64 37.4  
Yes 332 97.1 10 2.9  
Knowledge     <0.001 
Lower knowledge  408  100  0  0.0   
Higher knowledge  31  29.5  74  70.5   
Attitude     0.009 
Positive attitude   243  82.1  53  9.7   
Negative attitude   196  90.3  21  17.9   106                                                  Provision and Utilization of Routine Antenatal Care …  
 
Table 3 shows results from the multivariable logistic regression model, 
showing strong associations of education, parity, family income, perceived 
problems, and attitudes with antenatal  care utilization at government health 
facility. However distance and occupation lost their significance in the 
multivariable logistic model. Again, due  to complete nesting of knowledge with 
ANC status, knowledge could not be included in the model. 
 
Table 3: Multivariable logistic regressions 
95%CI p-Value  Independent variables  Odds 
Ratio  Lower Upper   
Distance of residence 
from health facility 
(kilometers, ref ≤15) 
      
16-20 5.64 2.23 14.26 <0.001 
≥20 0.38 0.11 1.32 0.131 
Parity (ref ≤ 3)  0.33  0.15  0.758  0.008 
Family monthly income 
(ref ≤ 75 US $) 
4.32 1.53  12.19 0.006 
Occupation (ref = 
government servant) 
2.86 0.42  19.17 0.279 
Perceived 
problems/complications 
(ref = no perceived 
problem) 
0.80 0.036 0.178 <0.001 
Negative attitude 
towards government 
health facility (ref = 
Positive attitude) 
0.513 0.252  1.042  0.065 
Education (ref = any 
years of education) 
5.92 2.027 17.325 0.001 
 
 
 A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          107 
4  Disscusion 
In this study the outcome variable was utilization of routine antenatal care at 
government facilities and the association of different factors were considered. The 
factors were selected from the literature review and after the qualitative portion of 
current study.  
According to the Multiple Indicator Cluster Survey (MICS) Balochistan and 
PDHS 2007 health survey utilization of ANC in rural areas is less than 10% with 
the standard being at least one visit  [19, 21]. Annual analysis reports of the 
District Health Information System  (DHIS) Balochistan 2010-11 reported 15% 
registration for ANC in all of Balochistan [24].The present study also found only 
14.4% of the pregnant women had antenatal care from the government facility.  
In both qualitative and quantitative studies it was observed that quite a 
significant proportion of the study participants had perceived pregnancy-related 
problems More than 60% of the respondents had perceived complications or 
problems related to pregnancy and this was significantly associated with less ANC 
utilization. The results of this study are consistent with other studies in the rural 
areas from neighboring countries [3,  28, 29] of the pregnant women who 
perceived problems or complications. The perceived complications and problems 
in the present study were significantly  associated with ANC at public health 
facilities. According to  the MICS Balochistan and  PDHS 2007 health survey 
utilization of ANC in rural areas is less than 10% at the standard of at least one 
visit [19, 21] at a government health  facility. Data from PDHS 2007, MICS 
Balochistan 2004 and a study conducted in a rural area at province of Sindh 
assessed the sources of ANC. According to their results most of their respondents 
had ANC from a doctor at a private clinic or hospital [19, 21, 26]. These studies 
also reported that in Balochistan Province about 60% of the pregnant women 
never had antenatal checkups from a government health facility or a private health 
facility and only 25% and 15% women had checkups from TBA and health 
personnel respectively.   108                                                  Provision and Utilization of Routine Antenatal Care …  
 
In this study the pregnant women who had fewer children had more ANC 
utilization. The literature reviews revealed a mixed pattern. Some studies revealed 
that decreased parity is associated more ANC [29-31]. On other hand studies also 
have reported increased ANC with increased parity [28, 32, 33]. Studies have 
reported that the number of children is directly associated with pregnant women’s 
health and utilization of ANC and the reason for the increased utilization may be 
related with health problems due to the increased number of children. With more 
complications more pregnant ladies are going to contact health personnel during 
pregnancy. But the current study and the study from the Mathews and colleagues 
[3]revealed less ANC among high parity women. This may be due to local cultural 
circumstances including low mobility and less education of women. Even women 
at risk of more complications may not go for ANC. 
In almost every study exploring barriers  at national or international level to 
ANC utilization, the educated pregnant  women are more likely to realize the 
benefits of using maternal health services. There is a highly significant association 
of more education with more ANC utilization. [3, 10, 28, 34-36]. Although there 
are few pregnant women in this study that had any formal education but it showed 
a highly positive significant association with antenatal care utilization.  
Family income and education serve as  indicators of socioeconomic status. 
Studies have reported socioeconomic factors are the most important barriers and 
have observed more ANC utilization in higher income families [30, 37, 38]. In the 
current study most of the community were illiterate and a  high proportion of 
women belonged to a low-income group. After multivariate logistic regression 
analysis, income was found to be a significant factor  for utilization of antenatal 
care. 
Studies have shown that awareness and knowledge of health facilities, 
benefits, complications and  realization of importance of ANC in community and 
individuals have significant positive effect on ANC utilization [38] and utilization 
rates are high among high knowledge pregnant mothers in Pakistan and other parts A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          109 
of world [12, 39, 40]. The current study showed that most of the respondents had 
low awareness and knowledge about antenatal care and government health 
facilities. The quantitative part of this study also revealed a tight positive 
association of ANC use with knowledge. 
In this study both qualitative and quantitative methodologies showed negative 
attitudes toward health facilities and health workers. These perceptions continued 
even though the majority of the health workers, including doctors, nurse, 
midwives, paramedics, and community health workers, provide private services as 
well. Focus group discussions and participant observation revealed that 
accessibility, staff behavior, shortage of medicines and financial costs were 
creating a negative perception. In the quantitative survey attitudes also showed 
significant negative association toward ANC at government health facilities. The 
logistic model confirmed this negative association. In the literature review some 
studies have reported that the negative attitudes of health care workers and 
reduced positive relationships between health care workers and pregnant women 
are one of the most powerful impediments to ANC utilization [14]. 
Many studies have reported significant associations of distance and 
occupation of women with ANC utilization[33, 36, 41]. In the rural areas, where 
roads and transport are not available, distance to the health facility appeared as an 
important barrier in the qualitative component of the study and in the quantitative 
survey. The Multivariable Logistic Model also showed statistically significant 
association with increased ANC use. 
Literature reviews also indicate that age is an important barrier for the 
utilization of ANC services[10, 42, 43]. Studies in Pakistan and neighboring 
countries also have shown that women in tribal society use less ANC [3, 35, 44] 
The reason might be the lack of autonomy of the females and their reduced 
mobility, which was expressed by the respondents in the qualitative part of the 
study.  110                                                  Provision and Utilization of Routine Antenatal Care …  
 
In the current study age did not show any significant association with ANC. It 
might be because of the culture of the  tribal society of the community studied. 
Baloch culture is a male dominant society and women in the society don’t have 
autonomy to travel alone or take decisions independently irrespective of the age of 
the women. 
ANC services in Pakistan are based on WHO protocols of at least 4 visits in 
uncomplicated or normal pregnancy and these visits can be carried out at the 
primary health care level. This study  also would have considered the outcome 
variable as four visits for ANC at any  facility. After pretesting and qualitative 
study results were analyzed, several limitations were encountered. For example, 
there was no established system of modern ANC in the community studied, and 
none of the respondents had complete four visits for any of normal pregnancy. 
ANC utilization is low and that may lead to the respondent’s recall bias, as 
fertility rate is high in the area studied.  
Seventy percent of the health services  in Pakistan are provided through the 
private (for profit or non-profit) health sector and the Government Public Health 
System provides remaining services. Because the aim of the study was to assess 
provision and utilization of ANC services at government health facilities, the main 
outcome variable was changed to at  least one visit to routine ANC at a 
government facility. This also reduced the chance of a recall bias. 
 
 
5  Conclusion 
This study found that knowledge about ANC, attitudes toward Government 
health facilities, education, income, and perceived problems and complications 
during pregnancy were important factors that influence utilization of ANC 
services in the Baloch tribal society  in the rural area. Due to continued bad 
experiences, disparities and negligence  of the rural areas the rural tribal A. Ghaffar, S. Pongpanich, R.S. Chapman, A. Panza, S. Mureed and N. Ghaffar          111 
community has developed negative attitudes to routine ANC in Government 
health facilities.  
The study has raised several direct and indirect, practical, policy and research 
issues. Rural areas in Balochistan Province don’t have the basic infrastructure and 
in normal circumstances during pregnancy uncomfortable travel and unavailability 
of good quality care hinder the utilization ANC services. Knowledge also plays an 
important role in utilization as it leads to awareness about the provision of 
Government services. Comprehensive health promotion through the Lady Health 
Workers Program and access of the health personnel in the tribal community to 
routine ANC should be increased and implementation should be more targeted to 
increase the uptake of routine ANC services.  
At the policy level this study suggests  that when interventions related to 
maternal health include women and their husbands, awareness and education will 
have long-term positive effects on ANC  utilization in the Baloch community. 
Further research studies are recommended to elaborate the problems and 
perceptions of the men in  the rural area, especially men living in tight cultural 
values in Balochistan province In addition, health workers should be trained 
according to the local and cultural values to increase the uptake of routine ANC 
and preventive services in general.   
 
 
Acknowledgements. This study would not have been possible without technical 
assistance from Chulalongkorn University, Bangkok, Thailand, Bolan Medical 
complex hospital Quetta and the Health Department, Government of Balochistan, 
Pakistan. 
 
 
 112                                                  Provision and Utilization of Routine Antenatal Care …  
 
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