National Conference on MDG 5 – Improving Maternal Health in Pakistan 25-26 November, 2013 Islamabad, Pakistan

Early Marriage and Childbearing – Issues in health provisioning Presenter: Dr Dina Neelofur Khan

Early marriage Definition As determined by the United Nations Convention on the Rights of the Child (CRC) occurs when the bride or groom is under 18 years of age

Prevalence Globally – 1/3rd of all girls by age 18 1 in 9 by age 15 Pakistan – UNICEF & PRB data 7% by age 15 24% by age 18

Early marriage and childbearing Social and cultural construct Social and economic outcomes - loss of peer support - discontinuation of education - fewer future employment opportunities

Consequences of early marriage and childbearing Medical/clinical Maternal mortality Low birth weight Preterm birth Neonatal, perinatal and infant mortality Prolonged and obstructed labour – VVF Anaemia

Health care seeking behaviour of young married girls Low utilization of services Delayed or insufficient utilization of services

Three Delays model – Thaddeus and Maine, 1994 1st delay: delay in deciding to seek care on the part of the individual, family or both 2nd delay: delay in reaching an adequate health care facility 3rd delay: delay in receiving adequate care at the facility

Health care seeking behaviour of young married girls – determinants and barriers Individual, social and cultural factors Limited autonomy Financial constraints Restricted mobility Perception of need Lack of knowledge and education Inability to recognise signs of complication Lack of information about existing services Perception of services – providers’ attitude Violence and abuse during pregnancy

Policy issues – Health service provision Lack of availability of services Lack of equipment and supplies Lack of accessibility of services Distance to services Poor infrastructure No or minimal transportation Transportation costs Providers training

Health care services for young married women Neglected cohort Difficult to reach Lack of policy and programming

MDGs and early marriage and childbearing Address morbidity and mortality associated with early childbearing Invest in policy and programmes to prevent or delay early marriage Focus on service delivery – strengthen health systems and develop programmatic capacity Prioritise health and well-being of girls and young women – urged at Women Deliver Conference 2013

To achieve MDGs – Different programmatic approaches and evidence Approaches - few programmes Preventing complications during pregnancy & childbirth Management of complications during pregnancy & childbirth Interventions and evidence Pre-pregnancy counselling Comprehensive ANC Intrapartum care – skilled attendant and EmOC Postpartum care

BUT….. The key issues remain Timely access and utilization of services Barriers to access and utilize services

Small scale qualitative study conducted in Lebanon Aim of the study identify factors that may influence young married women’s health care seeking behaviour, their access to and utilisation of health care services Sampling – purposive – limited to CLA Methodology – in-depth interviews with 3 doctors, 3 nurses and 2 midwives

Selected statistics for comparison Indicators Palestinian refugees Pakistan Youth aged 10-24 years - % of total population 34 32 % of women aged 20-24 years married by age 18 19 24 % of women aged 20-24 years married by age 15 - 7 Total fertility rate 3.2 3 adolescent fertility rate 48 28

Selected findings Health care seeking behaviour of young married Palestinian refugee girls Initiation of ANC Number of visits during pregnancy Regularity and punctuality of visits Postnatal visit Initiated ANC early in pregnancy Followed recommended regimen Attended clinics regularity Attended postnatal clinic

Other findings Preconception classes Appointment system Continuity of care and familial environment No transport costs Free or minimal consultation fees Postnatal home visits

Selected statistics on Palestinian refugees living in Lebanon 86.2% ANC coverage 6.4 average number of visits during pregnancy 86.2% of women with at least 4 antenatal visits 92.4% Postnatal visits 100% institutional deliveries Child immunization – more than 99% Infant mortality – 19/1000 live births Neonatal mortality – 14/1000 live births Maternal mortality ratio MMR – 14/100,000 live births among women registered with UNRWA antenatal services

Lessons learned Increasing accessibility and utilization of services Health care seeking behaviour can be influenced by Introduction of preconception classes – health promotion, counselling, screening/risk assessment, nutrition supplementation Providing information about services Making services available and affordable to all Increasing accessibility of services Reducing distance to facilities Minimising transportation costs

Lessons learned contd: Improving quality of services Focus on prevention and MCH MCH programme that reaches out to those in need Accessible to all Addresses the needs of vulnerable groups Training of health care providers Number of trained personnel

The way forward: Appropriate policies and proper allocation regimens. Addressing young married girls in all maternal and child health (MCH) programmes and policies Investing in policies and programmes that address young married girls will help accelerate the achievement of internationally-agreed Millennium Development Goals – not only MDG 5 but also MDG 1, 3, 4 and 6.

Thank you