1. National Conference on MDG 5 – Improving Maternal Health in Pakistan November, 2013 Islamabad, Pakistan

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

3. 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

4. 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

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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

15. 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

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

17. 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

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

19. 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

20. 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

21. 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

22. 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.

23. Thank you