Relation Between Low Birth Weight Babies and Antenatal Care With Nutritional Status in The Women of Private Industrial Workers

Relation between low birth weight babies and
antenatal care with nutritional status in the

women of
Private industrial workers
DR. TAHIR HUSSAIN KHARAL

M.B; B.S. (Pb), MPH (SWEDEN)
Relation between low birth weight babies and

antenatal care with nutritional status in the
women of
Private industrial workers
DR. TAHIR HUSSAIN KHARAL

M.B; B.S. (Pb), MPH (SWEDEN)
Submitted in partial fulfillment of the requirements for

The Master of Science in Community Health & Nutrition, at Faculty
of Sciences.
Allama Iqbal Open University, Islamabad
Adviser:
May, 2009
Dr. Shahzad Ali Khan

M.B;B.S. M.B.A, M.P.H
2
ACKNOWLEDGEMENTS
First and foremost, I would like to express my sincere gratitude to those pregnant
women of Social Security Hospital-Study center, whose participation in Maternal and
Neonatal Child Health program for making this study possible and also to those
Social Security Hospital staff, who were involved in collection of information used
for this study.
I am extremely grateful to my supervisor Dr Shahzad Ali Khan, for his professional

and logistic support, encouragement, patience and understanding in preparing this
thesis.
I would also like to extend my appreciation to my colleague Miss. Amna Jabeen for
helping me in data collection, and most respectable and honourable Mr. Najam Iqbal,
Chief executive of Science Centre, for sponsoring this research work.
I am highly appreciative of Dr. Javed Iqbal Janjua is a great friend and constant
source of support for me.
In the end, I am really grateful for my mothers constant support and prayers, which I
believe, have always carried me through in life. Lastly, I wish to appreciate my wife,
for her unflinching support and my children, Nayab, Qamber and Sibtain, for being
source of joy and satisfaction. I thank Almighty ALLAH for having made M.Sc not
only possible but also an unforgettable experience.
Accepted by the Faculty of Sciences, Allama Iqbal Open University, in partial

fulfillment of the requirements for the Master of Science in Community Health &
Nutrition.
Viva Voca Committee
_______________________
Chairperson of the Department
___________________
External Examiner
_____________________
Internal Examiner
DEDICATION
This work is dedicated to

my loving Mother and my Wife.
Without their prayers and support,

This work would not have been possible for me
LIST OF ABBREIVIATION USED
ABBREVIATIONS
TERMS
ANC.
Antenatal Care
CBA.
Child Bearing Age
C-SECTION
Caesarean Section
FATA Federally Administered Tribal area

FP.
Family Planning
LBW..
Low Birth Weight
MNCH
Maternal and Neonatal Child Health
MDG
Millennium Development Goals
NWFP..
North West Frontier Province
OPD.
Out Patient Department
ORT.
Oral Rehydration Treatment
SVD.
Spontaneous Vaginal Delivery
TBA................
Traditional Birth Attendant
WHO.....................
World Health Organization
ABSTRACT
Low Birth Weight among newborn is a worldwide risk factor for infant morbidity and
mortality across the world especially in South East Asia, Pakistan. Proper antenatal
care with nutritional advice can identify and improve the risk of low birth weight and
ultimately decrease the infant morbidity and mortality.
The aim of the study was to improve the mother and child health by testing the
hypothesis that four or more antenatal visits with proper nutritional advice could
improve the birth weight, compared to less than four visits.
The objectives of this study were to identify the nutritional status of pregnant women
and relation between Regular and Non-Regular cases with birth weight.
Information about antenatal visits and Food Frequency of 200 pregnant women of
private industrial workers were collected under the scheme of Public sector prepaid
health insurance system at Social Security Hospital, Islamabad. The duration of study
was six month from August 2007 to January 2008. Descriptive and cross tab analysis
were done by applying Chi Square and Fishers Exact Test with 95% confidence
interval.
There 40% were primigravida and 60% were multigravida women came for delivery.
Among all pregnant women in this study 53.5% were up to 25 years of age. 77.5%
pregnant ladies attended four or more antenatal visits. Regarding low birth weight
babies were found 23%. Significant relationship seen in body mass index of antenatal
user with non-antenatal user as 30% normal weight Regular cases compared to 8.5%
non-Regular cases (p<0.014).
Co-relation of maternal and newborn variables with birth weight showed significant
relationship between; maternal residence distance from hospital (p<0.001), mode of
delivery (p<0.000), maternal Antenatal visits (p<0.000), newborn age (p<0.000),
maternal BMI (p<0.078). Weak co-relation seen in maternal age (p<0.659), maternal
weight (p<0.440), maternal education (p<0.484), newborn gender (p<0.675) and
parity had no correlation (p<0.631) Nutritional advice was found very effective as
80.5% did diet modification upon advice of doctor during antenatal check-up
(p<0.000).
In order to prevent the prevalence of low birth weight babies, efforts to increase
scheduled visits in antenatal care with nutritional counseling must be strengthened.
KEY WORDS:
Antenatal visits, Regular, Non-Regular, Low birth weight, Social Security, Pakistan
TABLE OF CONTENTS
Sr.
TOPIC
PAGE
CHAPTER 1
1.1
Rationale and Background
1.2
Statement of The Problem
1.3
Aim
1.4
Objectives
1.5
Study Hypothesis
1.6
Operational Definitions
1.7
Significance of Proposed Study
1.8
Research Methodology
1.9
Limitation of Study
1.10
Social Security System in Pakistan
1.11
Antenatal Care Services in Social Security
CHAPTER 2
2.1
Low Birth Weight
11
2.2
Antenatal Care
11
2.3
Prenatal advice to break the vicious cycle
13
2.4
Nutrition Problems
14
2.5
Nutritional risk factors in pregnancy resulting in LBW babies
17
2.6
Low pre-pregnancy weight and insufficient weight gain
17
2.7
Maternal height and infant weight
17
INTRODUCTION
REVIEW OF LITERATURE
11
2.8
The Age factor
17
2.9
Pica
18
2.10
Smoking
18
2.11
Diet Plan for Pregnant Women
19
CHAPTER 3
20
PROCEDURE OF THE STUDY
3.1
Study Design
20
3.2
Place of Study
20
3.3
Study Population
21
3.4
Duration of Study
21
3.5
Sampling
21
3.6
Sampling Technique
21
3.7
Inclusion Exclusion Criteria
21
3.8
Data collection
22
3.9
Interview
22
3.10
Questionnaire
23
3.11
Pre-test of Questionnaire
23
3.12
Variables
24
3.13
Individual variables and Questions
24
3.14
Techniques of Observations
25
3.15
Elimination of Biases
26
3.16
Data Analysis
27
3.17
Ethical Consideration
27
CHAPTER- 4.A 4.
Analysis
AnalysisofofData
Data
4.2
Maternal Education
29
4.3
Distance from Hospital
30
4.4
Occupation
32
4.5
Maternal Height
32
4.6
Maternal Weight
33
4.7
Body Mass Index
33
4.8
Weight Gain during Pregnancy
35
4.9
Gravidity
35
4.10
Number of Antenatal visits
36
10
4.11
Status of Pregnancy
36
4.12
Mode of Delivery
37
4.13
Habit of Tobacco use
38
4.14
Illness during Pregnancy
39
4.15
Medication during Pregnancy
39
4.16
Infant Gender
40
4.17
Baby Weight Categories
40
4.18
APGAR Score
41
4.194.
Diet Modification
42
4.20
Advice for Diet Modification
42
4.21
Regular Meal Habits
44
4.22
PICA
44
4.23
Description of Different Meal Habits
45
4.24
Weekly Food Frequency
46
4.25
CO-RELATION OF MATERNAL AND NEW BORN VARIABLES
48
194
WITH BIRTH WEIGHT
CHAPTER -4.B
DISCUSSION
Discussion
53
53
57
CHAPTER 5
CONCLUSION
5.1
Summary of Findings
57
5.2
Conclusions
58
5.3
Recommendations
59
REFERRENCES
11
61
ANNEXXURES
70
ANNEX-A: CONSENT FORM
70
II
ANNEX-B: QUESTIONAIRRE
71
LIST OF TABLES
TABLE NO.
TITLE OF THE TABLE
TABLE 1
Maternal Age
28
TABLE 2
Maternal Education
30
TABLE 3
31
TABLE 4
Occupation
32
TABLE 5
Maternal Height
33
TABLE 6
Maternal Weight
33
TABLE 7
Body Mass Index
34
TABLE 8
Weight Gain during Pregnancy
35
TABLE 9
Gravidity
35
TABLE 10
Number of Antenatal visits
36
TABLE 11
Status of Pregnancy
36
TABLE 12
Mode of Delivery
37
TABLE 13
Habit of Tobacco use
38
TABLE 14
Illness during Pregnancy
39
TABLE 15
Medication during Pregnancy
39
TABLE 16
Infant Gender
40
TABLE 17
Baby Weight Categories
40
TABLE 18
APGAR Score
41
12
PAGE NO.
TABLE 19
Diet Modification
42
TABLE 20
43
TABLE21
Regular Meal Habits
44
TABLE 22
PICA
44
TABLE 23
Description of Different Meal Habits
45
TABLE 24-25
Weekly Food Frequency
46
TABLE 26-36
CO-RELATION OF MATERNAL AND NEW
48
BORN VARIABLES WITH BIRTH WEIGHT

TABLE 26
Maternal age
48
TABLE 27
Maternal Education
48
TABLE 28
Maternal Height
49
TABLE 29
Maternal Weight
49
TABLE 30
Parity
50
TABLE 31
Body Mass Index
50
TABLE 32
50
TABLE 33
Mode of delivery
51
TABLE 34
Regular or Non-Regular
51
TABLE 35
New Born Age
52
TABLE 36
New Born Gender
52
13
LIST OF FIGURES
FIGURE NO.
TITLE OF THE FIGURE
FIGURE 1
Conceptual framework of study hypothesis
FIGURE 2
Social Security System Model
10
FIGURE 3
International cycle of growth failure
13
FIGURE 4
Map of Rawalpindi Region, study area
20
FIGURE 5
Maternal Age
29
FIGURE 6
Maternal Education
30
FIGURE 7
Urban / Rural distribution
31
FIGURE 8
Body Mass Index(BMI)
34
FIGURE 9
Pregnancy Status
37
FIGURE 10
Mode of Delivery
38
FIGURE 11
Birth Weight
41
FIGURE 12
43
14
PAGE NO.
CHAPTER 1
INTRODUCTION
1.1 RATIONALE AND BACKGROUND:

Low Birth weight (LBW) babies have been defined by the World Health organization
(WHO) as weight at birth of less than 2500 gm (irrespective of gestational age i.e.
those born prematurely and those with fetal growth restriction), (WHO, 1992).
LBW is one of the most serious challenges in maternal and neonatal child health
(MNCH) in both developed and developing countries. The birth weight of an infant is
the single most important factor that affects neonatal mortality, in addition to being
significant determinants of post-neonatal infant mortality and of infant and childhood
morbidity (McCormick, 1998). Based on the epidemiological observation it is seen
that LBW babies are 20 times more likely to die than heavier babies (Kramer MS,
1987).It is an important risk factor for neonatal morbidity (Borja JB and Adair LS,
2003) and (Valero De Bernab et al. 2004).The cohort of LBW babies is likely to
reflect two effects, a short gestational age and small for gestational age usually results
for intra-uterine growth restriction (IUGR), (De Onis, 1998).
LBW, a public health problem is associated with a range of both short and long term
adverse consequences. Almost one half of all LBW infants in industrial countries are
born preterm (less than37 weeks gestational age). These are the main cause of death,
morbidity and disability. The short the gestation, the smaller the baby and more risk
of death, morbidity and disability. It has been observed that mortality range can be
vary 100 folds across the spectrum of birth weight and worsen with decreasing weight
(Wilcox AL, 2001).
Most LBW infants in developing countries are born at term and are affected by
intrauterine growth restriction that may begin early in pregnancy (Villar J and Belizan
JM, 1982). These babies are at risk of perinatal mortality and morbidity. They
remained effected throughout life and are associated with poor growth in child hood
and a higher incidence of adult diseases like diabetes, hypertension and cardio hepatic
15
diseases. It leads the girls to a vicious cycle being having smaller babies when they
become mothers (De Onis, 1998). Such babies remain a burden on the health
insurance system in developed countries and a permanent problem for their families in
developing countries.
In 1992, first time WHO released a global estimate of LBW, which was around 7%
for industrialized countries and in developing countries ranged between 5 to 33
percent, with an average of 17% (WHO, 1992). Now the incidence of LBW is
estimated to be 16% world wide, 19% in the least developed and developing
countries, and 7% in the developed countries. The incidence of LBW is 31% in South
Asia followed by Middle East and North Africa 15%, Sub-Saharan Africa 14%, and
East Asia / Pacific 7% (UNDP, 2007). This estimate was irrespective of gestational
age. While of the total estimated intra-uterine growth restriction (IUGR) babies, Asia
accounts for 75%, and with 20% and 5% both in Africa and Latin America,
respectively. IUGR accounts for 11 % of total babies in developing countries ranging
from 2% to 21% of that is 6 times higher compared to developed countries (De Onis,
1998). In South Asia the incidence of LBW is 36%, in India 30% and in Pakistan it is
19% (UNDP, 2007).
There are many factors which affect the duration of gestation and fetal growth leading
to LBW babies. Birth weight is affected by mothers own fetal growth and her diet
from birth to pregnancy. Deprived mothers give birth to LBW babies. Poor nutrition
both before and during pregnancy is recognized as a known cause of LBW especially
in developing countries. Kramer concluded that maternal nutritional factors both
before and during pregnancy account for more than 50% of cases of LBW in many
developing countries (Kramer MS, 1987). Reliable data indicates reduction in the
prevalence of early childhood malnutrition in some countries suggesting possible
decline in LBW (RW Steketee et al. 1996). This is further strengthen by data
indicating improved food supply, improved maternal nutrition status, favorable
demographic changes and increased access to antenatal care reduces the LBW.
In a land mark event at International Conference on Population and Development
(ICPD) at Cairo in September 1994 and later at Beijing 1998, a considerable
development in the provision of maternal care services were made and a number of
16
measures were initiated to improve the weight of new born babies. The family welfare
programme in Pakistan aimed
early registration of pregnant women for antenatal
care services and coverage of pregnant women for the visit of family health worker or
Mid-wife (Bhutta ZA, 1997)
Maternal and child health outcomes are closely associated throughout the life cycle
but most radical effects are during pregnancy and neonatal period. The antenatal
period clearly presents opportunities for reaching the pregnant women with many
interventions (Campbell OMR and Graham WJ, 2006). Which are vital to their health
and well being as well as of their infants and providing preventive and curative
services (Abou Zahr CL and Wardlaw T, 2003). Studies in
developing and
transitional countries have shown positive effects of ANC on perinatal outcomes,

including reduced rates of pre-term labour ( H Orvos et al. 2002) and (CA Brown,
2008). Low birth weight and also perinatal death (SK Kapoor, 1985) and (McCawBinns, 1994). WHO recommends four ANC visits for low risk pregnancies and
prescribes the evidence-based content for each visit (Villar J and Bergsjo P, 2002).
In addition to the direct effect of ANC on perinatal outcomes (i.e. health benefits
arising from the care itself), there may also be an indirect benefit associated with
ANC, since women attending ANC are more likely to have their delivery assisted
by a professional health care provider or in a health facility (AM Van Eijik et al.
2006). If antenatal care achieves high coverage, it provides a platform for evidencebased interventions, including vaccination, correction of anemia, ORT, FP, malaria
and other infections (SA Bhutta et al. 2005).
In Pakistan only 31 percent of the women seek antenatal care. Antenatal care has
shown some improvement over time, but there were wide urban-rural disparities.
Over 58 percent of childbearing aged women are anemic, a condition that can be
easily detected and treated during the prenatal care period. Two-thirds of the pregnant
women deliver at home and 80 percent of the deliveries take place without the
assistance of skilled birth attendants. Overall, about three-fifths of rural women do not
receive any antenatal check-up during their last pregnancy. Services actually received
are predominantly nutritional advices and supply of iron and folic acid tablets.
17
Women visited by health workers received fewer services compared to women who
visited a health facility. Home visits were biased towards households with a better
standard of living (FBS, 2004). One study in Pakistan has shown lesser prevalence of
anemia among women attending antenatal care facilities and concluded that
identification of danger signals in pregnancy and recognition of nutritional demands
of pregnancy are better understood by women utilizing antenatal care facilities (AY
Alam et al. 2005).
Reduction of LBW incidence by 1/3rd between 2000 2010 is one of the major
goals of WHO. A World fit for children, declared in United Nation General Assembly
session in 2002. In Millennium Development Goal (MDG) reduction of LBW is part
of reducing child mortality target, which leads to healthy start of life for new born and
ensuring that mothers commence pregnancy healthy and well nourished through
proper ANC and nutritional advice.
No studies on LBW babies have been conducted in the Social Security Health
Insurance system, covering industrial workers families, on the national level. Only
national studies are available which show the prevalence rate of LBW in Pakistan.
Malnutrition is a major health issue in Pakistan. Underweight and stunting are more
prevalent in rural areas. Treatment and prevention can bring down morbidity and
mortality so the accompanying health cares expense. Although the average per capita
caloric availability and health indicators have improved in Pakistan, but very little
improvement in nutritional status has been observed in the past decade.
All this problem of LBW is due to the malnutrition of women, who is in a child
bearing age and having no access to balance diet through out her life in a Pakistani
society where she has to work a whole day in home, field, or in a factory. The
condition becomes worse when she got pregnant being already deprived off balance
diet and now she has to feed her fetus for 40 weeks in the same ration, she is having
as a routine. All this results in the shape of LBW. Such a situation can be improved by
a nutritional counseling at the time of antenatal examination. In a society like Pakistan
and community which we are dealing is a labour class, who has no time for their
18
health care they have to work for their living, minimum 4 antenatal visits are
recommended for a normal pregnancy. In a study less than 3 prenatal visits were
associated with significantly higher incidence of prenatal feto-maternal complications
and low birth weight babies (Tasnim et al. 2005). Factors At the time of routine
antenatal examination women are screened for fetal wellbeing and mothers health
parameters. As a routine diet advice is given to her to avoid any complications due to
malnutrition.
A proper antenatal care covering all aspects of pregnant women can prevent
malnutrition and low birth weight babies in a developing country like Pakistan. By
this, burden of health sector for curative measures declines markedly; WHO dream
becomes true that Childrens health is tomorrow's wealth".
1.2 STATEMENT OF THE PROBLEM:

There is very high prevalence of low birth weight babies and this has very drastic
consequences for future generation as low birth weight leads to further complication
and high risk of mortality. The problem of low birth weight cannot be tackled by
improving antenatal coverage unless the nutritional counseling is done to the pregnant
mothers coming for antenatal at health care centers or at community level by the Lady
Health workers in the rural areas.
1.3 AIM:
To improve the maternal and neonatal child health (MNCH) services in Public sector
pre-paid health insurance model of Social Security in Punjab.
1.4 OBJECTIVES:
1.
To identify the prevalence of Low Birth Weight babies in women of lowincome families of Rawalpindi / Islamabad registered with the system of
Social Security health insurance.
2.
To describe the proportion of LBW babies in regular antenatal (Regular) and

non-antenatal (non-Regular) cases.
19
3.
To identify the nutritional status of pregnant women reporting for delivery at

the hospital.
1.5 STUDY HYPOTHESIS:

A regular antenatal care with proper nutritional counseling minimizes the risk of low
birth weight. It is a recognized fact that proper antenatal care through regular visits for
antenatal check up can substantially reduce the risk of pregnancy out come like low
birth weight babies (Moller et a., 1989) and (Ekwempu, 1988).
Null Hypothesis: H0 There is no risk of LBW babies in women without regular
ANC and proper nutritional counseling.
Alternate Hypothesis: HA There is a risk of LBW babies in women without regular
ANC and proper nutritional counseling.
Figure 1: Conceptual framework of study hypothesis.
1.6 OPERATIONAL DEFINITIONS:

Antenatal Visits: These are the schedule visits of pregnant women at any antenatal
care centers, where weight, blood pressure, anemia, edema, urine for sugar and
albumin, fetal condition, etc are regularly monitored and recorded by the skilled
health personnel. Immunization, micronutrient supplementation and nutritional
counseling are also included in antenatal visit.
20
Regular Cases: Having at least 4 antenatal starting from first trimester of pregnancy
with one antenatal in each of trimesters and two in the last trimester. For ease of
terminology "Regular" in this study means "ANC User"
Non-Regular: Having less than 4 antenatal or more than four but not distributed
evenly as described in ANC users. Word "Non-Regular" is used for "ANC Non-user"
in this study.
Perinatal: from 1st stage of labour to 24 hrs after delivery
Outcome: Mode of delivery, status of birth (live, stillbirth) birth weight, maternal
hemoglobin, maternal blood pressure.
Health Insurance: Prepaid Health Insurance system of Social Security in Pakistan.
1.7 SIGNIFICANCE OF PROPOSED STUDY:

Low birth weight is a grave problem in Pakistan where it leads to many complications
in infancy and at adulthood. Identifying its prevalence in low-income population and
suggesting interventions in minimizing this risk. It is important to identify the benefits
if any, in order to plan health programmes for the improvement of maternal and
neonatal child health in this insured group of the Social Security System in Pakistan.
1.8 RESEARCH METHODLOGY:

The present study is a hospital-based cross-sectional study. Pregnant women will be
interviewed, when they will be admitted in labour room for delivery. A detailed food
frequency questionnaire will be filled after a thorough inquiry in the food
consumption by them. A detailed data form of mother and delivered child will be
filled in the labour room after complete examination of child.
1.9 LIMINTATION OF STUDY:

The study population is not representative of general population but a selection of
21
women of private industrial workers who are insured under the Social Security Health
Care System. The number of home delivery cases not reporting to hospital issues a
limitation to this study.
Nutritional status is assessed on Food Frequency Questionnaire method and depends
on recording of data so there is a chance of false data entry bias.
1.10 SOCIAL SECURITY SYSTEM IN PAKISTAN:
Social Security is the only prepaid health insurance scheme in public sector. It
provides comprehensive medical care services to private industrial secured workers
and their families including parents. We can just take the example of Social Security
as a pilot institution of prepaid health insurance in Pakistan. It has been functioning
here for over 41 years, established in March 1967. It is present in three provinces,
Punjab, N.W.F.P and Sindh. It collects contributions from industry and then utilizes
these resources to provide health care services to the insured. Although it is in the
form of formal payments, is job-based, for private industry only and has limited
upper-ceiling level, it has two basic characteristics of prepaid public financing; it is
not risk-related, does not depend on individual health risks, and it is equal for all the
insured, as it provides health services to everyone irrespective of their individual
payments and health status and expenses. Social Security Punjab has approximately
28000 industrial units registered with it. The number of secured/registered workers is
about six lac (0.6 million), with dependents about 38 lacs (3.8 million). It has a
network of dispensaries and hospitals in major cities of Punjab, which are mostly
situated near industries. It provides medical care facilities to the secured workers and
their families. These include OPD and Indoor in its own Hospitals and Dispensaries,
Dental Care, Surgeries (including Cardiac Surgery), Physiotherapy, Diagnostics,
Haemodialysis, Comprehensive Maternity Care services (in hospitals only), Provision
of ambulance, Blood transfusion, Provision of spectacles, artificial aids and dentures,
Payment of diet charges on admission of workers and their dependents at the rate of
Rs.100/day. It provides transportation charges for bringing the patients to the
Hospitals and also the Reimbursements of expenses of Government Hospitals. In
22
addition, cash benefits (wages) during sickness, injury and disability and Pension to
survivor of deceased (due to employment injury).
1.11 ANTENATAL CARE SERVICES IN SOCIAL SECURITY:
Social Security system in the region operates through a network of dispensaries and
these dispensaries provide primary care services including the antenatal care. These
ANC cases are then referred to the Social Security Hospital for registration and
issuing ANC Card. The delivery is only carried out at the Hospital and not in the
dispensaries. All cases can report for delivery or any other outcome of pregnancy to
the Hospital 24 hours a day and seven days a week. There is no compulsion for the
ANC and all the cases are entertained in the emergency whether enrolled as ANC or
not. There is no segregating for the ANC enrolled or non-enrolled cases and no
preferential treatment is done for any of these groups. Regular and non-Regular have
the same treatment protocols and no special Labour room or Ward available for any of
theses groups (special labour room, basic labour room).
23
FIGURE 2: PREPAID HEALTH INSURANCE SYSTEM; SOCIAL SECURITY
E
M
P
L
O
Y
E
E
S
O
F
P
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I
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A
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SOCIAL SECURITY TAX
S
E
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R
E
D
E
M
P
L
O
Y
E
E
S
B
E
N
E
F
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SOCIAL
SECURITY
OFFICES
FUNDS
AND
MEDICAL
SUPPLIES
USE OF SERVICES
REIMBURSEMENTS
24
MEDICAL CENTRES
OF
SOCIAL SECURITY
(DISPENSARIES
&
HOSPITALS)
CHAPTER 2
REVIEW OF LITERATURE
2.1 LOW BIRTH WEIGHT:

Maternal and neonatal child health services are facing many hurdles in the
implementation of their programs due to lack of national data on the issues, like
LBW. There is scanty nationally representative data available. Mostly information is
derived from facility based studies that may not reflect the real situation at the
national level. Like in Pakistan the LBW rate varies from 5% to 23% in different
areas (Northrop-Clewes et al. 1998) and (ZA Bhutta et al. 2004). While IUGR are
seen 24.4% in a community based study (Fikree et al. 1994). WHO presently reflect
our LBW rate as 19% (UNICEF, 2007). This is because the proportion of infants who
are weighted at birth is very low in many developing countries, where only small
proportion of deliveries took place in hospital. For example in the period from 1995 to
2000 the proportion of babies weighted at birth in Asia and Africa was 27% and 26%
respectively. In Pakistan babies weighing at birth is only 9% (UNICEF, 2007). This
figure is due to the fact that birth weight in the Pakistan has not been studied on a
national scale because deliveries in many areas of country occur at home, often
attended by traditional birth attendants (TBAs) or by village midwives who do not
weigh the baby. Even the records of deliveries that occur at hospitals are not always
complete. This situation applies to the remote areas of Baluchistan, Tribal area,
NWFP, FATA and out reach areas of Kashmir where most of all deliveries occur at
home and attended by TBAs. This percentage is higher among illiterate and rural
women.
2.2 ANTENATAL CARE:

The recognized benefits of antenatal care (ANC) to babies include increased growth,
reduced risk of infection and increased survival (G Carrolie et al. 2001).
While elements of ANC package including nutritional advice have been shown costeffective in developing country context (T Adam et al. 2005). Early ANC benefit
women by reducing the burden of malaria and anemia (GL Dramstadl et al. 2005).
Complications of pre-eclampsia and eclampsia could be prevented by wide spread use
of adequate antenatal (AM Mohamed et al. 2006). Inadequate prenatal care is
25
associated with increased neonatal death in both the presence and the absence of
antenatal high-risk conditions. Association between inadequate prenatal care and
neonatal mortality may be mediated by increased risk of preterm delivery and low
birth weight in these pregnancies (XK Chan et al. 2007).
Most women reported waiting until the onset of labour to travel to the facility. The
woman's level of education was significant predictor of initiating ANC care,
continued ANC attendance, and delivery in hospital (RW Skeketee et al. 1994) and
(Mumtaz Z, and Salway S, 2007). This study suggested that interface between
community and secondary antenatal services needs improvement to minimize the
possible adverse effects from identifying women as being at risk during pregnancy
(CJ Jackson et al. 2006). A study in India showed that there was significant underutilization of nurse/midwives in the provision of antenatal services and doctors were
often the lead providers. The average number of antenatal visits reported in this study
was 2.4 and most visits were in the second trimester. Higher social and economic
status was associated with increased chances of receiving an antenatal check-up, and
of receiving specific components including blood pressure measurement, a blood test
and urine testing. Pregnant women from poor and uneducated backgrounds with at
least one child were the least likely to receive antenatal check-ups and services in four
large north Indian states (S Pallikadavath et al. 2004).
In another study significant increase was shown in the percent of women receiving
ANC with the establishment of the local MCH Clinic. Non-geographic barriers to
ANC are important and need to be addressed through community-based intervention
programmes (N Bilenko et al. 2007).
Poor quality of antenatal care is likely to reduce ANC utilization (M Rani et al. 2008).
Based on combined data of the ten countries, lack of health insurance was found to be
an important risk factor for inadequate prenatal care. Women with inadequate prenatal
care were more likely to be aged less than 20 years and with higher parity than
controls. Women with inadequate care were also more likely to have less education
and no regular income. They had more difficulties dealing with health services
organization and child care. Cultural and financial barriers were present, but after
26
adjusting for confounders by logistic regression, perceived financial difficulty was not
a significant factor for inadequate prenatal care (T Delvaux et al. 2001).
In developing countries unscheduled care is common during pregnancy (U Magriples

et al. 2008). Rates of caesarean section in secondary-level facilities markedly
increased over the last decade to the same levels as in major hospitals (G Sufang et al.
2007). An index of prenatal care use was calculated for each singleton live birth from
1991 to 2000. A study in Manitoba showed that highest rates of inadequate prenatal
care were among women living in neighborhoods with the lowest average family
income and the highest proportion of the population who were unemployed. Social
inequalities exist in the use of prenatal care. Regional disparities in rates of inadequate
prenatal care emphasize the need for further research to determine specific risk factors
for inadequate prenatal care in socioeconomically disadvantaged neighborhoods,
followed by provision of effective targeted services (MI Heaman et al. 2007).
2.3 PRENATAL ADVICE TO BREAK THE VICIOUS CYCLE:

A major component of antenatal care is antenatal or prenatal advice. The mother is
more perceptive to advice concerning herself and her baby at this time than at other
times.
FIGURE 3: International cycle of growth failure (ACC/SCN, 1992).
27
During the antenatal examination the pregnant mothers who herself were LBW are
pointed out to break the cycle of LBW babies outcome as Recent research has shown
that LBW is often perpetuated from one generation to the next. An infant whose
mother was herself an LBW baby is four times more likely to have a low birth weight;
the likelihood is six times greater in the case of an LBW father. This finding makes it
easier to identify parents at risk of having an LBW baby (Conley and Bennett, 2000).
It also suggests that a key to preventing LBW births is to break this cycleand that
will require a better understanding of it. Some researchers are focusing on educational
experience as a crucial factor. Studies have shown that LBW is associated with
weaker educational progress, even when you control for other factors. In fact, LBW
dramatically reduces (by 34 percent) the likelihood of a childs graduating from high
school by age 19, even when that child is compared to siblings growing up in the
same family and environment. Researchers have also found that LBW mothers are 40
percent less likely to have graduated from high school than other mothers. It appears
that biological health at infancy, through its impact on overall development, affects
education and eventual socioeconomic status. Which in turn increase the risk of LBW
and poor infant health. Providing educational support to LBW babies from the start
may be one way to interrupt this vicious cycle. Women who do not receive adequate
early prenatal care are more likely to give birth to a LBW baby (Annie E, 1999).
A mothers medical problems influence birth weight, especially if she has high blood
pressure, diabetes, certain infections or heart, kidney, or lung problems. An abnormal
uterus or cervix can increase the mother's risk of having a LBW baby. With timely
prenatal care, a woman can reduce risk to herself and her baby. Prenatal care can also
link women with services aimed at curbing smoking and improving nutrition
(Alexander and Korenbrot, 1995).
2.4 NUTRITIONAL PROBLEMS:

The nutritional needs of pregnant women are higher because she needs food both for
herself and for her growing fetus. The requirements of all pregnant women are higher
than those of the other women; younger mothers needs additional nutritional
requirements for their growth as well. Kramer (1997) published a review of available
evidence from controlled trials on the effects of energy and protein supplementation
during gestation on the outcome of pregnancy. He concluded that balanced
28
energy/protein supplementation modestly improves fetal growth but is unlikely to be

of long-term benefit to pregnant women or their infants. Female literacy is widely
recognized as an important determinant of health. The incidence of malnutrition has
been shown fall with the level of maternal education (Jafarey et al. 1995). Chronic
maternal malnutrition and poor nutrition during pregnancy are risk factor for IUGR.
In a selected urban squatter settlement in Karachi, 24 % of 738 singleton newborn had
IUGR, and they were more likely to have mothers who were poorly nourished (Fikree
et al. 1994).
Two large studies in industrialized nations involving 100,000 pregnancies clearly

indicate that favorable pregnancy outcomes are less frequent among anemic mothers
(Murphy et al. 1980) and (Gran et al. 1981). Both studies result shown higher rates of
fetal abnormalities, death and LBW newborns among malnourished anemic mothers.
Further studies shown positive results obtained in birth weights and decrease in fetal
death rate by successful treatment of malnutrition and anemia with iron and folic acid.
LBW was reduced from 50% to 7% and prenatal death rate dropped from 38% to 4%
in a study shown in Nigeria (Fleming, 1991). Maternal malnutrition especially iron
deficiency anemia may increase the risk of long term and even permanent
impairments in mental and physical development among such children (Barker,
1993).
Women who are not taking the balance diet during pregnancy may lead to anemia, it
still remains as a leading cause of LBW and major health issue amongst Pakistani
women as reported in the National Health Survey (1990-94). More than 40% of
women aged 15-44 years suffer from mild anemia as defined by standard cut-off
values WHO (WHO, 1996). In urban area resident women this prevalence fell to 35%.
Inter-provinces this varies widely (National Survey Of Pakistan 1998). Pregnant
women in Pakistan receive only 87 percent of recommended calories and lactating
women only 74 percent; their protein intake is only 85 percent of recommended
levels. Data from the National Nutrition Survey (Nutrition Division, 1988) show that
34 percent of pregnant and lactating mothers were underweight compared to other
women in the study, but the findings are unclear.
29
Malnutrition also includes protein-energy malnutrition, which is assessed by physical

growth and body assessments. Gender differences in malnutrition among children
under five have not been established in national surveys (UNICEF, 1998) but among
adults women suffer more from malnutrition than men.
Change of food habits during pregnancy is mostly advised by peers or some TBAs in
start due to morning sickness later on due to myths. In a baseline survey in all
provinces of Pakistan, 19% women increase their intake of diet during pregnancy.
41% of them did not change and 37% took less (The Anemia Task Force, 2000).
Relevant nutrition advice assumes significance in the context of developing countries

since dietary intake in pregnancy is strongly influenced by cultural beliefs and
practices. Data from 18 multicultural evidence that food restriction is practices during
pregnancy, in order to facilitate an easier labour and delivery, by lowering baby
weight (Brems S, and Berg A, 1988).
Fear factor of a difficult delivery or heavy baby may restrict the women to take even
required diet. There is false perception among health care providers in Pakistan that
there is phenomenon of eating down during pregnancy; however, only one study is
available in literature which supports it (Karim et al. 1994).
In a baseline survey found that 25% women (n=100) took iron supplements during
their pregnancy and the majority of them started after 2nd semester of pregnancy (Ali
N, 2001). On the other side, 30% of the women (n=100) stated that they would take
iron supplements if so advised by a health care professional. This is mostly advised
during antenatal checkup (Ali N, 2000).
30
2.5 NUTRITIONAL RISK FACTORS IN PREGNANCY RESULTING
IN
LBW BABIES:
In developing countries the maternal malnutrition is an important causative factor of
LBW babies. A mother whose weight at the end of pregnancy is less than 45 kg and
whose height is less then 150cm is likely to bear a LBW baby. The women who are in
the danger of becoming malnourished and can bear a LBW babies.
Nutritional risk during pregnancy is associated with age, socio-economic status, and a
history of past medical and obstetrical problems
2.6 LOW PRE-PREGNANCY WEIGHT AND INSUFFICIENT WEIGHT

GAIN:
Low pre-pregnancy weight (10% or more below a womans ideal weight for height)
and inadequate weight gain during pregnancy are associated with LBW infants. The
recommended weight gain for pregnant woman is 10-13 kg (22-28 lb) the pattern of
weight gain is most important. A gain of 1-2 kg during the 1st trimester followed by
about 0.4 kg each week throughout the last two trimesters is the recommended
pattern. Several studies have indicated that weight gain of poor Indian women
averaged 6.5 kg during pregnancy (ICMR, 1977). This study also shows that healthier
and taller mothers give birth to LBW infants less frequently (A Khalid et al. 1995).
Kramer (1987) has examined in detail the determinants of LBW. It is generally
accepted that birth weight is related to the mothers weight and to her gain in weight
during pregnancy.
2.7 MATRENAL HEIGHT AND INFANT WEIGHT:

In a study in Senegal there was also a significant correlation between birth weight
and mothers height, (Brined, 1985), and in Guatemala a close relationship was found
between maternal height and infant mortality (Martorell, 1989).
2.8 AGE FACTOR:

The metabolic demands made by younger pregnant women for their growth plus the
additional requirements of pregnancy, places teenager mothers at high nutritional risk.
They have more chances of premature births than older mothers have and more prone
to toxemia of pregnancy. A significant correlation with birth weight was teenage
31
pregnancies. Mothers whose age was less than 20 had higher risk of delivering lowbirth-weight infants (A Khalid et al. 1995).
2.9 PICA:
Iron deficiency anaemia can result if the amounts consumed sufficient.
2.10 SMOKING:
Smoking is known factor in pregnant woman leading to LBW babies. Nicotine causes
the necrosis of placenta resulting in low blood supply and anoxia to fetus. Smoking is
also responsible for loss of appetite, which also results in mothers nutrition and
anemia. All this collectively affects the health of fetus and out come is the low birth
weight baby.
Research consistently shows that, even after controlling for other factors, smokers are
about twice as likely to deliver a low birth weight baby as non-smokers (Chomitz et
al. 1995). Cigarette smoking during pregnancy is the single most important known
cause of low birth weight. About 13 percent of all births in the U.S. are to mothers
who smoked during pregnancy in 1999 (The Annie E, 2002).
In fact, epidemiologists estimate that up to 25 percent of all LBW could be avoided if
pregnant women did not smoke (Kleinman, and Mitchell Madan, 1988).
According to the U.S. Public Health Service, about one in five adolescent women are
smokers (Blumenthal, 1999). Early cessation is the ultimate goal, pregnant women
need to understand that it is worthwhile to quit or cut down at any stage.
According to a report by the Surgeon General, women who quit cigarette smoking at
almost any point during pregnancy have lower rates of LBW babies (U.S. Department
of Health and Human Services, 1990).
32
2.11 DIET PLAN FOR PREGNANT WOMEN:

Diet plan for a pregnant woman is always required to meet the challenges of
nutritional demands of the both mothers and foetus (Indiadiets, 2007). It should be
reviewed with time to time to re adjust the food items according to the need of the
pregnant mothers as follows:
i.
3 to 4 servings from the milk & dairy products
ii.
3 servings from the meat & meat substitutes.
iii.
3 servings from the vegetable group.
iv.
2 servings from the fruit group.
v.
6 servings from the bread & cereal, group.
Specially, the servings from the milk and dairy products could include low- fat or
non-fat type of milk, yogurt, and cheese. These foods supply extra protein, calcium,
riboflavin, and magnesium. Servings from the meat, poultry, fish, dry beans, eggs,
and nuts group should include both animal and vegetable sources. Besides protein, the
animal sources help provide the extra iron and zinc needed, and the vegetable sources
help to provide much of the extra magnesium needed during pregnancy.
The vegetable and fruit group servings provide a variety of vitamins and minerals.
One serving from this combination should be a good vitamin C source, and one
serving should be a green vegetable or other rich source of folate, such as spinach or
orange juice.
Selection from bread, cereal, and rice and pasta group should focus on the whole grain
and enriched foods.
33
CHAPTER 3
Procedure of the Study
3.1 STUDY DESIGN:

This is a cross-sectional study a type of an observational descriptive study, with a
food frequency questionnaire and mothers and infants data forms for data collection
at the Social Security Hospital Islamabad
3.2 PLACE OF STUDY:

It was a hospital-based study, done at the Social Security Hospital Islamabad. This
hospital provides maternity care services to the insured workers in the Five Districts
(Attock, Jhelum, Chakwal, Rawalpindi and Islamabad).
The proposed place of the study will be the Social Security Hospital in the
Islamabad/Rawalpindi region. It is a teaching hospital of Islamabad Medical and
Dental College. In Northern Punjab, it is the main hospital catering health care
facilities for the industrial workers from the following five districts; Rawalpindi,
Islamabad, Attock, Chakwal and Jehlum. All latest diagnostic and therapeutic
facilities are available. Its indoor has a capacity of 260 beds.
Figure 4: Map of Rawalpindi Region, study area (Rawalpindi, 2007)

34
3.3 STUDY POPULATION:

This study was done in the insured population of social security. The number of
registered population with the Social Security Hospital Islamabad is 210,000. Eligible
population is the pregnant women reporting for delivery at Social Security Hospital
Islamabad in study period.
3.4 DURATION OF STUDY:

August 2007 to January 2008.
3.5 SAMPLE SIZE:

All the cases reporting in the hospital for delivery were included and a total of sample
size of 200 was taken.
3.6 SAMPLING TECHNIQUE:

All the cases coming to the labour room for delivery were included in the study if they
fulfilled the Inclusion criteria. All the cases coming for delivery in the study site had
an equal chance of enrolment in the study, as the data was collected on 24 hour basis
without any break.
3.7 INCLUSION /EXCLUSION CRITERIA:

Those cases that were insured for more than one year and reporting in the Obstetrics
Department of Social Security Hospital for delivery were included in the study. They
are drawing a salary up to Rs.5000.per month under the Social Security health
insurance system.
Those maternity cases having any concurrent medical illnesses (not related to
pregnancy) were excluded.
Only singleton deliveries included.
35
3.8 DATA COLLECTION:

Data collection was done through structured questionnaire filled at the time of
delivery within the perinatal period. The questionnaire was pretested and validated.
There was no segregation of the Regular and Non-Regular during the data collection.
All the study participants were given the same questionnaire. All the data was entered
on the same day into the computer to maintain quality. 5% of the cases were verified
for ensuring quality of response entered in data. The data was entered on SPSS-15 and
necessary coding was done.
No one refused the study participation and thus the Response Rate was 100%.
3.9 INTERVIEW:
A structured interview was used for collecting information concerning most of the
variables listed for investigation; questions were asked orally. Self-administered
questionnaires were not used, since they require a certain level of skill and education
on part of the respondent, and as the study participants were likely to have low
literacy level, that would not have been the preferred approach. In the face-to-face
interview, the interviewer was able to maintain the respondents interest, and was able
to allay anxiety if it was aroused.
The components of the questionnaire were compiled with the use of previously
validated questions included in previous studies. The questionnaire was initially tested
on 10 cases and was modified as necessary. The questionnaire was translated into
Urdu, the language in which it was administered and subsequently back translated to
ascertain that the essence of the questions remained unchanged. It was ensured that all
questions had face validity, and it was expected that the respondents would know the
answer; questions were clear, non-ambiguous and fair. The sequence of questions
involved the inclusion of easy to answer questions in the beginning and leaving
difficult questions until later. Long questions were avoided; most questions were
designed to have fixed alternative responses for greater uniformity and simplicity of
analysis.
Measures were taken to attain complete reliability and to reduce variation to
reasonable limits. For this questions were asked in a standard manner. Particular
attention was also paid to reproducibility or the extent to which similar information is
36
supplied when the question is asked more than once, so as not to generate a bias and
to minimize variability of responses.
Factors that could influence the response to a question were identified and taken into
account. Questions were asked in a neutral manner without showing a preference for a
particular response; it was made sure that the respondents understood it in the same
way. The questionnaire was translated into Urdu ensuring consistency in phrasing of
questions so that the responses would not generate a bias. The interview took 25
minutes.
3.10 QUESTIONNAIRE:
Details about various components of the questionnaire are given in detail in the
Performa attached herewith (Appendix B).
3.11 PRE-TEST OF QUESTIONNAIRE:

The questionnaire was pre-tested on 10 cases. These were not included as study
participants. The interviewer recorded responses for which the questionnaire made
provision; in addition, the interviewer also made observations of the respondents
reactions, comments, criticism and suggestions concerning the questions, their
sequence, skip patterns and layout of the questionnaire form. The questions were
discussed with the respondent after they were answered. It was inquired whether the
questions seemed clear, in particular, clarifying the dont know answers, to make
sure that they were indeed, true dont knows as opposed to not answering because
of not understanding the question. On the basis of this, it was possible not only to
identify the difficult, offensive and hard to understand questions but also to identify
unsatisfactory questions yielding a dont know answer. The pre-test pointed to a
need for changes in the questionnaire, these changes were made and a new version
was again pre-tested.
37
3.12 VARIABLES:
During the planning stage, variables to be measured were selected and clarified on the
basis of their relevance to the objectives of the study. Suitable questions were
formulated which had face validity as a measure of these variables. To enhance
validity, multiple questions were designed on the same topic.
In addition to variables with obvious relevance to the study objectives, other variables
were also included; these included universal variables, such as age, sex, and measures
of time, i.e. the date the patient entered the study. In addition to these demographic
variables, over 61 variables were identified as being relevant for measurement with
respect to the objectives of the study. These included various dietary components,
social class and attributes that may be used as indicators of social class, such as
occupation, education, and exposure to tobacco / naswar and pica. These variables
were too complicated to be measured as single entities, and were therefore, broken up
into component aspects, regarded as separate variables and measured independently.
3.13 INDIVIDUAL VARIABLES AND QUESTIONS:
Name and age:
name of the individuals was noted. Age of the individual was
determined by the date of birth. Many of the study participants from rural
backgrounds with no formal education were unable to recall their exact dates of birth
in this situation approximate age in years was noted.
Occupation: there were inquired about their job status either they work at some place
(as fulltime or part time) or household.
Residence: Places of residence were categorized by distance from the hospital into 3
categories.
38
Education: number of years of education was calculated from the highest class
achieved in school or college. Since college and university education is not universal
in Pakistan and most people study up to the primary or secondary grades.
Socio-economic status: The class under our study belongs to low socio-economic as
their monthly salary is up to Rs. 5000.
Diet:
a Food Frequency Questionnaire (FFQ) carried out assessment of dietary
pattern in this study. Though this method has methodological problems including
recall bias and under-reporting of certain types of food, it nevertheless, gives useful
insight into the dietary pattern. FFQ have also been used with considerable field
success in a recently reported very large Pan-European (EPIC) study (International
Journal of Epidemiology,1997) Examples of foods within each food category were
listed, in order to provide a description of each category. Individuals were asked how
frequently they consumed food from each of the groups.
Tobacco use and other addictions: The problem of smoking in the women in
Pakistan is not a major health problem as like in developed countries. Tobacco use in
Pakistan is more than what the smoking of cigarettes indicates, therefore tobacco use
was defined as also including smoking of the hukka and chelum and smokeless
chewable tobacco in the form of naswar or pan.
3.14 TECHNIQUE OF OBSERVATIONS:
Several techniques of observation were also used as methods of data collection;
1) Measurement of weight by a weighing scale
2) Measurement of height by a height measure
Particular attention was paid to reliability or reproducibility of results; the procedures
were therefore standardized and performing two or more independent measurements
and comparing the findings minimized intra-observer variation; the mean of two or
more values was used wherever applicable. High quality instruments were used and it
was ensured that they gave consistent measurements. When more than one
measurement device was used, they were of the same model and were standardized
against each other. Equipment was tested from time to time and quality control
measures ensured.
39
Height: Standard height was measured with the subject bare foot, back straight
against the wall and eyes looking straight ahead. When the set square rested gently on
the scalp, height was recorded to the nearest 0.5 centimeter.
Weight: Weight was measured with the subject barefoot and wearing light clothing,
the scale was standardized to 0 before each use and the subjects weight was
recorded to the nearest 500 grams. Weighing scale of labour room was calibrated
daily before weighing the infants.
BMI: Body mass index was calculated assess health status.
For the age 18 and above international standards for BMI for adults is used for this
purpose Greys classification of nutritional status on the basis of BMI was used
(FNRI. 2007).The classification of nutritional status by Grey is shown below
Underweight------------- less than 20kg/m2
Normal ---------------- 20-25 kg/m2
Overweight -------------26-30 kg/m2
Obese -------------------greater than 30 kg/m2
3.15 ELIMINATION OF BIASES:

Traditionally, there are numerous sources of bias in a this study; efforts were made in
this study to mitigate these; with all members of the study population enrolled, a high
response rate and very few dropouts and non participants, several biases such as the
non-response bias, non-participant bias and drop-out bias were eliminated to a very
large extent. An attempt was also made to eliminate several other biases; selective
interviewer was used throughout the period of the study, thus minimizing interobserver variation. There were also efforts made to ensure quality control and
corrections for intra-observer variation, this was aided by strict standardization of the
anthropometric procedures
40
3.16 DATA ANALSIS:

Analysis was carried out in SPSS-15. Description and comparison of various
outcome variables in both the groups was carried out and test used for significance
were Chi-Square and Fishers Exact.
3.17 ETHICAL CONSIDERATIONS:

The study was conducted after approval from ethical committee of the organization
with the application of guide lines provided by ethical committee.
Consent: Informed verbal consent was taken after explaining to them the nature of
the study and building their confidence that confidentiality of information obtained
will be maintained.
Confidentiality: The participants were assured that confidentiality will be maintained
Compensation: The study did not provide monetary incentives to study participants.
Risks of participation in the research: We perceived no risks of this study.
Benefits of participation: There are no direct benefits of participation in the study
to study participants, but study results can drive efforts towards better health
programmes.
41
CHAPTER 4.A
Analysis of Data
4. MATERNAL VARIABLES:
4.1 MATERNAL AGE:
The mean age of women reporting for delivery was 25.93 years. Most of the women
were from the age bracket of 21- 25 years (87 women). The minimum age was 17
years while the maximum age was 39 years.
Out of the total 200 women, 107 (53.5%) were having age 15 years up to 25 years,
while 20 women (10 %) were less than 21 years of age (p < 0.011). There was
significant difference in maternal age between Regular and Non Regular. In Regular
cases, 70(35%) women were having age 21 years up to 25 years and 59(29.5%)
women were in age bracket 26 years up to 30 years, while no Regular case was seen
more then 36 years age group., while in Non-Regular cases 4(2%) women were in up
to 20 years age group and 17(8.5%) were up to 25years age, 15(7.5%) women in up to
30 years age group.
TABLE 1: MATERNAL AGE

AGE
GROUPS
FREQUENCY
15 to 20 yrs
21 to 25 yrs
26 to 30 yrs
31to 35 yrs
More than36yrs
20
87
74
16
3
PERCENT
NONREGULAR
n (%)
10.0
16(8%)
4(2%)
43.5
70(35%)
17(8.5%)
37.0
59(29.5%)
15(7.5%)
8.0
10(5%)
6(3%)
1.5
0%
3(1.5%)
Pearson Chi-Square: 13.118, Sig. (2-sided): 0.011
42
REGULAR
n (%)
FIGURE 5: MATERNAL AGE

70
Regula
rNonRegular
60
50
Count 40
35.0%
30
29.5%
20
10
8.0%
8.5%
7.5%
2.0%
15-20
21-25
5.0%
3.0%
26-30
31-35
1.5%
>36
AGE CATOGORIES
4.2 MATERNAL EDUCATION:

Out of 200 women, 66 (33%) women were having no education. Most women 98
(49%) were having Primary education, followed by secondary school certificate were
33 women (16.5%). There was a significant difference between Regular and NonRegular regarding education (p < 0.000). In Regular, 36(18%) were Illiterate,
89(44.5%) women were having primary education and 27(13.5%) women having
secondary schooling, while in Non-Regular category 30(15%) women were illiterate,
only 9(4.5%) were primary and 6(3%) were secondary school certificate passed .
43
TABLE 2: MATERNAL EDUCATION

EDUCATION
REGULA
NONR
REGULAR
n (%)
n (%)
33.0
36(18%)
30(15%)
49.0
89(44.5%)
9(4.5%)
16.5
27(13.5%)
6(3%)
1.5
3(1.5%)
0%
FREQUENCY
Illiterate
primary
secondary
graduate
66
98
33
3
PERCENT
FIGURE 6: MATERNAL EDUCATION

100
Regula
rNonRegular
80
Count 60
44.5%
40
20
18.0%
15.0%
13.5%
4.5%
3.0%
Illiterate
Primary
Secondary
1.5%
Graduate
Education
4.3 DISTANCE FROM HOSPITAL:
Among 200 women, 112(56 %) were living within the 20 km from the hospital, urban
area of Rawalpindi / Islamabad. While 88 (44. %) pregnant women came from rural
44
area around the Rawalpindi / Islamabad having a distance more than 20 km from the
hospital. In Regular cases 95(47.5%) women came from urban area and60 (30%) from
rural area, while 17(8.5%) Non-Regular cases came from urban area and 28(14%)
women came from rural area (p <0.005).
TABLE 3: DISTANCE FROM HOSPITAL

Distance from
Health facility
FREQUENCY
NONREGULAR
n (%)
112
56.0
95(47.5%)
17(8.5%)
88
44.0
60(30%)
28(14%)
Pearson Chi-Square: 7.825,
Sig. (2-sided): 0.005
Urban < 20km

Rural > 20km
PERCENT
REGULAR
n (%)
FIGURE 7: URBAN / RURAL DISTRIBUTION

100
Regula
rNonRegular
80
Count 60
47.5%
40
30.0%
20
14.0%
8.5%
0
Urban < 20km
Rural > 20km
Distance from Health facility
45
4.4 OCCUPATION:
Out of 200 women 185 (92.5%) were house wives, 11(5.5%) were fulltime employed
and only 4(2%) were part time working women. There is significant difference
between both categories. In Regular, 143(71.5%) women were house wives, 11(5.5%)
women were full time employed and only 1(0.5%) lady was working part time. In
Non-Regular 43(21.5%) out of 200 were house wives and only 3(1.5%) ladies were
working part time (p <0.010).
TABLE 4: OCCUPATION
OCUUPATION
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
Housewife
185
92.5
143(71.5%)
42(21%)
Full Time
Employed
Part Time
Employed
11
5.5
11(5.5%)
0%
2.0
1(0.5%)
3(1.5%)
Fishers Exact Test : 8.339,
Sig. (2-sided): 0.010
4.5 MATERNAL HEIGHT:

Out of 200 pregnant women 26(13%) were having height less than150 cm, while
more than 150 cm were 174(87%) ladies. 20(10%) ladies in Regular group and 6(3%)
ladies in Non-Regular group were less than 150 cm tall. There was a significant
difference as 135(67.5%) ladies were in Regular and 39(19.5%) were in Non-Regular
group (p <0.0940).
46
TABLE 5: MATHERNAL HEIGHT CATAGORIES

HEIGHT
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
Less than 150

cm
26
13.0
20(10%)
6(3%)
More than 150

cm
174
87.0
135(67.5%)
39(19.5%)
Sig. (2-sided): 0.940
4.6 MATERNAL WEIGHT:

Maternal weight less than 45 kg was observed as 43(21.5%) pregnant women and
157(78.5%) were more than 45 kg (n=200).there was a significant difference as
43(21.5%) ladies were less than 45 kg in Regular and nil in Non-Regular group.
While 112(56%) ladies were having weight more 45 kg in Regular and 45(22.5%)
ladies were in Non-Regular group (p <0.000).
TABLE 6: MATERNAL WEIGHT CATAGORIES
WEIGHT
Less than 45kg

More than
45kg
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
43
21.5
43(21.5%)
0%
157
78.5
112(56%)
45(22.5%)
Sig. (2-sided): 0.000
4.7 BODY MASS INDEX:

Body Mass Index (wt/m2) was observed as 73(36.5%) pregnant women were under
weight. 77(38.5%) were having normal weight, 50(25%) were over weight and no one
was obese (n=200). In Regular group 63(31.5%) were under weight and 60(30%)
47
were normal weight category. In Non- Regular group 10(5%) were under weight and
17(8.5%) ladies were of normal weight (p <0.014).
TABLE 7: BMI
BODY MASS
FREQUENCY
PERCENT
REGULA
R n (%)
73
36.5
63(31.5%)
NONREGULAR
n (%)
10(5%)
77
50
38.5
25.0
60(30%)
32(16%)
17(8.5%)
18(9%)
INDEX
Under Weight
15-19.9
Normal 20-24.9
Overweight
25-29.9
Obese More
than 30
Sig. (2-sided): 0.014
FIGURE 8: BMI
70
Regula
rNonRegular
60
50
Count40
30
31.5%
30.0%
20
16.0%
10
8.5%
9.0%
5.0%
0
15-19.9
20-24.9
BMI (wt/m2)
48
25-29.9
4.8 WEIGHT GAIN DURING PREGNANCY:

Out of 200 pregnant women only 8(4%) gained in weight during pregnancy more than
7 kg and these were from Regular group. 192(96%) women gained weight less than 7
kg.
TABLE 8: WEIGHT GAIN DURING PREGNANCY

WEIGHT
GAIN
FREQUENCY
PERCENT
REGULAR
n (%)
192
96.0
147(73.5%)
Less than 7kg

More than 7kg
NONREGULAR
n (%)
45(22.5%)
4.0
8(4%)
0
Fishers Exact Test: 0 .203
4.9 GRAVIDITY:
Out of 200 women, 80 (40%) were Primigravida, 120 (60%) were Multigravida.
There was a significant difference between Regular and Non-Regular cases as
71(35.5%) Regular and 9(4.5%) Non-Regular primigravida women. 84(42%) Regular
and 36(18%) Non-Regular cases were Multigravida (p <0.002).
TABLE 9: GRAVIDITY
NONGRAVIDITY FREQUENCY PERCENT REGULAR
n (%)
REGULAR
n (%)
80
40.0
71(35.5%)
9(4.5%)
Primigravida
120
60.0
84(42%)
36(18%)
Multigravida
49
4.10 NUMBER OF ANTENATAL VISITS:

Cases having less than four (4) antenatal were grouped as Non-Regular while those
with 4 or more antenatal were grouped as Regular. There were 155 women (77.5%)
categorized as Regular; while 45 (22.5%) as Non-Regular (n=200).
Out of 200 cases, 7 cases (3.5%) had no antenatal. Most women 38 (19%) had less
than 4 antenatal (Standard deviation 0.841, mean 3.13).
TABLE 10: NUMBER OF ANTENATAL VISITS

NUMBER OF
ANTENATALS
FREQUENCY
7
PERCENT
3.5
38
19.0
77
38.5
78
39.0
None
Less than 4
4 to 5
More than 5
4.11 STATUS OF PREGNANCY:

Out of 200 cases, 160 were Full term (80%); 24 were Preterm (12%) and 16 were Post
term cases (8%). There was significant difference between the Regular and NonRegular, as there were 19(9.5%) cases of Preterm labour in Non-Regular but only
5(2.5%) in Regular (p<0.000).
TABLE 11: PREGNANCY STATUS

PREGNACY
STATUS
FREQUENCY
PERCENT
REGULAR
n (%)
PRETERM
24
12.0
5(2.5%)
NONREGULAR
n (%)
19(9.5%)
FULLTERM
160
80.0
140(70%)
20(10%)
POSTTERM
16
8.0
10(5%)
6(3%)
50
FIGURE 9: PREGNANCY STATUS

140
Regula
rNon-
Regular
120
100
Count
80
70.0%
60
40
20
10.0%
9.5%
0
2.5%
Preterm
Full term
5.0% 3.0%
Post term
Infant age
4.12 MODE OF DELIVERY:
Out of total 200 deliveries, 56 (28%) were spontaneous vaginal deliveries (SVD);
90(45%) were spontaneous vaginal deliveries with Episiotomy.
There were 49
(24.5%) Caesarian (C-section); 5 cases (2.5%) were delivered through Forceps with
Vacuum (p<0.000).
TABLE 12: MODE OF DELIVERY
MODE OF
DELIVERY
SVD
SVD with Epi
C section
Vacuum/forceps
FREQUENCY
PERCENT
REGULAR
n (%)
56
28.0
34(17%)
90
49
5
NONREGULAR
n (%)
22(11%)
45.0
84(42%)
6(3%)
24.5
37(18.5%)
12(6%)
2.5
0
5(2.5%)
Fisher Exact Test: 37.274, Sig. (2-sided): 0.000
51
FIGURE 10: MODE OF DELIVERY

Regular or NonRegularRegula
100
rNonRegular
80
Count 60
42.0%
40
20
18.5%
17.0%
11.0%
6.0%
3.0%
SVD
SVD with Epi
C section
2.5%
Vacuum/forceps
Mode of delivery
4.13 HABIT OF TOBACCO USE:
Habit of Tobacco use was seen in 8(4%) women which were 5(2.5%) Regular and
3(1.5%) Non-Regular cases. 192(96%) pregnant women replied No for Tobacco use
(p<0.300).
TABLE 13: TOBACCO USE
TOBACCO
USE
Yes
No
FREQUENCY PERCENT REGULAR

n (%)
NONREGULAR
n (%)
8
4.0
5(2.5%)
3(1.5%)
192
96.0
150(75%)
42(21%)
52
4.14 ILLNESS DURING PREGNANCY:

Out of 200 pregnant women 156(78%) gave a history of no illness. While 33
(16.5%) women got anemia, 14(7%) Regular and 19(9.5%) were Non-Regular. 4(2%)
were diagnosed as Hypertensive all were Non-Regular cases. in Pre-eclampsia
category 7(3.5%) seen out of which 2(1%) were Regular and 5(2.5%) were NonRegular (p<0.000).
TABLE 14: ILLNESS DURING PREGNANCY
ILLNESS
Anemia
HTN
Pre-eclampsia
NA
FREQUENCY PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
33
16.5
14(7%)
19(9.5%)
4
2.0
0%
4(2%)
7
3.5
2(1%)
5(2.5%)
156
78
139(69.5%)
17(8.5%)
Pearson Chi-Square: 58.715 Sig. (2-sided): 0.000
4.15 MEDICATION DURING PREGNANCY:

History of medication for illness were as 47(23.5%) women said Yes, 33(16.5%)
Regular and 14(7%) Non-Regular cases. 153(76.5%) women said No in response to
use of any medicine (p<0.171).
TABLE 15: MEDICATION

MEDICINE
Yes
No
REGULAR
NONn (%)
REGULAR
n (%)
47
23.5
33(16.5%)
14(7%)
153
76.5
122(61%)
31(15.5%)
FREQUENCY
PERCENT
53
NEW BORN VARIABLES:

4.16 INFANT GENDER:
Out of 200 infants 88(44%) were male, 68(34%) in Regular and 20(10%) in NonRegular cases.
112(56%) were female infants, 87(43.5%) were in Regular and 25(12.5%) in NonRegular cases (p<0.946).
TABLE16: INFANT GENDER
GENDER
Male
Female
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
88
44
68(34%)
20(10%)
112
56
87(43.5%)
25(12.5%)
4.17 BABY WEIGHT CATEGORIES:
Out of 200 cases, 46 (23%) had birth weight less than 2.5kg; 154 cases (77%)
weighing more than 2.5kg. In the Regular weight above 2.5kg was 133(66.5%) as
compared to 21(10.5%) in the Non-Regular (p<0.000).
TABLE 17: BABY WEIGHT CATEGORIES
NONWT. CATEG
FREQUENCY PERCENTAGE REGULAR

n (%)
REGULAR
n (%)
LESS THAN 2.5

KG
46
23
22(11%)
24(12%)
MORE THAN 2.5

KG
154
77
133(66.5%)
21(10.5%)
54
FIGURE 11: BIRTH WEIGHT

Regular or emergency
Regula
rNon
Regular
140
120
100
Count
80
66.5%
60
40
20
12.0%
11.0%
10.5%
Less than 2500gm
More than 2500gm
LBW/NBW
4.18 APGAR Score:
Majority, 172 cases (86%) babies had an APGAR score of 7 or more. There was
significant difference of APGAR between Regular and Non-Regular(n=200).
TABLE18: APGAR SCORE
APGAR
SCORE
Less than 7/1st

min
More than
7/1st min
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
28
14.0
20(10%)
8(4%)
172
86.0
135(67.5%)
37(18.5%)
55
Sig. (2-sided): 0.407
NUTRITIONAL VARIABLES:
4.19 DIET MODIFICATION:

Diet modification during pregnancy is mostly observed. Among 200 pregnant women
161(80.5%) did diet modification and only 39(19.5%) did not made any change in
their diet. Between Regular and Non-Regular groups 133(66.5%) women said Yes
and 22(11%) said No among Regular cases. While among Non-Regular 28(14%)
said Yes and 17(1=8.5%) lady did not modified their diet (p <0.000).
TABLE19: DIET MODIFICATION

DIET
MODIFICATI
ON
FREQUENC
Y
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
Yes
161
80.5
133(66.5%)
28(14%)
No
39
19.5
22(11%)
17(8.5%)
4.20 ADVICE FOR DIET MODIFICATION:
Out of 200 pregnant women 109(54.5%) did diet modification upon the advice of
doctor or health care providers at health facility. 43(21.5%) did it upon family advice
and only 9(4.5%) did diet modification upon the advice of TBA. In Regular cases
101(50.5%) women made a change in their diet after consultation from their health
services providers. While in Non-Regular cases 8(4%) women did by advice of doctor
(p<0.000).
56
TABLE 20: ADVICE FOR DIET MODIFICATION

EDUCATION
FREQUENCY
PERCENT
REGULAR
n (%)
Doctor / Health
care staff
TBA
family
NA/No
109
54.5
101(50.5%)
9
43
39
NONREGULAR
n (%)
8(4%)
4.5
1(0.5%)
8(4%)
21.5
31(15.5%)
12(6%)
19.5
22(11%)
17(8.5%)
FIGURE 12: ADVICE FOR DIET MODIFICATION

120
Regula
rNonRegular
100
80
Count
60
101
40
20
31
0
Doctor / Health
Care staff
12
8
TBA
Family
Who advised to change diet
57
22
17
NA/No
4.21 REGULAR MEAL HABIT:

When it was enquired from 200 pregnant women how many of them eat regularly,
then 133(66.5%) said Yes, and 67(33.5%) said No. In Regular cases 104(52%)
lady have the habit of regular meals and in Non-Regular cases 29(14.5%) lady dont
eat regularly (p<0.740).
TABLE21: REGULAR MEAL HABIT
REGULAR
MEAL HABIT
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
Yes
133
66.5
104(52%)
29(14.5%)
No
67
33.5
51(25.5%)
16(8%)
4.22 PICA:
Foods other then diet were consumed by 95(47.5%) pregnant women (n=200). While
105(52.5%) said No. In Regular cases 69(34.5%) ladies have habit of Pica, and
86(43%) ladies were not consuming non-food items. In Non-Regular cases 26(23%)
ladies said Yes and 19(9.5%) said No.
TABLE 22: PICA

NON-FOOD
ITEMS
FREQUENCY
PERCENT
REGULAR
n (%)
NONREGULAR
n (%)
Yes
95
47.5
69(34.5%)
26(23%)
No
105
52.5
86(43%)
19(9.5%)
58
4.23 DESCRIPTION OF DIFFERENT MEAL HABITS
During the study it was revealed that out of 200 study participants the habit of taking
morning meal in a week was in a rang of minimum 2 to maximum 7 times, with a
mean of 5.68 and Standard deviation 1.762.
Mid-morning Snack habit was seen from 1 time per week to 6 times per week, with a
mean of 2.29 and Standard deviation 1.141.
Lunch is more frequent and observed in a range of minimum 4 times per week to 7
times per week, with a mean of 6.40 and standard deviation 0.851.
Habit to take snack at after-noon was seen as minimum 0 to maximum 4 times per
week, with a mean of 1.43 and standard deviation 0.562.
Habit to take evening meal was seen in a range of minimum 3 and maximum 7 with a
mean of 6.121 and standard deviation 1.258
TABLE 23: DESCRIPTION OF DIFERENT MEAL HABITS

MEALS
Morning Meal in a
week
Mid-morning snack in
a week
Lunch or Midday
Meal in a week
After-noon snack in a
week
Evening Meal in a
week
PARTICIPANTS
200
Minimum Maximum
2
7
Mean
5.68
Std. Deviation
1.762
200
2.29
1.141
200
6.40
0.851
200
1.43
0.562
200
6.12
1.258
59
4.24 WEEKLY FOOD FREQUENCY:

Weekly food frequencies were recorded for the participants in the study. In the food
group of milk and milk products out of 200 participants 4(2%) were not dinking milk
and its products at all. 102(51%) of the participants were taking milk and its products
1-3 times a week and 94(47%) of them were taking milk and its products 4-7 times a
week.
Table 24: WEEKLY FOOD FREQUENCY
Frequency
Milk & its
Meat
Meat
Vegetables
Vegetables
Chapatti
/week
products
n (%)
substitute
Leafy
others
n (%)
n (%)
n (%)
n (%)
0%
n (%)
Not at all
4(2%)
93(46.5%)
0%
0%
0%
1-3 times/wk
102(51%)
101(51%)
188(94%)
192(86%)
186(93%)
0%
4-7 times/wk
94(47%)
6(3%)
12(6%)
8(4%)
14(7%)
200(100%)
In the food group of meat and meat products out of 200 participants 93(46.5%) were
not eating at all. 102(51%) participants were eating meat and its products 1-3 times a
week. Only 6(3%) participants were eating meet 4-7 times a week. However meat
substitutes such as pulses, red beans and kidney beans were taken by 188(94%)
participants 1-3 times a week. 12(6%) of the participants were taking these 4-7 times
a week.
In the green leafy vegetable group out of 200 participants 192(96%) were eating 1-3
times a week and 8(4%) participants were eating it 4-7 times a week.
60
In the other vegetable group out of 200 participants 186(93%) were eating 1-3 times a
week, while 14(7%) were eating it 4-7 times a week.
In the cereals group out of 200 participants 4(2%) were not eating at all. 196(98%)
were eating 1-3 times a week. All the 200 participants were eating chapatti 4-7 times a
week.
In the citrus fruit group out of 200 participants 152(76%) were taking it 1-3 time a
week. While 48(24%) participants were taking citrus fruit 4-7 times a week.
In the other fruit group out of 200 participants 1(0.5%) taking not at all, 158(79%)
were taking 1-3 times a week and 41(20.5%) were taking 4-7 time a week.
Table 25: WEEKLY FOOD FREQUENCY
Frequency
Cereals
Fruit citrus Fruit others
Sweet dish
/week
Not at all
1-3 times/wk
4-7 times/wk
4(2%)
0%
1(0.5%)
41(20.5%)
Juice/sweet
Jam/
drinks
honey
120(66%)
183(91.5%)
196(98%)
152(76%)
158(79%)
156(78%)
77(38.5%)
17(8.5%)
0%
48(24%)
41(20.5%)
3(1.5%)
3(1.5%)
0%
Out of 200 participants 41(20.5%) were not at all taking sweet dish. 156(78%) were
taking 1-3 times a week and only 3(1.5%) participants were taking 4-7 times a week.
Juices and sweet drinks were also not taken by 120(66%) participants at all.
77(38.5%) were taking 1-3 times a week and only 4(2%) participants were having it
61
4-7 times a week. Similar trend is seen in jam and honey 184(92%) participants were
not taking at all. Only 16(8%) out 200 were taking 4-7 times a week.
4. 25:CO-RELATION OF MATERNAL AND NEW BORN VARIABLES WITH

BIRTH WEIGHT:
Co-relation for maternal and newborn variables with outcome i.e. Birth weight were
computed. The results are shown in the following tables. Since some cells have
expected count of less than 5, Chi-Square Test is not valid application here; instead
Fishers Exact Test is applied to explore the level of significance.
Table 26: RELATIONSHIP OF MATERNAL AGE WITH BIRTH WEIGHT

MATERNAL AGE
RANGE
15-20
21-25
26-30
31-35
>36
BIRTH WEIGHT
LBW n=59
NBW n=141
1.5%
8.5%
11%
32.5%
9%
28%
1.5%
6.5%
0%
1.5%
Total n=200
10%
43.5%
37%
8%
1.5%
Maternal age shows weak correlation with birth weight, as there was count less than
5 in a cell we applied Fishers Exact Test (p < 0.659).
Table 27: RELATIONSHIP OF MATERNAL EDUCATION WITH BIRTH
WEIGHT
EDUCATION
Illiterate
Primary
Secondary
Graduate
BIRTH WEIGHT
LBW n=59
NBW n=141
9%
24%
9.5%
39.5
4.5%
12%
0%
1.5%
62
Total n=200
33%
49%
16.5%
1.5%
Maternal education shows weak correlation with birth weight, as there was count less
than 5 in a cell; we applied Fishers Exact Test (p < 0.484)
Table 28: RELATIONSHIP OF MATERNAL HEIGHT WITH BIRTH

WEIGHT
HEIGHT
Less than
150cm(n=10)
More than 150cm
(n=190)
BIRTH WEIGHT
LBW n=59
NBW n=141
0%
5%
23%
Total n=200
5%
72%
95%
Maternal height shows weak correlation with birth weight, as there was count less
than 5 in a cell; we applied Fishers Exact Test (p < 0.121).
Table 29: RELATIONSHIP OF MATERNAL WEIGHT WITH BIRTH
WEIGHT
WEIGHT
Less than
45kg(n=43)
More than
45kgcm (n=157)
BIRTH WEIGHT
LBW n=59
NBW n=141
4%
17%
19%
Total n=200
59.5%
Maternal weight shows poor correlation with birth weight (p < 0.440).
63
21.5%
78.5%
Table 30: RELATIONSHIP OF MATERNAL PARITY WITH BIRTH

WEIGHT
PARITY
Primigravida
Multigravida
BIRTH WEIGHT
LBW n=59
NBW n=141
8.5%
31.5%
14.5%
45.5%
Total n=200
40%
60%
Maternal parity is poorly significant related to birth weight (p < 0.631).

Table 31: RELATIONSHIP OF MATERNAL BMI WITH BIRTH WEIGHT
BMI (kg/m2)
15-19.9
20-24.9
25-29.9
BIRTH WEIGHT
LBW n=59
NBW n=141
8%
28.5%
6.5%
32%
8.5%
16.5%
Total n=200
36.5%
35.5%
25%
Maternal nutritional status computed as BMI was correlated with birth weight
applying Chi-Square test. The correlation ship was weak (p<0.078).
Table 32: RELATIONSHIP OF DISTANCE FROM HOSPITALWITH BIRTH

WEIGHT
DISTANCE
Urban < 20km
Rural > 20km
BIRTH WEIGHT
LBW n=59
NBW n=141
8%
48%
15%
29%
Total n=200
56%
44%
Distance of the health facility from pregnant women residence was computed and
64
correlated with birth weight applying Chi-Square test. The correlation ship was very
strong (p < 0.001).
Table 33: RELATIONSHIP OF MODE OF DELIVERY WITH BIRTH
WEIGHT
MODE OF
DELIVERY
SVD
SVD with Epi
C section
Vacuum/forceps
BIRTH WEIGHT
LBW n=59
NBW n=141
8.5%
19.5%
6.5%
38.5%
7.5%
17%
0.5%
2%
Total n=200
28%
45%
24.5%
2.5%
Mode of delivery shows correlation with birth weight, as there was count less than 5
in a cell; we applied Fishers Exact Test (p < 0.000).
Table 34: RELATIONSHIP OF REGULAR OR NON-REGULAR WITH

BIRTH WEIGHT
REGULAR /NONREGULAR
Regular
Non-Regular
BIRTH WEIGHT
LBW n=59
NBW n=141
11%
66.5%
12%
10.5%
Total n=200
77.5%
22.5%
Maternal status of ANC use is strongly correlated with birth weight (p < 0.000).
65
Table 35: RELATIONSHIP OF NEW BORN AGE WITH BIRTH WEIGHT

NEW BORN AGE
Preterm
Term normal
Post term
BIRTH WEIGHT
LBW n=59
NBW n=141
7%
5%
14.5%
65.5%
1.5%
6.5%
Total n=200
12%
80%
8%
New born age was computed for correlated with birth weight Fishers Exact Test to
check the correlation. The correlation ship was strong (p<0.000).
Table 36: RELATIONSHIP OF NEW BORNS GENDER WITH BIRTH

WEIGHT
GENDER
Male
Female
BIRTH WEIGHT
LBW n=59
NBW n=141
9.5%
34.5%
13.5%
42.5%
Total n=200
44%
56%
New born gender was computed for correlated with birth weight Chi-Square Test to
check the correlation. The correlation ship was weak (p<0.675).
66
CHAPTER 4.B
DISCUSSION
Maternal age is important factor in reduction of perinatal and neonatal deaths
according to a study done by Haksari in Indonesia, mothers less than 19 years were at
higher risks (Haksari, 1997). Thats why BRAC health programmes in Bangladesh
recommend the women to become pregnant after 20 years of age because of their
vulnerability of health in childbearing, due to lack of sufficient physical and mental
maturity during adolescence. If women are not physically capable, it is difficult for
them to become healthy mothers as well as to deliver healthy children without any
life-threatening complications.
A high percentage of women (53.5%) reporting for delivery at the age of up to 25

years in this study is the same as found in other studies (RW.Steketee et al. 1994).
Women of less than 21 years of age (10% in this study) is a common phenomena in
Pakistan where early marriage and pregnancy is a cultural norm. There was
significant difference between the Regular and Non-Regular showing it general
phenomena related to the antenatal use in this population. However in some studies
chances of being non-regular were more from age less than 20 years (T.Delvaux et
al.2001). This is observed in this study as 2% Non-Regular cases. It was found
through other study (MM. Rahman et al. 1997) that younger women are more likely to
consult health professionals in their pregnancies and in this way, to be relatively more
exposed to get more information about the health care facilities than the older women.
The significant difference among Regular and Non-Regular regarding maternal

education describe it as an important variable as the educated women were attending
the ANC services / nutritional advice and their education had positive effect on the
health of their foetus. This is also been shown in many other studies in Pakistan and
internationally (CJ. Jackson et al. 2006).
Same is observed in this study that
education level up to secondary school certificate was 58% in Regular cases and 7.5%
in Non-Regular cases. It was proven through a study on antenatal care seeking
behavior that higher female education is significantly associated with seeking
67
antenatal care services from health centers (MM. Rahman et al. 1997). The literacy
rate of Pakistan has increased from past, now it is claimed by the government up to
40% in females. As the population under our study belong to labour class where
education is free and financial assistance is also given through the Workers Welfare
Board schools during their school age. The education level among the 200 women
was very hopeful as 49% were primary, 16.5% were secondary level and 1.5 % was of
graduate level of education. 33% (n=200) were illiterate women.
Study conducted in Bangladesh showed that women with higher parity are more likely
to seek antenatal care from health centers / professionals (MM. Rahman et al. 1997).
In this study the participants belong to a labour class having poor socio-economic
status but they have a facility of free health care, so by the knowledge this facility
mostly came for antenatal check-up. This is evident by data that out of 200 women,
40% were primigravida, 60% were multigravida. There was a significant difference
between Regular and Non-Regular cases as 35.5% Regular and 4.5% Non-Regular
primigravida women and same is the case in multigravida 42% Regular and 18%
Non-Regular cases.
This has important implication as this can lead us to the
conclusion that ANC is the learned choice in this population otherwise majority of
women in the Regular category would not have been multigravida. But in some
studies multigravidas were found to be more inclined towards ANC as compared to
primigravidas (Mumtaz Z and Salway S., 2007).
A distance of less than 20km is taken as good accessibility indicator and in this group
56% participants were living within the 20 km from the hospital, urban area of
Rawalpindi / Islamabad. While 44% pregnant women came from rural area around the
Rawalpindi / Islamabad having a distance more than 20 km from the hospital and
This fact is also supplemented by the results showing significant difference in the
Regular and Non-Regular with reference to distance from hospital. 8.5% urban and
14% rural Non-Regular cases. Non-Regular cases imply the importance of
accessibility issue. This difference of urban and rural is seen due the concentration of
industrial colonies near to the cities, having all the urban facilities provided by the
factory owners at subsidized rates.
68
Economics condition of pregnant women has a positive relation ship with seeking
antenatal care, which was observed in a study in Bangladesh (MM. Rahman et al.
1997). Compared to the women who are working outside, housewives can offer more
time to the educational activities provided by the health care service providers. It is
more difficult for women working out side the house to make suitable time space for
these activities during their working hours. This is seen in this study that 71.5% were
housewives and Regular cases. Full time employed were 5.5% and they were all
Regular cases which is supported by an other study , it was found that employment of
women increases their tendency to get antenatal care from the health professionals
(HH. Akhtar et al. 1996).
In the status of pregnancy, 80% Regular reporting with Full-term pregnancy. Preterm
labour seen in Non-Regular cases as compared to Regular cases, again signify the
importance of ANC, as ANC use provides the chances to filters the high risk cases.
Studies have shown reduced preterm labour in the ANC Users (Campbell OMR, and
Graham WJ, 2006).
A C-section rate of 24.5% is slightly higher than the estimated 5-15% international
figure, but this is significantly different in Regular as 18% and 6% in Non-Regular.
The managed care system like Social Security may provide such specialist service
more in order to avoid the other risks of delivery. As this is secondary level facility,
the 88.4% deliveries assisted by Doctor is within the expected range. But importantly
the 12% cases assisted by Nurse and LHV and their birth outcome not different than
the Doctors, highlights the importance of skilled attendants other than Doctors
(Zaman T, 2008. personal communication).
To accept or reject our study hypothesis following discussion lead us to decision that,
The birth weight is an important birth outcome. In this study 23% babies having lower
weight than 2.5 kg can be explained on the basis of the fact that this not was the
normal distribution, and all of them belonged to the poor class of income level less
than Rs.5000 per month. But the effect of ANC use is significant as among Regular
the 66.5% were having birth weight of more than 2.5 kg as compared to the
69
Non-Regular where 10.5% had weight 2.5 kg or more. Other studies have also shown
the similar findings with poor outcomes in the Non-Regular and good outcome in
ANC Users (Campbell OMR, and Graham WJ, 2006).
The birth outcome having such difference in the two groups highlights the importance
of ANC use in this system of health care delivery and needs further elaboration. There
were 77.5% Regular and 22.5% were Non-Regular cases, only 3.5% had no antenatal
check-up out 200 participant of this study. This signifies the importance of ANC
usage in pre-paid health insurance system. Thus it is proved that regular antenatal care
with proper nutritional counselling improves the birth weight of babies.
Diet modification was seen in 66.5% women who came for regular ANC and got
nutrition advice by health care staff. This is significant that nutritional advice is
important and honoured by pregnant ladies belong to a low socio-economic
community.
In evaluating the relationship of food frequency with birth weight was computed and
no significant association could be found. The main reason of this is that the pregnant
ladies were regularly advised about the nutritional importance during pregnancy.
Maternal height was less than 150cm in 13% ladies, out that 10% were in Regular
group and 3% in Non-Regular group. Short statured ladies got regular ANC check-up
as they were more worried about their delivery complications and birth out-come.
Their nutritional counselling is far more important to decrease the chances of LBW
due to mal nutrition mothers.
Maternal nutritionals status was an important factor to give birth to a healthy child. In
Bangladesh, malnourished mothers give birth to underweight babies and cause high
rate of maternal deaths (National Plan of action for children 1997-2002). Maternal
weight was seen in this study as 21.5% pregnant ladies were less than 45kg. Women
who were under weight and bearing pregnancy were more concerned for ANC checkup and nutritional counseling to improve their health and birth weight of baby.
70
CHAPTER 6
6.1 SUMMARY OF FINDINGS:

This study revealed that the efforts being made by social security for the mother and
neonatal child health (MNCH) has positive outcome. Which is augmented by
awareness and education by media especially regarding the maternal age. Now trend
of teenage marriages have been reduced. Pregnant women know about the importance
of their health. There was increased trend to seek antenatal care with nutritional
consultation (77%). With of improvement in literacy rate of women the trends for
seeking early antenatal care are seen 41.5% in house wives and 60% are multigradia
women.
This study revealed that 56% women were urban residents mostly living in industrial
colonies, which minimizes the travel time towards the health care facilities.
The study population was mostly belong to lower socio-economics group of
community but the pregnant women were found aware about the importance of diet
during pregnancy and they reported the regular meal habit and intake of milk and
meat and meat products with green leafy vegetables 1-3 time a week more than 50
percent. Over all nutritional status was seen like whole nation.
A better antenatal service with effective nutritional counselling has improved the
newborn weight as compared to past. Low birth weight babies are seen only 23%,
although it is not a desirable figure but the population under study belongs to the poor
socio-economic class. This improvement of LBW rate was seen only by a regular
ANC with diet modification advised them during every antennal visit. The prevalence
of anaemia in pregnant mother is a usual finding besides pica and smoking which has
been reduced to non significant percentage by regular antenatal care with effective
nutritional counselling. This supports the alternative hypothesis of this study.
6.2 CONCLUSION:
71
As there are many barriers to improvement of mother and child in the developing
countries including economic costs involved; accessibility issues; lack of skilled and
qualified health care staff; lack of autonomy to financial resources and decisionmaking choice of women at home; the progress in maternal and child health in this
region has been very slow. But this study highlights the importance of the fact that if
costs and accessibility issues are addressed and the health system provides coverage,
then the use of regular antenatal services can be very effective in order to decrease the
incidence of low birth weight babies and improve the child survival rate.
The most important approach to the problem of LBW is prevention. This could be
done through improving the living standards among the general population, and by
systematic care of pre-pregnant women by improvements in nutrition, medical care
and work conditions (WHO, 1995).
This study elaborates one such system of Public Sector prepaid health insurance
system of Social Security providing comprehensive medical care services to the poor
workers of the private sector employees. This study has highlighted the importance of
ANC use for improving perinatal outcomes in the poor insured population of the
private industrial workers in Pakistan. The results of the study further elaborate the
protective effect of ANC use as is shown in the various other studies in the
developing world. Absence of any statistical significance does not always mean
absence of public health impact. This observation can be used to device policies and
interventions in the Social Security Health Care System to reduce the burden of
maternal and neonatal child health illnesses. The importance of ANC use in the
managed care system like Social Security can be a cornerstone in minimizing the
disease burden related to the pregnancy-related complications.
There are not many studies on this public sector health insurance model of Pakistan
and therefore more research is needed to identify issues related with the ANC Nonusers in such a system where the costs are minimal, there are several incentives
attached with health care uses and where there are no restrictions for the use of
medical care.
72
Even in proper health insurance coverage, the antenatal examination is not enough to
minimize the risk of low birth weight babies. It needs proper nutritional counseling to
minimize the risk of low birth weight babies.
6.3 RECOMMANDATIONS:
1. The underlying determinant of low birth weight babies are prenatal and natal
related with mothers health pre pregnancy and during pregnancy which
effects the growth of fetus. A health mother give birth to healthy babies and
the mothers who were themselves LBW, have more chances to born a LBW
baby thats why it is always recommended that girls at teenage and women
during pregnancy must be fed well. Balance diet is the ultimate requirement
and choice to minimize the economic burden of LBW on the nation leading to
further LBWs in next generation.
2. Strengthening of the existing services and expansion of MNCH services at
gross root level by the help of lady health workers, trained TBAs / mid wives
and lady health visitors.
3. Registration and weighing of every newborn at local union council level must
be assured.
4.
Early identification of risk factors and proper referral of cases to the

secondary health care centers is most effective intervention at periphery to
reduce the LBWs and newborn morbidity and mortality.
5. Antenatal care is only effective if it is regular and attention being paid on the
nutritional counseling.
6. De-worming and correction of anemia with micro nutrient has an important
role.
7. Advocacy for home made available balance diet is always effective and long
term strategy.
8. Discourage the commercial food supplements which act as poverty trap for
already poor nation.
9. Food fortification is a recommended measure to fulfill micronutrients
requirement and reduce the mal nutrition.
10. Food security must be provided to vulnerable families.
73
11. School health program must be started in every school of country with regular
supply of milk, energy biscuits and lunch.
REFEREANCES
74
Abou Zahr CL, Wardlaw T. (2003). Antenatal care in developing countries:

Promises, achievements and missed opportunities: An analysis of trends, level and
differentials, 1990-2001, WHO, Geneva.
Adam T, Lim SS, Mehta S, Bhutta ZA, Fogstad H, Mathai M, Zupan J, Darmstadt
GL. (2005). Achieving the millennium development goals for health - Cost
effectiveness analysis of strategies for maternal and neonatal health in developing
countries. British Med J; 331: 1107-1110.
Akhter HH, Chowdhuey MEK, Sen A. (1996). A cross-sectional study on maternal
morbidity in Bangladesh Institute of research for Promotion of essential &
reproductive health and Technologies (BERPERHT), Dhaka, Bangladesh.
Alam AY, Qureshi AA, Adil MM, Ali H. (2005). Comparative study of knowledge,
attitude and practices among antenatal care facilities utilizing and non-utilizing
women. J Pak Med Assoc. Feb;55(2):51-2
Alexander, G. R. and Korenbrot, C.C. (1995). The role of prenatal care in preventing
low birth weight. The Future of Children 5(1).
Ali N. (2000). Trials of improved Practices (TIPS) study report for anemia and
women health project. Islamabad, Pakistan: The Asia foundation.
Ali N. (2001). Baseline report community based support on MCH and nutrition. MCH
impact Assessment Study. Islamabad, Pakistan: The Asia Foundation.
Annie E. Casey Foundation. (1999). The Right Start. Baltimore, MD.
Baker DJP, Gluckman PD. Godfrey KM. and Robinson JS. (1993). Fetal nutrition and
cardiovascular disease in adult life. Lancet; 341:938-41.
Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. (2005). Community-based
interventions for improving perinatal and neonatal health outcomes in developing
countries: A review of the evidence. Pediatrics, 115: 519-617.
75
Bhutta ZA, Khan I, Salat S, Raza F, Ara H. (2004). Reducing length of stay in
hospital for very low birth weight infants by involving mothers in a stepdown unit: an
experience
from
Karachi
(Pakistan).
BMJ;
13;329:11515.
doi:
10.1136/bmj.329.7475.1151.
Bhutta ZA. Initiatives for control of Low Birth Weight in Pakistan, (1997). (personal
communication).
Bilenko N, Hammel R, Belmaker I. (2007).Utilization of Antenatal Care Services by
a Semi-Nomadic Bedouin Arab Population: Evaluation of the Impact of a Local
Maternal and Child Health Clinic Maternal and Child Health J;11(5):425-30
Blumenthal, S. J. (1999). Young women and smoking. Washington, DC: U.S. Public
Health Services Office on Womens Health, Department of Health and Human
Services.
Borja JB, Adair LS. (2003). Assessing the net effect of young maternal age on
birthweight. Am J Hum Biol.;15:73340. doi: 10.1002/ajhb.10220
Brems S, Berg A. (1988). Eating down during pregnancy: Nutrition, obstetric and
cultural considerations in the third world. Discussion Paper prepared for the
ACC/SCN. Washington DC, World Bank.
Brown CA, Sohani SB, Khan KS, Lilford RJ, Mukhwana W. (2008). Antenatal care
and Perinatal outcomes in Kwale District, Kenya. BMC Pregnancy and Childbirth
2008; 8:2 Article URL: http://www.biomedcentral.com/1471-2393/8/2 (last accessed
June 2008)
Campbell OMR, Graham WJ. (2006). Strategies for reducing maternal mortality:
getting on with what works. The Lancet: 368; 1284-99.
Carrolie G, Rooney C, Villar J. (2001). How effective is antenatal care in preventive

maternal mortality and serious morbidity? An overview of evidence. Pediactr perinat
epidemiol; 15(1): 1-42.
76
Ceesay SN, Prentice AM, Cole TJ, et al. (1997). Effects on birth weight and perinatal
mortality of maternal dietary supplements in rural Gambia: 5 year randomized
controlled trial. BMJ;315:78690.
Chen XK, Wen SW, Yang Q, Walker MC. (2007). Adequacy of prenatal care and
neonatal mortality in infants born to mothers with and without antenatal high-risk
conditions. Aust N Z J Obstet Gynaecol ;47(2):122-7.
Chomitz, V. R., Cheung, L. W. Y., & Lieberman, E. (1995). The role of lifestyle in
preventing low birth weight. The Future of Children 5(1).
Conley, D. and Bennett, N. (2000). Is biology destiny? Birthweight and life chances.
American Sociological Review 65: 458-67.
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de-Bernis L. (2005). Cost
effective intervention: how many newborn babies can we save? Lancet; 365: 977-88.
De Onis M, Blossner M, Villar J. (1998). Levels and patterns of intrauterine growth
retardation in developing countries. Eur J Clin Nutr.;52:S515
Delvaux T, Buekens P, Godin I, Boutsen M. (2001). Barriers to Prenatal care in
Europe. Am J Prev Med; 21(1):52-9.
Ekwempu CC. (1988). The influence of antenatal care on pregnancy outcome. Trop
Obstet Gyaecol; 1: 667-71
Falkner,F. (1980). Prevention in Childhood of Health Problems in Adult
Life,WHO.Geneva (2002). The Right Start. Baltimore, MD.
Fawzi WW, Msamanga GI, Spiegelman D, et al. (1998). Randomized trial of effects
of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected
women in Tanzania. Lancet;351:147782.
Fikree FF, Berendes HW. (1994). Risk factors for term intrauterine growth
retardation: a community-based study in Karachi. Bulletin of the World Health
Organization.;72:581587.
77
Fleming AE. (1991). A study of anemia of pregnancy in Ibadan. Western Nigeria,

with special reference to Folic Acid Deficiency. MD Thesis, University of
Cambridge.
FNRI. (2007). Food and nutrition research institute. www.fnri.dost.gov.ph (accessed
September, 2007).
Government of Pakistan. (2004). Pakistan Demographic Survey 2003. Islamabad,

Pakistan: Federal Bureau of Statistics.
Gran SM, Ridella SA, Petzold AS. (1981). Maternal Mortality Haematological levels
and Pregnancy outcomes. Br Med J; 5: 115-162
Haksari EL. (2000). Analysis of perinatal and neonatal mortality in five districts
hospitals in Yogyakarta, 1995-1998. Department of epidemiology and clinical
Medicine, Umea University, Umea, Sweden.
Heaman MI, Green CG, Newburn-Cook CV, Elliott LJ, Helewa ME. (2007). Social
inequalities in use of prenatal care in Manitoba. J Obstet Gynaecol Can.;29(10):80616.
Herrera-MG, Mora-JO et al. (1980). Maternal weight / height and the effect of food
supplementation during pregnancy and lactation.
ICMR. (1977). ICMR Bulletin.
Indiadiets. (2007). www.indiadiets.com (last accessed December, 2007).
Jackson CJ, Bosio P, Habiba M, Waugh J, Kamal P, Dixon-Woods M. (2006).

Referral and attendance at a specialist antenatal clinic: qualitative study of women's
views. BJOG.;113(8):909-13
78
Jafarey SN, Krejo R. (1995). Social and cultural factors leading to maternal
malnutrition. Int J Gynecol Obstet; 50(2): 97-99.
Jelliffe,D.B. (1966). The assessment of The Nutritional Status of the Community.
WHO Monograph Sr. No. 53
Kapoor SK, Reddiah VP, Lobo J. (1985).Antenatal care and Perinatal Mortality.
Indian Journal of Pediatrics,; 52:159-62.
Karim SA, Khurshid M, Memon AM, et al. (1994). Anemia in pregnancy its cause
in the underprivileged class of Karachi. JPMA; 44(4):90-92.
Khalid A. Madani, Hassan A. Nasrat, Abdulrahman A. Al-Nowaisser, Rufaida H.
Khashoggi and Bahaa A. Abalkhail.(1995). V Low birth weight in the Taif Region,
Saudi Arabia, Eastern Mediterranean Health Journal, Volume 1, Issue 1, Page 47-54.
Kleinman, J., Mitchell, B., Madan, J.H., et al. (1988). The effects of maternal
smoking on fetal and infant mortality. American Journal of Epidemiology 127(2):27482.
Kramer MS. (2003). Effects of energy and protein intakes on pregnancy outcome: an
overview of the research evidence from controlled clinical trials. Cochrane Database
Syst Rev; 1.
Kramer MS. (1987). Intrauterine growth and gestational duration determinants.
Pediatrics; 80:50211.
Kramer MS. (1987). Determinants of low birth weight methodological assessment and
meta analysis. Bulletin of the WHO 65:663-67
Lechtig- AHJP et al. (1975). Effect of food supplementation during pregnancy on
birth weight. Pediatrics 56:508-520
Magriples U, Kershaw TS, Rising SS, Massey Z, Ickovics JR. (2008). Prenatal health
care beyond the obstetrics service: utilization and predictors of unscheduled care. Am
J Obstet Gynecol. Jan;198(1):75-7
79
McCaw-Binns A, Greenwood R, Ashley D, Golding J. (1994). Antenatal and

Perinatal-Care in Jamaica - do They Reduce Perinatal Death Rates. Paediatric and
Perinatal Epidemiology; 8: 86-97.
McCormick MC. (1985). The contribution of low birth weight to infant mortality and
childhood morbidity. New England J Med; 312:82-90.
MCH Division. (1994). National child Survival and Safe Motherhood Programme.
Meeting of advisory group on maternal nutrition and low birth weight, Geneva, 4 6
December 2002.
Merchant K, Martorell-R, Hass-JD. (1990). Consequence for maternal nutrition of
reproductive stress across consecutive pregnancies. Am J of Clin Nutr; 52:606-20
Mohamed AM, Kishk NA, Shokeir NF, and Kassem MS. (2006). Role of antenatal
care in toxemia of pregnancy in Alexandria. J Egypt Public Health Assoc. 81(1-2):128.
Moller B, Lushino O, Meirik O, Gebre-Medhin M, Lindmark GC. (1989). A study of
antenatal care at village level in rural Tanzania. Gynaecol obstet; 30 123-31.
Mumtaz Z and Salway S. (2007). Gender, pregnancy and the uptake of Antenatal
care services in Pakistan. Sociology of Health & Illness. (29(1):1-26.
Murphy JF, Riordan J, Newcomb RG. (1980). Relation of Haemoglobin levels in first
and Second trimesters to outcome of pregnancy. Lancet; 11:992-995.
National Nutrition Survey (Nutrition Division 1988).
Nisar N, White F. (2003). J Pak Med Assoc. Feb;53(2):47-53).
Northrop-Clewes CA, Ahmad N, Paracha P, David IT. (1998). Impact of health
services provision on mothers and infants in a rural village in North West Frontier
province, Pakistan. Public Health Nutr.;1:5159. doi: 10.1079/PHN19980008.
80
Orvos H, Hoffmann I, Frank I, Katona M, Pal A, Kovacs L. (2002). The perinatal

outcome of pregnancy without prenatal care - A retrospective study in Szeged,
Hungary. Euro J Obstetrics Gynecology and Reproductive Biology,100: 171-3.
Pallikadavath S, Foss M, Stones RW. (2004). Antenatal care: provision and inequality
in Rural North India. Soc Sci Med;59(6):1147-58.
Pratinidhi-ASU et al. (1986). Risk approach strategy in neonatal care. Bulletin of the
WHO 64:291-97
Prentice-AM, Whitehead-RG
et al. (1983). Prenatal dietary supplementation of
African women and birth of lancet 1:489-92

Rani M, Bonu S. (2008). Harvey S. Differentials in the quality of antenatal care in
India. Int J Qual Health Care; 20(1):62-71.
Rawalpindi
(2007).
Pakistan
Atlas-Style
Relief
www.travelpost.com/ME/Pakistan/Punjab/Rawalpindi/map (accessed
Map.
September,
2007).
Rehman MM, Khuda B-E, kane TT, Mojumder KA, Reza MM.(1997). Determinants
of antenatal care seeking behavior in rural Bangladesh, ICDDR, B, Bangladesh.
Schultz LJ, Steketee RW, Chitsulo L, Macheso A, Nyasulu Y, Ettling M. (1994).
Malaria and childbearing women in Malawi: knowledge, attitudes and practices. Trop
Med Parasitol.;45(1):65-9.
Slutsker L, Lindblade KA. (2006). Use of antenatal services and delivery care among
women in rural western Kenya: a community based survey. Reproductive Health ;3.
Steketee RW, Wirima JJ, Hightower AW, Slutsker L, Heymann DL, Breman JG.
(1996). The effect of malaria and malaria prevention in pregnancy on offspring
birthweight, prematurity, and intrauterine growth retardation in rural Malawi. J Trop
Med Hyg;55:3341.
81
Sufang G, Padmadas SS, Fengmin Z, Brown JJ, Stones RW. (2007). Delivery settings
and caesarean section rates in China.. Bull World Health Organ.; 85(10):755-62.
Tasnim N, Mahmud G, Arif MS. (2005). Impact of reduced prenatal visit frequency
on obstetric outcome in low-risk mothers. J Coll Physicians Surg Pak. Jan;15(1):26-9
U.S. Department of Health and Human Services. (1990). The health benefits of
smoking cessation: A report of the Surgeon General. DHHS/CDC 90-8416.
Washington, DC: DHHS
UNDP.
(2007).
Infants
with
low
birth
weight.
http://hdrstats.undp.org/indicators/67.html. (accessed November 2007).

UNICEF. (1999). Composition of a multi-micronutrient supplement to be used in
pilot programmes among pregnant women in developing countries. Report of a United
Nations Children's Fund (UNICEF), World Health Organization (WHO), United
Nations University (UNU) workshop held at UNICEF headquarters. New York.
UNICEF. (2007). http;//www.unicef.org/infobycountry/Pakistan.html. (Last accessed
November, 2007)
UNICEF. (2007). Low Birth Weight, Country Regional and Global estimates.
http://www.unicef.org/publications/index_24840.html (Accessed November, 2007).
Valero De Bernab J, Soriano T, Albaladejo R, Juarranz M, Calle ME, Martnez D,

Domnguez-Rojas V.(2004). Risk factors for low birth weight: a review. Eur J Obstet
Gynecol Reprod Biol. 116:315. doi: 10.1016/j.ejogrb.2004.03.007
Van Eijk AM, Bles HM, Odhiambo F, Ayisi JG, Blokland IE, Rosen DH, Adazu K,
Slutsker L, Lindblade KA. (2006).Use of antenatal services and delivery care among
women in rural western Kenya: a community based survey. Reproductive Health; 3
82
Villar J, Belizan JM. (1982). The relative contribution of prematurity and fetal growth
retardation to low birth weight in developing and developed societies. Am J Obstet
Gynecol;143:7938
Villar J, Bergsjo P. (2002). WHO antenatal care randomized trial: Manual for
implementation of the new model. World Health Organization; Geneva.
Villar J, Merialdi M, Gulmezoglu AM, Abalos E, Carroli G, Kulier R, de Onis M.
(2003). J Nutr.May;133(5 Suppl 2):1606S-1625S)
WHO. ACC/SCN. (1992). Second report on the world nutrition situation. Geneva:
(ACC/SCN, WHO, and Washington, DC: IFPRI).
WHO. (1995). The state of child health in the Eastern Mediterranean region, 2nd ed,
revised. Geneva, World Health Organization.
Wilcox AJ, Skaeven R. (1992). Birth weight and perinatal mortality: the effect of
gestational age. American Journal of Public Health, 82:378-83.
ANNEX - A
Informed Verbal Consent Form

83
Principal Investigator: __________________

Designation: ___________________
Contact information: ______________
Name of participant: __________________ Age: _____________
Contact information: ________________
We are conducting a research to determine the Prevalence of low birth weight babies
in antenatal cases (Regular) and Non-antenatal (Non-Regular) cases with their
nutritional status in Rawalpindi / Islamabad region. You will be asked some questions
related to ANC services and food frequencies. There will be no monetary
compensation for participation in the study. It will take roughly around 25 min to
complete a questionnaire. We assure you full confidentiality about your identity and
the information you provide. You have the right to withdraw whenever you wish.
There are no risks or benefits of the study as such.
Kindly give your verbal consent if you have understood the purpose of the study.
Dated__________
QUESTIONNAIRE
ANNEX - B
84
MOTHER'S DATA
A. Personal Information
1. Sr. No.
2. Name
w/o
3. Age
4. Years of marriage
5. Education
6. Distance from SS Hospital, Islamabad
7. Occupation
House wife........ /
Employed...........Full time....Part time...........
B. Clinical Information
1. Weightkg
2. Weight gain during pregnancy_________kg
3. Height_________cm
4. Parity-----------Primigravida / Multigravida_____________
5. H/O abortions_____________/ still births_____________
6.
H/O smoking/chewing tobacco/naswar/pan. Yes /No
7. Antenatal visits Yes________1/2/3/4/5/_____/ No_________

8. Regular / Non Regular
9. H/O any illness--- Fever..Malaria/ Typhoid / chicken pox /T.B../
Anemia /
hemorrhage / Hepatitis B / C /Hypertension / Eclampsia----
Pre-eclampsia /
Diabetes / Asthma / Proteinuria
10. Routine Investigations...CP&ESR / BSR / Urine R.E / Hepatic Profile /

USG
11. H/O any medication during pregnancy Yes/ No
C. Dietary Information
1. Nutritional
status
during
FFQ(enclosed)
INFANT'S DATA
85
pregnancy
----data
collected
by
1. Gestational age----- a.Pre-term .....................weeks (37 weeks)

b.Term............................weeks (37--41 weeks)
c. Post-term...................weeks (42 weeks or more)
2. Mode of delivery----SVD / SVD WITH Epi / CS / Others- Vacuum

forceps /
3. Complications-----H/O bleeding / APH / Retained Placenta

4. APGAR Score----At 1 min.
At 5 min.
5. Weight........................
6. Sex
DIETARY INFORMATION
1. Sr................
86
2. Is due to pregnancy you changed the way you eat or drink?

3. On whom advice?
Yes/ No,
Doctor. DaiFamily
4. Do you eat at regular times each day?... Yes/ No,
5. How many times a week do you eat?

A morning meal?..........................................................................
A lunch or midday meal?...............................................................
An evening meal?...........................................................................
6. How many times a week do you have snacks?
In midmorning...................................................................................
In mid afternoon.................................................................................
7. Would you say your appetite is good?...........fair?............. poor?..............
8. Do you eat anything not usually considered food (e.g., clay, dirt, starch,
others)?
If yes, what?...................................
How many times per /week do you eat the following foods (at any meal or
between meals)? Fill the appropriate column: (Enclosed Performa.)
WEEKY FOOD FREQUENCY QUESTIONNAIRE
87
How many times per week do you eat following foods?
A. Milk and Milk Products

Not at all
1-3 Times/wk
4-7 Times/wk
1-3 Times/wk
4-7 Times/wk
1. Milk
2. Lassi/Yogurt
3. Butter/Cream/Ghee
4. Tea
B. Meat and Meat Substitutes
Not at all
1. Meat
2. Beef
3. Chicken
4. Liver / Kidney / Bones /
Phaye
5. Fish
6. Egg
7. Pulses / Red Beans / Peas
C. Vegetable
88
Not at all
1-3 Times/wk
4-7 Times/wk
1. Green leafy Vegetable

2. Other Vegetables
D. Fruits Citrus
Not at all
1-3 Times/wk
4-7 Times/wk
E.Other Fruits
Not at all
1-3 Times/wk
4-7 Times/wk
1-3 Times/wk
4-7 Times/wk
Apple / Banana / Mango/ Others

F. Cereals
Not at all
1. Rice
2. Porridge
G. Chapatti
H. Jam /Honey
I. Desserts / Sweets
J. Juice / Sweet Drinks
Note: Please make note of daily frequency consumption and calculate for
seven days a week and then fill the appropriate column.
ANNEX - C
89
RESUME
TITLE OF THESIS:
Relation between low birth weight babies and antenatal care with nutritional status in
the women of Private industrial workers.
MAJOR DEPARTMENT: Curative and Preventive Health care services.

MINOR DEPARTMENT:
Emergency and Accident / Industrial workers
Health Care services
NAME:
Dr. Tahir Hussain Kharal
PLACE AND DATE OF BIRTH: Tulamba (Khanewal , Punjab). 1st May, 66.
COLLAGE AND UNIVERSITIES WITH YEARS ATTENDED
AND DEGREES OBTAINED:
M.B:B.S.----1992- Rawalpindi Medical Collage, University of Punjab. Pakistan.
PGD (Nutrition)2004 Allam Iqbal Open University, Islamabad. Pakistan.
MPH ----2007 Umea University , Sweden.
MEMEBERSHIPS IN LEARNED OR HONORARY SOCIETIES:

Member of UNV.
Member of Umea University Medical Students Union, Sweden
Member of Umea IKSU, Sweden.
Member Pakistan Medical & Dental Council, Islamabad, Pakistan.
PUBLICATIONS:
Tuberculosis in Private Industrial Workers of Pakistan; what could be improved to
make the DOTS strategy more effective. Masters Thesis 2006/07, Umea, Sweden.
DATE: 1st May, 2009
90

Relation Between Low Birth Weight Babies and Antenatal Care With Nutritional Status in The Women of Private Industrial Workers

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Relation Between Low Birth Weight Babies and Antenatal Care With Nutritional Status in The Women of Private Industrial Workers

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Relation between low birth weight babies and

antenatal care with nutritional status in the

DR. TAHIR HUSSAIN KHARAL

Relation between low birth weight babies and

DR. TAHIR HUSSAIN KHARAL

Submitted in partial fulfillment of the requirements for

Dr. Shahzad Ali Khan

I am extremely grateful to my supervisor Dr Shahzad Ali Khan, for his professional

Accepted by the Faculty of Sciences, Allama Iqbal Open University, in partial

Viva Voca Committee

This work is dedicated to

Without their prayers and support,

LIST OF ABBREIVIATION USED

Child Bearing Age

FATA Federally Administered Tribal area

Low Birth Weight

Maternal and Neonatal Child Health

Millennium Development Goals

North West Frontier Province

Out Patient Department

Oral Rehydration Treatment

Spontaneous Vaginal Delivery

Traditional Birth Attendant

World Health Organization

Rationale and Background

Statement of The Problem

Significance of Proposed Study

Social Security System in Pakistan

Antenatal Care Services in Social Security

Low Birth Weight

Prenatal advice to break the vicious cycle

Nutritional risk factors in pregnancy resulting in LBW babies

Low pre-pregnancy weight and insufficient weight gain

Maternal height and infant weight

The Age factor

Diet Plan for Pregnant Women

PROCEDURE OF THE STUDY

Inclusion Exclusion Criteria

Individual variables and Questions

Distance from Hospital

Body Mass Index

Weight Gain during Pregnancy

Number of Antenatal visits

Habit of Tobacco use

Illness during Pregnancy

Medication during Pregnancy

Baby Weight Categories

Advice for Diet Modification

Regular Meal Habits

Description of Different Meal Habits

Weekly Food Frequency

CO-RELATION OF MATERNAL AND NEW BORN VARIABLES

WITH BIRTH WEIGHT

ANNEX-A: CONSENT FORM

TITLE OF THE TABLE

Distance from Hospital

Body Mass Index

Weight Gain during Pregnancy

Number of Antenatal visits

Habit of Tobacco use

Illness during Pregnancy

Medication during Pregnancy

Baby Weight Categories

Advice for Diet Modification

Regular Meal Habits

Description of Different Meal Habits