We retrieved 54 unique policy documents pertaining to Pakistan. We excluded one document because it was not specific to Pakistan. Upon screening the full text of the remaining 53 documents, we found that 16 (30.2%) did not discuss maternal health or related topics, which we excluded from our analyses. Excerpts were used as the unit analysis. We characterized excerpts as paragraphs of content that used maternal health or related concepts one or more times. Since each excerpt may use more than one relevant term, we attributed multiple codes to each excerpt. In total, we coded 352 excerpts with a total 541 codes in 34 policy documents. Our descriptive analysis including the date of publication, topics of documents, types of organizations, types of documents, and target users are included in the Additional File.
Framing of Maternal Health and Related Concepts in Policy Documents
Four of the 12 themes in table 1 comprised more than 10% of total codes each: Theme 1 Measures of Burden (n = 115; 21.3% of 541 codes), Theme 3 System and Organizational Capacity (n = 93; 17.2% of 541 codes), Theme 4 Access and Availability of Health Services (n = 76; 14.0% of 541 codes), and Theme 8 Policy and Planning (n = 75; 13.9% of 541 codes). Two themes comprised of between 5% and 10% of total codes each: Theme 2 Gaps and Needs (n = 46; 8.5% of 541 codes) and Theme 11 Socioeconomic Factors (n = 42; 7.8% of 541 codes). Theme 12 (Drug Abuse, Overuse and Misuse) was only represented in one code in a policy document published by the Government of Sindh Health Department. The concept of integrated care was only coded five times in Theme 8 (Policy and Planning): three from community-based organizations and two from government bodies. For the purposes of this paper, we only describe the content of themes 1, 2, 3, 4, 8, and 11 in more detail because collectively they capture 83% of total codes. Table 1 provides a summary of the content of each theme.
Theme 1: Measures of Burden. We divided measures of burden into the following three domains: data about indicators on mortality and morbidity, empirical evidence on the lagging state of maternal health, and disparities between regions in Pakistan. Seven documents discussed the decrease in mortality ratios in mothers, infants, and children since 1990 [13–19]. Two documents discussed the rates of abortions and the number of lives that availability of safe abortion services puts at risk [13, 14]. Similarly, six documents demonstrated the many reasons behind health complications in mothers as well as infants [3, 15, 19, 20–22] including one document which examined the rate of immunizations in children to curb common diseases like measles . Finally, utilization of family planning services was mentioned in two documents [23, 24].
The second domain focused on providing evidence that maternal health is lagging in Pakistan. Seven documents discussed the poor health infrastructure built around maternal and child health including inadequate staff training, lack of medical supplies and equipment, all of which contributes to a high proportion of reported morbidity and mortality in mothers and their infants [16, 17, 29, 22, 25–27]. Five documents discussed the consequences of low numbers of antenatal and postnatal visits common in the region as well as the limited obstetric care [16, 19, 20, 22, 27]. Four documents discussed the value and use of common contraception methods, such as sterilization and intra-uterine devices [28–31]. Considering the state of maternal health to be the worst in Asia (25), two documents promoted the idea of focusing on reproductive health facilities as well as birth spacing to reduce fertility and mortality rates in Pakistan [14, 32].
The last category pertains to the disparities that exist within the provinces of Pakistan. Five documents dissected the topic from rural vs. urban perspective in terms of maternal mortality ratios, abortion rates, and breastfeeding practices [15, 17, 26, 33]. Two documents explored Balochistan’s healthcare system which lags behind on many maternal health indicators including maternal and child mortality ratios, antenatal care, malnutrition, contraception methods, and immunization [26, 34] in comparison to the other three provinces as examined in five other documents [3, 15, 31, 34, 33]. Two documents also discussed the role of public vs. private vs. non-profit models of health services delivery and their varying degrees of outreach in the country [29, 35].
Theme 3: System and Organizational Capacity. We categorized codes on system and organizational capacity according to the following: investment and improvement, technological and physical infrastructure, performance measurement and management, and strategies and interventions. First, 14 documents mention investment and improvement in the following formats: heavy investment by the government to improve maternal health [13, 18, 36], low investment by the government [3, 17], some improvement in maternal health because of investment (15; 28), and suboptimal improvement in maternal health despite significant investment [3, 13, 17, 18, 26, 30, 31, 37]. Two documents mentioned the United Nations Sustainable Development Goals in reference to investing resources to improve maternal health outcomes [15, 20]. Interestingly, two documents specified that investment leads to improvement in maternal health outcomes by reducing fertility rates in the population [26, 32].
Second, 16 documents cited technological and physical infrastructure of maternal health services. These mentions were commonly in the context of technology infrastructure or human resource capacity. Technology infrastructure mentions included supplies, equipment, and systems for centralized management [3, 17]. Documents also mentioned the need to reduce the duplication of services by increasing coordination between collaborating agencies, upgrading existing facilities, and establishing women friendly hospitals and referral systems [3, 34, 38]. Increasing coordination was an important topic in one document that mentioned a constant battle for “turf” between various government agencies (3), that in another document was due to improper allocation of government resources (18). Five documents identified the need for resources and capacity to provide maternal health services at all levels of the health system [3, 13, 14, 18, 24]. With regards to human resources, three documents recommended that increasing the quantity of healthcare providers did not increase service utilization by patients [17, 24, 30]. Other human resource issues included frequent staff transfers, understaffing, poor governance, staff absenteeism, scope of practice, and low reach of healthcare providers [3, 17, 19, 30, 35, 36].
Third, 12 documents mentioned codes related to performance measurement and management. Three documents described the methods to track maternal mortality ratios in different regions [15, 18, 22], whereas three documents mentioned the lack of data or systems to track maternal health indicators [3, 18, 19]. Three documents mentioned discrepancies between performance measurement indicators: reported vs. true vaccination status and utilization of family planning services [30, 36, 39].
Finally, six documents identified strategies or interventions to improve system and organizational capacity. Strategies in five of the six documents pertained to improving government commitment to increasing the availability of maternal health services through mandates, prioritization, and separation of maternal health issues from religious controversies [13, 14, 20, 40]. The remaining study discussed how non-governmental organizations can administer contraception to lower human resource burden on public health service organizations .
Theme 4: Access and Availability of Health Services. We divided the access and availability of health services into the following three domains: universal healthcare system, access to services, and affordability and costs of services. First, few documents discussed the need for a universal health coverage pertaining to women’s needs. Four documents did not explicitly mention university health care but discussed limited access to women and child health services [3, 13, 18, 34]. Furthermore, the 2010 health policy emphasized the need for universal health coverage, especially for reproductive health services , two documents discussed the need for targeting the right audience to maximize utilization and making the healthcare system more responsive to women’s needs [13, 20].
Second, studies stressed the need for greater access to basic services pertaining to women’s and children’s health. Nine documents stressed the need for greater access to skilled birth attendants, increasing public outreach of reproductive planning programs, and birth spacing programs. Of these nine documents, six discussed the need for greater access to skilled birth attendants even in geographically challenging areas as their availability in other areas decreased maternal mortality [17, 20, 22, 25, 38, 41]. Two documents suggested to increase the outreach of reproductive planning programs via public and private stakeholders [14, 31], whereas one document mentioned birth spacing for improving maternal and child health . Family planning services were generally accessed when available to citizens [3, 28], but three documents asserted the need to increase their availability, which might reduce maternal mortality [19, 26, 29]. Four documents discussed some of the most common methods of family planning, which were barrier methods (e.g., condoms), sterilization, and intra-uterine contraceptive devices [28–31]. However, the availability of such services alone was not enough to reduce maternal mortality according to three documents and services need to be provided to all eligible women regardless of existing socioeconomic disparity to enhance survival [17, 33, 38]. One document discussed the varying audiences of the Ministry of Health and Ministry of Population Welfare, which served particular niches of eligible population .
Third, lack of a universal healthcare system suggested the need for affordable services. Two documents asserted that family planning services were mostly accessed through self- or co-payment mechanisms [28, 29]. Three documents discussed poverty as a factor leading to higher risk during pregnancy and childbirth with 1 in 4 women without any means to afford family planning [26, 29, 31]. Two documents discussed government’s budget for family planning and its future intent on establishing new mother and child health centers [34, 36]. Interestingly, one document also discussed the need to employ women to make reproductive health care more affordable .
Theme 8: Policy and Planning. We categorized codes under policy and planning as follows: formal policies and policy vs. practice. In the first category, documents indicated a number of formal policies and their relation to the government’s position on improving maternal health. Among the policies mentioned in documents included Policy 2010, the Anti-Women Practices Bill, Population Policy, the Women Protection Act, the Protection Against Harassment of Women at the Workplace Act, Domestic Violence (Prevention and Protection) Bill, the Reproductive Healthcare and Rights Bill, National Health Policy, and Pakistan National Policy for Development and Empowerment [14, 17, 19, 26, 34, 41]. Three documents stated that having formal policies conveys that the government prioritizes family planning, reproductive health, and women empowerment and education [3, 14, 26].
Documents also emphasized the relationship between policy and practice in the following formats: policies contribute to the successful implementation of programs [14, 33], policies contribute to achieving superior maternal health outcomes [14, 18, 19, 26, 34], programs are necessary for policies to have their intended effects [14, 26, 32], and strategic frameworks informed by formal policies provide guidelines for community-based program implementation [17, 19]. On the other hand, three documents emphasized the need to review and evaluate existing programs, particularly how well family planning programs reach women [16, 28, 29].
Theme 2: Gaps and Needs. We divided the gaps and needs into the following four domains: unmet needs associated with affordability, accessibility, and availability of services, need for maternal health services and training programs, gaps between policy statements and practice, and call for action to improve the design and delivery of such services. First, five documents discussed the general state of unmet needs associated with affordability, accessibility, and availability of family planning services in Pakistan [28–31, 37]. Two documents discussed the need to involve non-governmental organizations to fill in the gap and scale up existing services [30, 31]. Another two documents posited that maternal and child mortality could be reduced by increasing the availability of contraceptives and other family planning methods as evidence suggests that those with limited access to family planning suffer the most [26, 42]. Two documents discussed the heavy financial investment in family planning since 1960s but with little gain [3, 18].
Second, three documents stressed the need to develop long-term voluntary family planning methods to address birth spacing [26, 37, 42]. Another three documents emphasized the need to strengthen the existing infrastructure by employing more midwives, providing comprehensive sexual care including pre- and post-natal care, and establishing nutrition programs [13, 19, 25] where one document identified similar strategies for the province of Balochistan . Increasing the marketing of contraceptives was also discussed by two documents to enhance access [3, 33].
There are, however, several gaps between policy and practice when considering the delivery of maternal health services. One document identified several gaps including lack of an overarching maternal and child health framework, underestimation of nutritional status, and lack of 24-hour emergency obstetric care and referral systems, especially in rural areas . Two other documents examined the poor implementation of policies leading to waste of resources [28, 30]. Surprisingly, gaps between policy and practice were only discussed in a handful of documents and only one document discussed the steps the government has taken to address this challenge .
Lastly, two documents addressed the steps that must be taken to improve the design and delivery of maternal health services. The document that identified gaps between policy and practice also detailed potential solutions including effective nutritional programs, emergency obstetric care, behavior changing interventions . The second document called for producing highly effective campaigns, like that of polio vaccine, addressing maternal and child health issues .
Theme 11: Socioeconomic Factors. We divided mentions of socioeconomic factors into the following: economic opportunities (including education and employment), gender inequities, migration and urbanization, and religion and culture. First, 11 documents mentioned economic opportunities, six of which mentioned the relationship between adverse maternal health outcomes and the socioeconomic status of women [17, 24, 26, 31, 34, 39]. Women who lived in poverty, had a more difficult time accessing family planning or other health services, even these documents explicitly recognized that this population benefitted the most from these services [17, 24, 26, 34]. With regards to sterilization, one document mentioned how women living in poverty were more likely to sterilize compared to wealthier women . Four documents mentioned the need to create opportunities for women to contribute to the labor market [13, 14, 26, 43–45]. Creating policies that make family planning and other health services that control fertility may empower women by increasing their participation in the workforce. A key component of women empowerment was investing in interventions that increase health literacy which will lead to positive maternal health outcomes as indicated by five documents [14, 23, 25, 34, 39].
Second, six documents mentioned gender inequities in the form of social structures geared towards male dominance, eliminating systems that discriminate against women, and increasing the availability and accessibility of maternal health services [14, 17, 23–25, 43]. One document emphasized the need for research to clarify the socio-political realities of maternal health services, particularly intimate partner violence .
Surprisingly, only three documents mentioned religion and culture in reference to maternal health services [17, 31, 34]. These mentions were broad; there were no specifications of why or how religious or cultural values influence women’s access to maternal health services. This was also the case for codes on migration and urbanization, which were only mentioned in two studies that described how women’s mobility was limited [14, 17].