Topic

Submitted To:

DR. MUHAMMAD ATIF

Submitted By:

MUHAMMAD SAJID AFRIDI

ANWAR ALI
NOUMAN KHAN
(BS Statistics)

DEPARTMENT OF STATISTICS
UNIVERSITY OF PESHAWAR
(SESSION: 2018-2022)
 Topic

This thesis is submitted to the Department of Statistics, University of Peshawar

in the partial fulfillment of the requirement for the award of BS degree

In

STATISTICS

Submitted To:

DR. MUHAMMAD ATIF

Submitted By:

MUHAMMAD SAJID AFRIDI

ANWAR ALI
NOUMAN KHAN
(BS Statistics)

DEPARTMENT OF STATISTICS
UNIVERSITY OF PESHAWAR
(SESSION: 2018-2022)
 APPROVAL SHEET

It recommended that the thesis prepared by entitled “_____________” as fulfilling

this part of the requirement for the degree of BS in Statistics.

Supervisor: _______________________
Dr. Muhammad Atif
Department of Statistics
University of Peshawar

External Examiner _______________________

Chairman _______________________
Prof. Dr. Muhammad Iqbal
Department of Statistics
University of Peshawar

DEPARTMENT OF STATISTICS
UNIVERSITY OF PESHAWAR
(SESSION: 2018-2022)
 DEDICATION
Thanks to ALLAH Almighty that we are able to reach this milestone This
humble piece of work is dedicated to the following respectable and great
personalities especially our father and mother Besides, this endeavor is
also dedicated To our supervisor Dr. Muhammad Atif who gave us
psychological, mental and emotional support and encouraged us.
 ACKNOWLEDGEMENT
All glory is to Allah compassionate and the most merciful and all respect for his last
prophet (S.A.W.W) who enabled us to recognize our creator and spread the message
of love and humanity.
It is unambiguous fact that writing of an acknowledgement is consider to be just a
formality word like compassion decency modestly and conscience have now bighted.
Everyone in this speedy running world want to go ahead to achieve fame and name
Despite fret and fear that we have expressed our profound heart full and affectionate
graduate to all those from whom we sought any type of help for the accomplishment
of this arduous task.
We wish to express our deep and sincere thanks to our respected research supervisor
Dr. Muhammad Atif, Department of Statistics, University of Peshawar for his skill
full guidance keen and continued interest and encouraging during this thesis, and
their constant encouragement positive altitude we owe a great dept. I would like to
express my thanks to Dr. Muhammad Farooq for their guidelines that provide
opportunities to young researchers to advance their studies.

i
 ABSTRACT
This study determined the level of safe pregnancy in Pakistan also problem, diseases
that have influential effect on delivery type of women and to overcome these
problems and diseases that will result into safe and normal vaginal delivery. The
Pakistan Demographic and Health Survey (PDHS) 2019 maternal mortality data set
was used to overcome these objectives with the help of some Descriptive Statistics
and mainly a Multinomial logistic regression model. The pregnancy level in Pakistan
is improved because 31.1% of the women lost their pregnancy and 67.7% women
have normal vaginal delivery. Mainly problem and disease like Blurring of vision,
Obesity, Severe anemia and Any infectious disease have influential effect on
delivery type, also to overcome these problems and diseases we can have safe and
normal vaginal delivery as compare to assisted vaginal delivery (use of forceps or
vacuum extraction) and cesarean section delivery. The model also give some
additional information that is women with antenatal care: BP(blood pressure) check
and women suffered from Diabetes before pregnancy have batter and normal vaginal
delivery without any difficulty.

ii
 Table of Contents

ACKNOWLEDGEMENT..............................................................................................i
ABSTRACT...................................................................................................................ii
Chapter-1.....................................................................................................................iv
INTRODUCTION........................................................................................................1
1.1 Direct Causes.......................................................................................................2
1.1.1 Unsafe abortion:.......................................................................................2
1.1.2 Hemorrhage:.............................................................................................3
1.1.3 Sepsis:......................................................................................................3
1.2 Indirect Causes.....................................................................................................3
1.2.1 Socio-Economic Factors:.........................................................................4
1.2.2 Education:................................................................................................4
1.2.3 Cultural Factors:.......................................................................................4
1.2.4 Human Factors:........................................................................................5
1.2.5 Family Planning:......................................................................................5
1.2.6 Physical Factors:......................................................................................5
1.2.7 Delay in receiving timing:........................................................................6
Chapter-2......................................................................................................................8
LITERATURE REVIEW............................................................................................8
Research Objectives.....................................................................................................11
Chapter-3....................................................................................................................12
METHODOLOGY.....................................................................................................12
3.1 PDHS.................................................................................................................12
3.2 Descriptive Statistics.........................................................................................13
3.3 Qualitative Variable...........................................................................................13
3.4 Quantitative Variable.........................................................................................13
3.5 Cross Tabulation................................................................................................13
3.6 SPSS..................................................................................................................13
3.7 Multinomial Logistic Regression......................................................................14
Chapter-4....................................................................................................................15
STATISTICAL ANALYSIS......................................................................................15
Chapter-5....................................................................................................................23
DISCUSSION.............................................................................................................23
Chapter-6....................................................................................................................25
CONCLUSION...........................................................................................................25
References:..................................................................................................................26
Appendix.....................................................................................................................29

iii
 List of Tables

Table 1: Descriptive Statistics......................................................................................17

Table 2: Case Processing Summary.............................................................................18

Table 3: Goodness-of-Fit.............................................................................................19

Table 4: Likelihood Ratio Test.....................................................................................19

Table 5: Classification..................................................................................................20

Table 6: Parameter Estimates is given in Appendix 1.1..............................................20

1.1 Table 6:Parameter Estimates..................................................................................29

iv
 List of Figures

Figure 1: Pie chart count of number of pregnancy losses............................................15

Figure 2: Simple Histogram Count of Pregnancy losses..............................................15

Figure 3: Simple Bar Count of visited by a LHW in last 12 months...........................16

Figure 4: Simple Histogram Count of Delivery type...................................................16

v
Chapter-1
INTRODUCTION
Motherhood is something that many women aspire to at some point in their lives.
Yet the normal, life-affirming process of pregnancy and delivery carries with it
serious risks of death and disability. Each year, an estimated 303,000 maternal
deaths occur globally, resulting in a maternal mortality ratio (MMR) of 216 per
100,000 Live Births (LB) (80% CI: 207-249), based on the most recent WHO report,
from 2015. A more complex indicator is lifetime risk, which accumulates the
chances of dying from the complications of pregnancy and childbirth during a
woman’s reproductive life, and so accounts for fertility rate as well as obstetric risk.
Globally, the lifetime risk of dying from maternal causes is one in 180. In other
words, for every 180 women, one will die of maternal causes. Global maternal
mortality rates have shown significant reduction in recent times, from 380 in 1990 to
210 in 2013, and a reduction of 45%. However, this reduction is below the planned
MDG goal of reducing maternal mortality by 75% by 2015 [1]. The status of
maternal health is poor in Pakistan and it is estimated 500 maternal deaths per
100,000 live births each year. Resent estimates of WHO and UNICEF that is 340
maternal deaths per 100,000 live births, but in reality it may be higher because of
under registration of deaths in country and absence the information of cause of death
(A. M kashif). In South Asia, there are countries like Pakistan, India, Bangladesh
and Nepal that are contributing major shares in maternal deaths worldwide. Pakistan
ranks third highest in the entire world in account for the increased maternal
mortalities in Pakistan, this rate is very high 220 deaths per 100,000 live births. The
risk of women dying due to pregnancy related causes is 1:40 in developing countries
as compare to developed countries (Drife. J 2000). Information about the level and
trends of maternal mortality is required not only for what it tells us about the risks of
pregnancy and childbirth, but also for what it implies about women's health in
general and social and economic status. Thus maternal mortality is not only a health
disadvantages it is also a social disadvantages (WHO 1986).
Maternal mortality is defined as "The death of woman while pregnant or within 42
days of termination of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its

1
management but not from accidental or incidental causes" (WHO 1992). Almost
every women in her reproductive life gets an opportunity to become pregnant which
is normal healthy event. Pregnancy is not a disease pregnancy related to morbidity
and mortality which are preventable (J. Mehtab 2013). The death of a woman in
childbirth is a tragedy, an unnecessary and wasteful event that carries with a huge
burden of grief and pain (M .kashif; 2013). Women who become pregnant in
developing countries face a risk of death due to pregnancy that is 80 t0 600 times
higher than women in developed countries. In 1990, the average maternal mortality
ratio in the developed countries was 27 per 100,000 live births (Ce. Shen & B. John;
1999). In developing countries the maternal mortality ratio is vary widely and the
number of maternal mortality is large but the exact number is not known due to
incomplete registration of vital events like death and birth. The studies to determine
the number and causes of maternal deaths on a national basis are both costly and
complex (Jafarey. N.S; 2002).Even in countries where the maternal mortality ratio is
very high, a maternal death is a rare event, and a large sample is required to estimate
maternal ratio and analyze the cause of maternal mortality (Bhatia. J.C; 1993).WHO
groups the causes of maternal death into two broad categories: direct and indirect.

1.1 Direct Causes

Direct maternal deaths are those resulting from obstetric complications of the
pregnant state. Almost two-third of maternal deaths over worldwide are because of
five direct causes namely hemorrhage, obstructed labor, sepsis, complications of
unsafe abortion and eclampsia (pregnancy-induced hypertension) (Shah. N et.al;
2008). One study in India found that inadequate medical treatment contributes to 36%
to 47% of maternal death in hospitals (G. Pillai 1993). In developing countries
complications of pregnancy and child birth are the leading causes of death among the
age between 15 and 19 year. with 15% of total maternal death worldwide occurring
among this age group (Naanda, ( et.al: 2000). Sone more frequent direct causes are:
1.1.1 Unsafe abortion:
Unsafe abortions are the third major determinant of maternal mortality. They
are responsible for 13% of maternal mortality and cause 70, 000 maternal deaths
each year in developing countries, It depends upon the training of the health. care
personnel, who is performing deliveries. The reasons of unsafe abortions include
poor socioeconomic status, illiteracy, and domestic violence (shah.N.et.al 2008).

2
1.1.2 Hemorrhage:
It has been found in several researches that hemorrhage is the most common
cause of death in Pakistan. Approximately, 10-15%% of the maternal deaths occurred
due to hypertensive disorders and eclampsia. All maternal deaths in eclampsia
mothers are due to poverty and illiteracy (lftikhar.R 2009).
1.1.3 Sepsis:
Sepsis is considered as another common cause of maternal mortality in
European, Western and Asian countries. In Pakistan, unhygienic, unsafe practices by
TBAs during the process of delivery are the leading cause of sepsis, which increases
the proportion of maternal mortality. The associated factors leading to develop sepsis
include maternal anemia, prolonged labor, premature membrane rupture, frequent
vaginal examination and use of unsterilized/unwashed instruments during delivery
process. According to Pakistan demographic and health survey (2007), 65% of
women delivered at home. These deliveries are conducted in unsafe settings by
untrained IBAs under unhygienic conditions (Jatarev. N.S: 2002).

1.2 Indirect Causes

Indirect causes are those resulting from previously existing disease. In developing
countries the common indirect causes of maternal death are HIV, Malaria and
Tuberculosis, these disease are closely associated with poverty because pregnancy
depresses a women's immune system (Ahmed et al: 1999). Other illnesses like
malaria, heart disease and asthma were cited as the leading indirect cause of maternal
death. Indirect causes contains all the socio-economic factors like education, maternal
nutrition, cultural factors, antenatal and prenatal care, age, family planning, lack of
resources, overwork, poverty, early marriages and lack of skilled births attendants etc.
(Stokue. U; 1991). There are an estimated 4 million neonatal deaths and 500,000
maternal deaths worldwide each year. The vast majority of these deaths occur in
developing countries, where 43% percent of births are attended by traditional birth
attendants generally the proportion being higher in rural areas (H. Abdul; 2005).Some
indirect causes of maternal deaths are the following:
1.2.1 Socio-Economic Factors:
Socio-economic factors includes poverty, lack of education and lack of empowerment
which play a more significant role in causing maternal death. The economic condition
of our country is not able to provide the basic health facilities to the people of our
3
society. Due to poor socio economic status the frequency of unsafe abortions were
increase (A. Blogs; 2013).
1.2.2 Education:
Another important factor that has been liked with maternal health is
education. Education may be related to higher level of maternal health e.g. women
with higher education may have some awareness about the effect of illness and
treatment. They may have a higher demand for contraceptives and prenatal care.
Increasing in education reduce maternal mortality (S. Jayachandran & A. Lleras-
Muney: 2009). Low literacy also keeps women at the level where they are totally
unconscious about their rights and facilities provided (WHO 2000).
Education is linked to improved health outcomes through its association with
employment, income and living conditions. Educated women seek antenatal care: a
trained medical professional to assist them in birth; have incomes through
employment: have better nutritional status; are able to identify danger signs during
pregnancy; bear fewer children with larger gaps between children: and are more
likely to marry later (G. Sen, et.al 2007). Due to lack of education rate of abortion
and maternal mortality increases.
1.2.3 Cultural Factors:
Cultural factors also promote maternal death in many areas, such as low status
and neglect to girl and women, polygamy, etc. contribute to increasing the statistics
of maternal mortality especially in developing countries. Cultural factors include
male dominance, non-availability of males, absence of husbands from home,
devaluing of females, family traditions of not seeking health care facilities, hesitancy
to go to hospital without head of the family or on their own are some very important
contributing factors (Jafarey. SN; 2002) .35% of women under gone for induced
abortions in first trimester due to their husband's influence and due to the lack of
empowerment of the women of our society to make their own decisions. In this case,
it is very difficult for women to deal with such stiff socio-cultural restrictions (Shah.
N, et.al 2011)
1.2.4 Human Factors:
Human factors includes lack of skilled birth attendants and traditional birth
attendants.

4
 i. Lack of skill birth attendants: According to WHO skill birth attendants are
those who have sufficient knowledge and have been expert in dealing with all
type of normal and complicated pregnancies, like doctors, nurses and
midwives. Skilled birth attendants play more significant role in reducing
maternal mortality.
ii. Traditional birth attendants: In rural area of Pakistan most of the deliveries
take place at their home by untrained health personnel like traditional birth
attendants and dais. They have limited knowledge about pregnancies
complications. Because of their limited knowledge most of abortions
occurred. 89% of deliveries are conducted by traditional birth attendants at
home who are unable to manage (A. Blogs; 2013).
1.2.5 Family Planning:
In 1990s, the lady health worker program was introduced which has a major
emphasis on maternal health. Lady health worker program is an important element in
government of Pakistan's plan to raise the health status of women and children in
rural villages and poor urban areas. In most setting family planning services would
contribute to a 15-20% reduction in maternal mortality (Jhokio. A; 2005).

1.2.6 Physical Factors:

Majority of the women living in rural areas, do not have access to receive
adequate antenatal, intra-natal and postnatal care because of the unavailability of the
adequate health facilities to provide the care during pregnancy. One of the important
reasons behind this factor is the physical delay in arrival to an appropriately equipped
medical facility e.g. poor or no transportation and long-distance (Jabeen, et.al 2010).
1.2.7 Delay in receiving timing:
Majority of the women living in rural areas, do not have access to receive
adequate and antenatal and postnatal care because of the inability or the health
facilities to provide the care during pregnancy. Another important factor like delay in
receiving timing also result in maternal death. Delay can occur at three levels;

 Delay in decision to achieve care, i.e. late recognition of the problem.

 Delay in reaching the appropriate facility like difficulty in transport.

5
  Delay in receiving sufficient care in the facility, i.e. difficulty in getting
blood supplies and operation theatre etc. (shah et.al, 2009).
Poor maternal nutrition contributes to at least 20% of maternal deaths, and increase
the probability of other poor pregnancy outcomes, including newborn deaths. The
target for millennium declaration is to reduce the maternal mortality ratio by three
quarters from 1990 10 2015 but progress has been slow and some countries the
progress has been non-existence (public health association). One study in India found
that inadequate medical treatment gives 36% to 47% of maternal deaths in hospitals.
The poor health status of women, rendering a woman's pelvis too small, which causes
obstructed labor and even death (Pillai, 1993)
A high maternal mortality ratio can leave a long lasting flow effect on the whole
society creating problems for families left without protective, guiding and nurturing
hand of a mother. Jafarey and Karjo suggest that economic, social and cultural factors
play a more significant role in maternal deaths than medical causes. According to
experts at a seminar held in Peshawar. Pakistan has the highest maternal mortality
ratio in South Asia. There is no proper mechanism of data collection in Pakistan and
it is extremely difficult to assess level of maternal mortality. For correct estimation of
maternal mortality it requires knowledge of death of pregnant women and causes of
death (M. kashif: 2005).Pakistan's national health policy emphasized the need to
improve quality and accessibility of maternal health services, especially in the rural
area.

6
Chapter-2
LITERATURE REVIEW
Bhatia (1993) tried to find out the l evel and causes of maternal mortality in an area of
India, based on such deaths that are occur in hospitals or at home. The study was
carried out in anantapur. There are 22 primary health centers that all were include in
the study. For the entire district the maternal mortality ratio is 7.98. It is 5.45 for the
urban and 8.30 for the rural areas. About 66.9% of maternal death were due to direct
causes and the remaining 33.1% were identify to indirect causes. From the study of
Bhatia infection hepatitis, severe anemia from pregnancy, gastroenteritis and
dehydration, enteric fever, respiratory and pulmonary diseases are consider as indirect
causes.
Iftikhar (2009) studied the causes of maternal mortality in Pakistan. From the study
puerperal sepsis is the most common cause of maternal mortality. This retrospective
study was conducted in the unit II department of obstetrics and gynecology, Fatima
hospital baqai medical university Karachi. During the study period 5400 deliveries
were conducted. Data was collected from maternal death records. Other factors, place
of pregnancy. Home private hospital /clinic, hygienic condition, prolonged rupture of
membranes etc. were also noted. In the first week of delivery 70% deaths occurred,
and 30% died within 40 days after delivery. In the study period there were 30
mortalities out of 30, 20 were due to sepsis, 5 due to postpartum hemorrhage. 3 due to
eclampsia and 2 due to rupture uterus. From the above results sepsis is more frequent.
Shah, et.al (2009) tried to identify the various socio-demographic and the three delay
of maternal mortality and the study was carried out in the department of obstetrics
and gynecology unit III, civil hospital Karachi. In worldwide the maternal mortality
are due to five direct causes namely, hemorrhage, obstructed labor, eclampsia, sepsis
and unsafe abortion. These causes do not usually result in maternal death, other
factors like delay in receiving timing can also result in maternal death i.e. delay in
decision to achieve care, delay in reaching the appropriate facility and delay in
receiving sufficient care in the facility. In this study majority of mothers to be
illiterate and almost 63% of deceased women belongs to lower socio-economic class.
70% maternal deaths were due to direct causes and 17%% of death were due to
indirect causes, like hepatic encephalopathy, anemic heart failure, congenital heart

7
disease. From the study first, second and third delay were present in women by 94%,
74% and 48% respectively. The second delay was the most frequent present due to
poor socio-demographic factors.
Safdar (2002) searched the maternal health care in a rural area of Pakistan. The study
was conducted in the rural area of Talukahala, District of Hyderabad. The population
of Talukahala is 247,257. Majority of the people are Muslims and Sindhi speaking. A
sample of 1.150 households was selected from 47villages. In the sample all married
women who were between aged 15 to 49 years, interviewed. The mean age of female
respondent was 2916 years. In the sample 20% women were pregnant at the time of
interview. From the study female doctors were provide more frequent antenatal care
i.e. 55%. Sixty-five percent deliveries were at home and twenty percent were in a
government hospital. The obstetric complications were prolonged labor, hemorrhage,
swelling of face, high blood pressure after delivery etc. The most common
complication was prolonged labor and hemorrhage 28% and 25% respectively. The
study shows that women's continue to deliver at home. The estimated annual maternal
ratio was 689/100,000 live births. It means 324 maternal deaths per year. The
maternal mortality is an indicative of neglect of women's health.
Jafarey (2002) studied the maternal mortality and causes of maternal deaths in
Pakistan. In Pakistan available information on maternal mortality collected from both
hospitals and community based. On the basis of various hospitals, reports the
maternal mortality ratios vary between 17 in private tertiary hospital to 2736 is a
government tertiary hospital. On the community based, the maternal mortality ratios
range is from 160 in Sindh to 673 in Khuzdar. In the hospital 80% of deaths are due
to direct causes. In most of the studies hemorrhage is the leading cause. From indirect
causes, the severe anemia as the most common cause of death (39% and 18.1%).
Hepatitis too contributes significantly. In the community 78.1%of the deaths were
due to direct causes and remaining 21.96% were due to indirect causes. Another
factor that caused n the maternal death is delay women in reaching hospital in time.
There are many reasons for delay was economic, like lack of finance and difficulty in
transport, socio-cultural factor etc. The most common cause of death was hemorrhage
i.e. 63% followed by eclampsia, ruptured uterus 19.3% and 9.3% respectively. From
the study the maternal mortality ratios show no decline and the trend remains the
same during the last twenty to thirty years. The deficiencies identified include lack of

8
drugs, equipment, inadequate knowledge and skills of health care providers .There
was no proper referral system and support services like blood bank and laboratories
were not in place.
Jabeen (2010) find the causes and determinants of maternal mortality. The study was
conducted in obstetrics and gynecology department at Bahawal, Victoria hospital,
affiliated with Quaid-e-Azam medical college Bahawalpur. During pregnancy both
direct and indirect causes of maternal deaths were included in the study. Other
information like age, parity, booking status, gestational age, along with the distance
from the hospital. During last 3 years total 331 maternal deaths occurred and the
highest maternal mortality age group was 20-30 years in which 54.2% deaths were
observed. The most frequent cause is hemorrhage i.e. 44.4% followed by
hypertensive disorders and sepsis 21.8% and 15% respectively, the leading cause of
maternal deaths is hemorrhage which are preventable.
(Ghebrehiwet. M and H. Richard) studied the determinant of maternal mortality in
Eritrea. The study was a case control study which compared 50 women whose
pregnancies led to death (cases) with 50 individually matched women that survivors a
sever life threatening obstetric complications (controls) in the same community. In
this study the factors which effect the maternal deaths are: age, education. ANC,
place of delivery, parity and seeking medical care. The comparison of case and
controls is analyze by bivariate and multivariate analysis, from both analysis seeking
medical care on the part of survivors was significantly more frequent then was the
case in those who died and was protective. From the study seeking medical care was
negatively associated with maternal mortality.

9
RESEARCH OBJECTIVES
1. Determining the level of safe pregnancy in Pakistan.
2. Identification of the Problems and diseases that influence the
women delivery type.
3. Overcome some problems and diseases to have normal vaginal
delivery.

10
Chapter-3
METHODOLOGY
In the current study Pakistan demographic Survey 2019 data is used to identify the
determinant of maternal mortality in Pakistan. Checking the dependency of delivery
type on different vital variables related to women pregnancy by using multinomial
logistic regression model through the software SPSS version 20.

3.1 PDHS
Pakistan's first Health Demographic Survey was undertaken in 1990-91. Other
surveys concentrating on fertility and family planning, reproductive health, and status
of women were conducted. The current demographic and health survey has special
features. Including maternal mortality and infant and child health, mortality and
morbidity. The 2019 Pakistan Demographic and Health Survey (PDHS) was
undertaken to address the noticing and evaluation needs of maternal and child health
and family planning programmers. The DHS program was established in 1984 by the
United States Agency for International Development. It was planned as a follow up to
the World fertility survey project. The survey was designed with the broad objective
to provide policymakers, primarily in the Ministries of Population Welfare and
Health, with information to improve programmatic interventions based on empirical
evidence. The aim is to provide reliable estimates of the maternal mortality ratio
(MMR) at the national level and a variety of other health and population indicators at
national, urban-rural and provincial levels.
The 2019 Pakistan Maternal Mortality Survey (2019 PMMS) was implemented by the
National Institute of Population Studies (NIPS) under the aegis of the Ministry of
National Health Services, Regulations and Coordination, Islamabad, Pakistan. ICF
provided technical assistance through The DHS Program, a project funded by the
United States Agency for International Development (USAID) that provides support
and technical assistance in the implementation of population and health surveys in
countries worldwide. Support for the survey was also provided by the Foreign,
Commonwealth and Development Office (FCDO), the United Nations Population
Fund (UNFPA), and Bill and Melinda Gates Foundation (BMGF).

11
3.2 Descriptive Statistics
Descriptive statistics is that branch of statistics which deals with methods
concerned with summarization and description of the important aspect of numerical
data. Like mean, standard deviation, median etc.

3.3 Qualitative Variable

Also known as categorical variables, qualitative variables are variables with no
natural sense of ordering. They are therefore measured on a nominal scale. For
instance. hair color Black. Brown, Gray, Red. and Yellow) is a qualitative variable, as
is name (Adam. Becky,Christina. Dave..). Qualitative variables can be coded to
appear numeric but their numbers are meaningless, as in male=l. female-2.
{Qualitative variable is also known as categorical variable.}

3.4 Quantitative Variable

Variables that have are measured on a numeric or quantitative scale. Ordinal, interval
and ratio scales are quantitative. A country's population, a person's shoe size, or a
car's speed are all quantitative variables. Quantitative variables are numeric and they
represent a measurable quantity.

3.5 Cross Tabulation

Cross tabulation method is use to identifying a relationship between variables. They
are usually present in matrix called a contingency table. Crosstab are frequently used
because. they are easy to understand and they can used with any level of data like
nominal, ordinal and interval.

3.6 SPSS
The computer program SPSS (statistical package for social science) its first version
was released in 1960s. It is usually used for market researchers, health researchers,
government and education researchers etc. The SPSS data editor is useful for
performing statistical test, such as descriptive frequencies, one way ANOVA, cross
tabulation, one sample and paired sample t-test, correlation, regression and non-
parametric test etc.

3.7 Multinomial Logistic Regression

The multinomial logistic regression model has much important application in
statistical inference as well as in Econometrics. Multinomial logistic regression is

12
used to predict categorical placement in or the probability of category membership on
a dependent variable based on multiple independent Variables. The independent
variables can be either dichotomous (i.e., binary) or continuous (i.e. interval or ratio
in scale). Multinomial logistic regression is a simple extension of binary logistic
regression that allows for more than two categories of the dependent or outcome
variable. Like Binary logistic regression, multinomial logistic regression uses
maximum likelihood estimation to evaluate the probability of categorical
membership.
Multinomial logistic regression does necessitate careful consideration of the sample
size and examination for outlying cases. Like other data analysis procedures, initial
data analysis should be thorough and include careful univariate, bivariate, and
multivariate assessment. Specifically, multicollinearity should be evaluated with
simple correlations among the independent variables. Also, multivariate diagnostics
(i.e. standard multiple regression) can be used to assess for multivariate outliers and
for the exclusion of outliers or influential cases. Sample size guidelines for
multinomial logistic regression indicate a minimum of 10 cases per independent
variable. (Schwab, 2002). Multinomial logistic regression is often considered an
attractive analysis because; it does not assume normality, linearity, or
homoscedasticity.

13
Chapter-4
STATISTICAL ANALYSIS
Following are some graphical and analytical result of the study
Figure 1: show that 60.03% of women losses their pregnancy one time, 24.82% of
women losses their pregnancy two time, 8.15% of women losses their pregnancy 3
and more then number of pregnancy lost by women contain 0.43%.

Figure 1: Pie chart count of number of pregnancy losses

Figure 2 show that the number of women with pregnancy lost are 4601 whereas
number of women with normal delivery are 10102 with the total sample of size from
all over the Pakistan is 14703.

Figure 2: Simple Histogram Count of Pregnancy losses

14
Figure 3 tells us that 3204 women visited by a LHW in last 12 months while 11499
women does not visited LHW in last 12 months. It also indicates women are careless
about their health in pregnancy case.

Figure 3: Simple Bar Count of visited by a LHW in last 12 months.

Figure 4 tells us that 3122 pregnancy cases solved through Normal vaginal delivery,
140 pregnancy cases solved through Assisted vaginal delivery and through Cesarean
section delivery 1299 pregnancy cases are solved.

Figure 4: Simple Histogram Count of Delivery type

15
 Table 1: Descriptive Statistics

Variables N Minimum Maximum Mean Std. Deviation

Delivery type 4561 1 3 1.60 .900
Problems during last 7186 1 8 2.76 .547
pregnancy: Blurring of vision
Problems during last 7187 1 8 2.25 .760
pregnancy: Feeling of extreme
weakness
Problems during last 7186 1 8 2.63 .842
pregnancy: Severe anemia
Problems during postpartum: 7186 1 8 2.91 .329
Cough with difficulty in
breathing
Problems during postpartum: 7185 1 8 2.98 .245
Tear/ulcer in breast
Ever informed about had: Any 7076 1 8 2.05 .728
other infectious disease
Ever informed about had: 7076 1 8 1.97 .571
Problems associated with the
position of baby
Before last pregnancy suffered: 7187 1 8 2.01 .362
Diabetes
Before last pregnancy suffered: 7187 1 8 1.97 .317
Obesity
Any antenatal care: Ultrasound 6296 1 8 1.07 .340
Any antenatal care: BP check 6296 1 2 1.10 .293
Valid N (listwise) 4390

Table 1 shows the descriptive analysis of all the variables that contained in the data
i.e. mean, standard deviation, ranges and sample size N. Here the sample size is 4390.
The mean and the standard deviation of the variable Delivery type is 1.60 and +.900.
Similarly the mean and standard deviation of the variable any antenatal care:
Ultrasound is 1.07 and +.340 respectively.

16
 Table 2: Case Processing Summary

Marginal
N Percentage
Delivery type Normal vaginal delivery 2966 67.6%
Assisted vaginal delivery 138 3.1%
(use of forceps or vacuum
extraction)
Cesarean section delivery 1286 29.3%
Problems during last Yes, before prompting 183 4.2%
pregnancy: Blurring of vision Yes, after prompting 659 15.0%
No 3545 80.8%
Don't know 3 0.1%
Problems during last Yes, before prompting 791 18.0%
pregnancy: Feeling of Yes, after prompting 1788 40.7%
extreme weakness No 1808 41.2%
Don't know 3 0.1%
Problems during last Yes, before prompting 555 12.6%
pregnancy: Severe anemia Yes, after prompting 928 21.1%
No 2890 65.8%
Don't know 17 0.4%
Problems during postpartum: Yes, before prompting 46 1.0%
Cough with difficulty in Yes, after prompting 325 7.4%
breathing No 4019 91.5%
Problems during postpartum: Yes, before prompting 26 0.6%
Tear/ulcer in breast Yes, after prompting 87 2.0%
No 4273 97.3%
Don't know 4 0.1%
Ever informed about had: Yes 416 9.5%
Problems associated with No 3957 90.1%
the position of baby Don't know 17 0.4%
Ever informed about had: Yes 178 4.1%
Any other infectious disease No 4172 95.0%
Don't know 40 0.9%
Before last pregnancy Yes 32 0.7%
suffered: Diabetes No 4346 99.0%
Don't know 12 0.3%
Before last pregnancy Yes 185 4.2%
suffered: Obesity No 4198 95.6%
Don't know 7 0.2%
Any antenatal care: Yes 4265 97.2%
Ultrasound No 123 2.8%
Don't know 2 0.0%
Any antenatal care: BP Yes 4143 94.4%
check No 247 5.6%
Valid 4390 100.0%
Missing 10753
Total 15143
Subpopulation 409a
a. The dependent variable has only one value observed in 280 (68.5%) subpopulations.
Table 2 show the total number of respondent of all variables that are under our study
that is 4390 in which number of respondent of normal vaginal delivery is 2966 and
problem during last pregnancy: Burning of vision affected women are 183.
Table 3: Goodness-of-Fit

Chi-Square df Sig.

Pearson 682.580 766 .986

17
 Deviance 579.046 766 1.000

The Table 3 show Pearson value as .987 that is greater then then 0.05, so we will not
reject Ho that is the model is adequately fit. From Table 3, we declared as the data
develop a good model. The R2 value is .78 that tells 78% proportion of variation in
the dependent variable is explained by variation in independent variable.
Table 4: Likelihood Ratio Test

Likelihood Ratio Tests

Effect Chi-Square Df Sig.
Intercept .000 0 .
Problems during last pregnancy: Blurring of vision 23.306 6 .001

Problems during last pregnancy: Feeling of extreme 42.813 6 .000

weakness
Problems during last pregnancy: Severe anemia 16.799 6 .010

Problems during postpartum: Cough with difficulty 50.664 4 .000

in breathing
Problems during postpartum: Tear/ulcer in breast 27.860 6 .000

Ever informed about had: Any other infectious 11.487 4 .022

disease
Ever informed about had: Problems associated with 79.480 4 .000
the position of baby
Before last pregnancy suffered: Diabetes 11.905 4 .018

Before last pregnancy suffered: Obesity 16.199 4 .003

Any antenatal care: Ultrasound 39.704 4 .000

Any antenatal care: BP check 19.644 2 .000

Table 4 gives the significance value of every independent variable. If the significant
value of any independent value is greater than 0.05 then we will exclude them from
analysis, so luckily against each independent variable the significant value is smaller
then 0.05.
Table 5: Classification

Observed Predicted

18
 Assisted
vaginal
delivery (use
Normal of forceps or Cesarean
vaginal vacuum section Percent
delivery extraction) delivery Correct
Normal vaginal delivery 2824 2 140 95.2%
Assisted vaginal 127 2 9 1.4%
delivery (use of forceps
or vacuum extraction)
Cesarean section 1112 0 174 13.5%
delivery
Overall Percentage 92.6% 0.1% 7.4% 68.3%

Table 5 tells the percentage of correct prediction about the level of dependent
variables Normal vaginal delivery are classified 95.2% in the given levels of
independent variables. Assisted vaginal delivery are classified 1.4% in the given
levels of independent variables. Cesarean section delivery are classified 13.5% in the
given levels of independent variables.
Table 6: Parameter Estimates is given in Appendix 1.1.
Following are some results achieved with the help of Parameter Estimates.
Comparison Between Assisted Vaginal Deliveries And Normal Vaginal
Delivery.
1. Women with the problem after postpartum have did 5.885 time
more assisted vaginal delivery (use of forceps or vacuum
extraction) as compare to normal vaginal delivery.
2. Women that Ever informed about had: Any infectious disease have
did 2.983 time more assisted vaginal delivery (use of forceps or
vacuum extraction) as compare to normal vaginal delivery.
3. Women that Ever informed about had: Problem associated with the
position of baby have did 3.515 time less assisted vaginal delivery
(use of forceps or vacuum extraction) as compare to normal vaginal
delivery.
4. Women that are suffered from diabetes before last pregnancy have
did 7.7885 time less assisted vaginal delivery (use of forceps or
vacuum extraction) as compare to normal vaginal delivery.

19
 5. Women that are suffered from obesity before last pregnancy have
did 17.3045 time more assisted vaginal delivery (use of forceps or
vacuum extraction) as compare to normal vaginal delivery.
6. Women that take antenatal care: Ultrasound have did 11.91 time
more assisted vaginal delivery (use of forceps or vacuum
extraction) as compare to normal vaginal delivery.
7. Women with the problem during last pregnancy have did 11.0095
time more assisted vaginal delivery (use of forceps or vacuum
extraction) as compare to normal vaginal delivery
8. Women that take antenatal care: BP (blood pressure) check have
did .074 time less assisted vaginal delivery (use of forceps or
vacuum extraction) as compare to normal vaginal delivery.
Comparison Between Cesarean Section Delivery And Normal Vaginal
Delivery.
1. Women with the problem during last pregnancy have did 7.94 time
more cesarean section delivery as compare to normal vaginal
delivery.
2. Women with the problem after postpartum have did 0.365 time
more cesarean section delivery as compare to normal vaginal
delivery.
3. Women taking protection against problem related to pregnancy
have did .304 time more cesarean section delivery as compare to
normal vaginal delivery.
4. Women suffered from Diabetes and obesity before last pregnancy
did 0.398 time more cesarean section delivery as compare to normal
vaginal delivery.
5. Women that take antenatal care: BP(blood pressure) did 0.804 time
more cesarean section delivery as compare to normal vaginal
delivery.

20
Chapter-5
DISCUSSION
Like economy man power is also one of the important pillar for a country in building
of prosperous and a developed country. As man power is one of the important
worldwide issue which is directly related to maternal mortality because it is source of
man power. Countries always try to improve their pregnancy related deaths to have
well known place in the world with strong and a remarkable manpower. Keeping the
importance of maternal mortality in mind this study was conducted to explore and
indicate the main problems effecting the maternal mortality in Pakistan. The
objectives was to find the level of safe pregnancy in Pakistan, Problems and diseases
that influence the women delivery type, to overcome some problems and diseases to
have normal vaginal delivery. The data set used in this study was PDHS 2019
Maternal Mortality Survey.
To achieve the objectives of the study some charts, descriptive statistics and
Multinomial Logistic Regression Model was used.
To know the level of safe pregnancy a simple bar chart was used for “pregnancy
lost”. After the analysis we have come to know that the level of pregnancy status is
moving toward improvement in Pakistan day by day.
To overcome the second and third objective of this study that is “Problems and
diseases that influence the women delivery type and to overcome some problems and
diseases to have normal vaginal delivery” a multinomial regression model was used.
For model fitting criteria Goodness of fit test is used beside this to know the
proportion of variation in dependent variable is explained by variation in independent
variable Pseudo R-Square is used. The Goodness of fit test declared the model is
adequately fit with Pearson value 0.987 that is greater than 0.05 ordinary P value
which determine that the variables of the current study develop a good model.
To overcome the second objective of the study that is problems and diseases that
influence the delivery type of women Likelihood ratio Test is used. All the variables
of problems and diseases have P value less than 0.05 that means that the variables that
explain the specific types of problems and diseases have influential effect on the
delivery type of women.

21
The Parameter estimates table was used to achieve third objective of the study that is
to overcome some problems and diseases to have normal vaginal delivery.

22
Chapter-6
CONCLUSION
The current study includes variables through which we can determine the level of
pregnancy in Pakistan, problems and diseases that effects the delivery type and
controlling of some problems and diseases that are hazardous for pregnant women
and new born baby. The first objective is achieved thought simple bar chart that state
that 4601 women lost their pregnancy where as 10102 women have fine pregnancy
with fine delivery from the sample size of 14701 all over the Pakistan. This show that
31.3% of women have pregnancy lost due to some health issues while 68.7% of
women have healthy pregnancy without any problem all over the Pakistan, So the
level of pregnancy in Pakistan is moving toward improvement day by day. The
second objective is achieved with the help of Likelihood ratio test which declared that
the problems and diseases have like Cough with difficulty in breath, Blurring of
vision, Feeling of extreme weakness, Severe anemia, Diabetes and Obesity have
influential effect on the delivery type of pregnant women, health of women and health
of the new born baby. The third objective is achieved from Parameter Estimation by
modelling a multinomial logistic regression. So to have a normal vaginal delivery as
compare to assisted vaginal delivery (use of forceps or vacuum extraction) and
cesarean section, problems and diseases like Cough with difficulty in breath, Blurring
of vision, Feeling of extreme weakness, Severe anemia, Diabetes and Obesity should
be controlled.

23
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26
 Appendix
1.1 Table 6:Parameter Estimates

Delivery typea B Wald df

Assisted vaginal delivery (use of Intercept -69.095 .001 1
forceps or vacuum extraction) [Problems during last 11.137 649.715 1
pregnancy: Blurring of vision=1]
[Problems during last 11.327 1736.797 1
pregnancy: Blurring of vision=2]
[Problems during last 11.697 . 1
pregnancy: Blurring of vision=3]
[Problems during last 0b . 0
pregnancy: Blurring of vision=8]
[Problems during last 11.382 .000 1
pregnancy: Feeling of extreme
weakness=1]
[Problems during last 11.018 .000 1
pregnancy: Feeling of extreme
weakness=2]
[Problems during last 10.719 .000 1
pregnancy: Feeling of extreme
weakness=3]
[Problems during last 0b . 0
pregnancy: Feeling of extreme
weakness=8]
[Problems during last 10.192 .003 1
pregnancy: Severe anemia=1]
[Problems during last 9.839 .003 1
pregnancy: Severe anemia=2]
[Problems during last 10.056 .003 1
pregnancy: Severe anemia=3]
[Problems during last 0b . 0
pregnancy: Severe anemia=8]
[Problems during postpartum: .575 .817 1
Cough with difficulty in
breathing=1]
[Problems during postpartum: -.588 1.489 1
Cough with difficulty in
breathing=2]
[Problems during postpartum: 0b . 0
Cough with difficulty in
breathing=3]
[Problems during postpartum: 9.802 .004 1
Tear/ulcer in breast=1]
[Problems during postpartum: 8.479 .003 1
Tear/ulcer in breast=2]
[Problems during postpartum: 7.507 .002 1
Tear/ulcer in breast=3]
[Problems during postpartum: 0b . 0
Tear/ulcer in breast=8]
[Ever informed about had: -2.983 8.010 1
Problems associated with the
position of baby=1]
[Ever informed about had: -4.047 15.288 1
Problems associated with the
position of baby=2]

27
 [Ever informed about had: 0b . 0
Problems associated with the
position of baby=8]
[Ever informed about had: Any 2.983 4.044 1
other infectious disease=1]
[Ever informed about had: Any 2.836 3.785 1
other infectious disease=2]
[Ever informed about had: Any 0b . 0
other infectious disease=8]
[Before last pregnancy suffered: -13.410 .001 1
Diabetes=1]
[Before last pregnancy suffered: -2.167 2.713 1
Diabetes=2]
[Before last pregnancy suffered: 0b . 0
Diabetes=8]
[Before last pregnancy suffered: 17.289 .001 1
Obesity=1]
[Before last pregnancy suffered: 17.320 .001 1
Obesity=2]
[Before last pregnancy suffered: 0b . 0
Obesity=8]
[Any antenatal care: 11.799 .000 1
Ultrasound=1]
[Any antenatal care: 12.021 .000 1
Ultrasound=2]
[Any antenatal care: 0b . 0
Ultrasound=8]
[Any antenatal care: BP -.074 .045 1
check=1]
[Any antenatal care: BP 0b . 0
check=2]
Cesarean section delivery Intercept -38.619 .003 1
[Problems during last 10.594 .001 1
pregnancy: Blurring of vision=1]
[Problems during last 11.248 .001 1
pregnancy: Blurring of vision=2]
[Problems during last 11.462 .001 1
pregnancy: Blurring of vision=3]
[Problems during last 0b . 0
pregnancy: Blurring of vision=8]
[Problems during last 10.985 .001 1
pregnancy: Feeling of extreme
weakness=1]
[Problems during last 11.258 .001 1
pregnancy: Feeling of extreme
weakness=2]
[Problems during last 11.560 .001 1
pregnancy: Feeling of extreme
weakness=3]
[Problems during last 0b . 0
pregnancy: Feeling of extreme
weakness=8]
[Problems during last 1.456 3.080 1
pregnancy: Severe anemia=1]
[Problems during last 1.616 3.830 1
pregnancy: Severe anemia=2]
[Problems during last 1.336 2.624 1
pregnancy: Severe anemia=3]
[Problems during last 0b . 0
pregnancy: Severe anemia=8]

28
[Problems during postpartum: .432 1.547 1
Cough with difficulty in
breathing=1]
[Problems during postpartum: .859 45.660 1
Cough with difficulty in
breathing=2]
[Problems during postpartum: 0b . 0
Cough with difficulty in
breathing=3]
[Problems during postpartum: -.179 .016 1
Tear/ulcer in breast=1]
[Problems during postpartum: -.748 .305 1
Tear/ulcer in breast=2]
[Problems during postpartum: .001 .000 1
Tear/ulcer in breast=3]
[Problems during postpartum: 0b . 0
Tear/ulcer in breast=8]
[Ever informed about had: .410 .225 1
Problems associated with the
position of baby=1]
[Ever informed about had: -.459 .286 1
Problems associated with the
position of baby=2]
[Ever informed about had: 0b . 0
Problems associated with the
position of baby=8]
[Ever informed about had: Any .468 .886 1
other infectious disease=1]
[Ever informed about had: Any .796 2.920 1
other infectious disease=2]
[Ever informed about had: Any 0b . 0
other infectious disease=8]
[Before last pregnancy suffered: -.414 .130 1
Diabetes=1]
[Before last pregnancy suffered: -1.372 1.596 1
Diabetes=2]
[Before last pregnancy suffered: 0b . 0
Diabetes=8]
[Before last pregnancy suffered: 1.926 1.577 1
Obesity=1]
[Before last pregnancy suffered: 1.453 .907 1
Obesity=2]
[Before last pregnancy suffered: 0b . 0
Obesity=8]
[Any antenatal care: 12.306 .001 1
Ultrasound=1]
[Any antenatal care: 10.316 .000 1
Ultrasound=2]
[Any antenatal care: 0b . 0
Ultrasound=8]
[Any antenatal care: BP .804 16.513 1
check=1]
[Any antenatal care: BP 0b . 0
check=2]

29