Economic Determinants of Childbirth Decisions and Maternal Recovery: A Comparative Mixed-Methods Study among Postpartum Women in Islamabad, Pakistan

Abstract

Background: Maternal healthcare utilization is influenced by socioeconomic inequalities, healthcare accessibility, and availability of quality services. Household income may affect women’s choice of healthcare facility, mode of delivery, and ability to access postnatal care. In Pakistan, increasing caesarean section rates and differences between public and private healthcare utilization highlight the need to understand the role of socioeconomic factors in maternal healthcare decision-making. Objective: To assess the association between household income and choice of delivery mode and healthcare facility among postpartum women in Islamabad, Pakistan, and to explore women’s perceptions regarding financial influences on childbirth decisions, healthcare access, and postnatal recovery. Methods: A comparative mixed-methods cross-sectional study was conducted among 384 postpartum women recruited from two public tertiary hospitals and two private gynecology hospitals in Islamabad. Quantitative data were collected through a structured questionnaire assessing socioeconomic characteristics, household income, healthcare facility type, delivery mode, and postnatal outcomes. Associations were examined using chi-square tests and multivariable logistic regression. Qualitative data were collected through four focus group discussions involving 24 postpartum women and analyzed using thematic analysis. Results: Household income was significantly associated with healthcare facility selection and delivery mode. Women from higher-income households (>100,000 PKR/month) were more likely to utilize private hospitals compared with women from lower-income households (<50,000 PKR/month) (80.9% vs. 13.7%, p<0.001). Caesarean delivery was also more frequent among higher-income women (64.7%) compared with lower-income women (27.5%, p<0.001). Multivariable regression showed that higher household income (aOR 2.81; 95% CI: 1.76–4.49) and private hospital delivery (aOR 3.25; 95% CI: 2.02–5.22) were independently associated with caesarean section. Qualitative findings identified five themes: financial influence on hospital selection, socioeconomic influence on delivery decisions, limited maternal autonomy, perceived differences in public and private healthcare quality, and financial barriers affecting postnatal recovery. Conclusion: Household income significantly influences maternal healthcare choices, delivery practices, and postnatal experiences in Islamabad. Addressing socioeconomic disparities through affordable, high-quality maternal healthcare services and strengthening public-sector maternity care is essential to promote equitable maternal health outcomes in Pakistan.