Digital access and maternal healthcare inequalities in Pakistan, 2024–2025: a population-based cross-sectional study

Abstract

Digital access may influence how women obtain health information, communicate, and navigate healthcare, but it is also strongly shaped by socioeconomic and geographic disadvantage. We examined associations between recent digital access and maternal healthcare utilization among women in Pakistan and assessed whether these associations differed by socioeconomic position. We analyzed 2024–25 Household Integrated Economic Survey data from 10,723 ever-married women aged 15–49 years who reported a live birth during the preceding three years in Pakistan's four provinces. Recent digital access during the three months before interview was classified into four mutually exclusive nominal categories: fully disconnected, offline device use, Internet use without any of 11 specified ICT activities, and Internet use with ≥1 recorded ICT activity. Primary outcomes were ≥4 antenatal-care contacts (ANC ≥4), facility delivery, and maternal postnatal care (PNC) within six weeks. Survey-weighted modified Poisson models estimated adjusted prevalence ratios (aPRs), with maternal age modeled using linear and quadratic terms and lifetime live births continuously. Marginal standardization estimated adjusted prevalences and absolute differences. Fully disconnected women had lower adjusted prevalence of ANC ≥4 than women reporting Internet use with ≥1 recorded ICT activity (aPR 0.75, 95% CI 0.67–0.85), corresponding to standardized prevalences of 47.2% and 58.6%, respectively (difference −11.4 percentage points, 95% CI −13.9 to −8.9). The association with ANC differed across household consumption quintiles (interaction P  = 0.004). Among women in the poorest quintile, 19.2% reported Internet use with ≥1 recorded ICT activity, compared with 84.2% among women in the richest quintile. Associations were smaller for facility delivery (aPR 0.94, 95% CI 0.89–1.00) and maternal PNC (0.87, 0.76–0.99) and were less consistent across sensitivity analyses. The ANC association remained evident after additional social-context, temporal, missing-data, and finer-geographic analyses. Complete digital disconnection was consistently associated with lower antenatal-care utilization and was concentrated among socioeconomically disadvantaged women. Associations with facility delivery and maternal PNC were weaker and more context-sensitive, indicating that recent digital access does not relate uniformly to all stages of maternal care. Because digital status was measured near the survey interview and may have changed after the index pregnancy, these findings are associational and do not establish a causal effect of digital access on maternal healthcare use.