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Article History

Received: 31 July 2024

Accepted: 29 September 2025

First Online: 20 November 2025

Competing interests

: The authors declare no competing interests.

: Ethical considerations were strictly observed in this study, which is based on secondary data from the Pakistan Demographic and Health Survey (PDHS) 2017–18. The PDHS 2017–18 protocol was reviewed and approved by both the ICF Institutional Review Board (IRB) and the National Bioethics Committee (NBC) of the Pakistan Health Research Council. The ICF IRB approval (FWA00000845) was granted on October 19, 2017, and the NBC approval (Reference No. 4-87/NBC-285//17/1438) was granted on November 17, 2017. The ICF IRB ensured compliance with the U.S. Department of Health and Human Services regulations (45 CFR 46), while the NBC ensured adherence to national ethical standards. The study was conducted in accordance with the principles of the Declaration of Helsinki. Data collection for the PDHS 2017–18 occurred between November 22, 2017, and April 30, 2018. As this research involved secondary analysis of publicly available data, no additional ethical approval was required.

: Prior to participation, informed consent was obtained from all respondents by the PDHS survey teams. Respondents were informed about the purpose of the study, the voluntary nature of their participation, procedures for maintaining confidentiality, and their right to withdraw at any stage without consequences. For minors, consent was obtained from a parent or legal guardian in addition to assent from the child when appropriate. All consent procedures were approved by the ICF IRB and the National Bioethics Committee of the Pakistan Health Research Council, in compliance with international and national ethical guidelines.

: Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.