{"paper_id":"32b8fa17-7187-485f-94a8-8ab643dce355","body_text":"1\n1 Maternal health in rural Pakistan: An analysis of \n2 knowledge and practices of antenatal care using the \n3 socio-ecological model. \n4\n5 Nadia Agha1#a, Rahim Dad Rind1#a, Shoukat Ali Mahar2#b, Moomal Mendhri Channa3#c, Fizza Ansar4, Sadiq \n6 Bhanbhro4#e*\n7 1Department of Sociology, Shah Abdul Latif University, Khairpur, Sindh, Pakistan\n8 2Department of Public Administration, Shah Abdul Latif University, Khairpur, Sindh, Pakistan \n9 3Institute of Gender Studies, Shah Abdul Latif University, Khairpur, Sindh, Pakistan \n10 4Department of Community Health Sciences, Aga Khan University, Karachi \n11 5Centre for Applied Health and Social Care Research, Sheffield Hallam University, United Kingdom \n12 #aCurrent Address: Department of Sociology, Shah Abdul Latif University, Khairpur, Sindh, Pakistan\n13 #bCurrent Address: Department of Public Administration, Shah Abdul Latif University, Khairpur, Sindh, Pakistan \n14 #cCurrent Address: Institute of Gender Studies, Shah Abdul Latif University, Khairpur, Sindh, Pakistan\n15 #eCurrent Address: Centre for Applied Health and Social Care Research, College of Health, Wellbeing and Life \n16 Sciences, Robert Winston Building, Collegiate Campus, Sheffield Hallam University, UK.   \n17 *Corresponding author \n18 Email: s.bhanbhro@shu.ac.uk \n19 All authors contributed equally to this work.  \n20\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\n21 Abstract\n22 Background\n23 Pakistan carries a heavy burden of maternal and child health vulnerabilities. Maternal health can \n24 be prevented with culturally specific interventions and women’s enhanced access to healthcare \n25 facilities, yet women in rural areas in Pakistan are deprived of such interventions. In this study, \n26 we assessed the prevalent knowledge and practices of antenatal care and the impact of low-\n27 income and gender inequalities on maternal health in rural areas of Pakistan. \n28 Method\n29 We conducted a cross-sectional study using the Socio-Ecological Model (SEM) in five villages \n30 in the Sindh province of Pakistan. We tested hypotheses using descriptive reliability and \n31 regression techniques. \n32 Results\n33 Findings show that the socio-geographical and cultural factors influencing maternal health were \n34 embedded within the different levels of SEM. The prevalence of Maternal Health Vulnerabilities \n35 (MHV) was high in villages where women had limited literacy and awareness. Of the 352 \n36 participants, 173 (49%) women were not literate and could not read pregnancy-related \n37 information imparted through leaflets or brochures. Data showed that women consumed less \n38 milk, multivitamins, and proper food due to poverty. At the same time, they had restricted access \n39 to health facilities: 119 (34%) women had lost their babies after birth. In this study, poverty and \n40 gender inequality correlate with MHV (significant 65.60% and .000 and 10.50% and .000, \n41 respectively) and exacerbate the situation by complementing each other.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n3\n42 Conclusion\n43 Culturally appropriate and evidence-based interventions are needed to reduce gender inequality \n44 and prioritise women’s and girls’ maternal health needs. This study has considered cultural, \n45 social, geographical, and economic factors influencing maternal health. It provides a nuanced \n46 account of a complex web of barriers to attaining Sustainable Development Goals (SDGs), \n47 particularly goals 3, ‘Good health and well-being’ and 5 ‘, Gender equality’.\n48 Keywords: Maternal health, Antenatal care, poverty, gender inequality, Pakistan, Socio-\n49 Ecological Model (SEM)\n50\n51 Introduction\n52 Background\n53              Maternal and child mortality is a crucial health challenge prevailing in many low and \n54 middle-income countries (LMICs) [1]. Worldwide, around 800 women died every day in 2020 \n55 from pregnancy and childbirth-related complications [2], making the global Maternal Mortality \n56 Rate (MMR) 216 deaths per 100,000 births [3]. It is estimated that 94% of maternal mortality \n57 occurs in LMICs [4]. \n58 Globally, South Asia and Sub-Saharan African countries carry the burden of maternal deaths [5]. \n59 Maternal mortality in these regions reached up to 87% of the total global burden [2]. About 80% \n60 of these cases could have been prevented if women were given access to basic healthcare \n61 facilities [6]. Pakistan is one of the leading South Asian countries in terms of high MMR [7]. It \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n4\n62 carries a more significant burden of maternal, foetal and child mortality rates [8]. The MMR in \n63 Pakistan is 186 deaths per 100,000 live births, which is 26% higher in rural than in urban areas \n64 [9].\n65 There are myriad factors contributing to maternal and perinatal health vulnerabilities. The \n66 leading factors of pregnancy-related mortality and morbidity are low household income, low \n67 education, poor healthcare services, gender-based disparities, socio-cultural values, more \n68 considerable distance, malnutrition, unfair resource distribution and political environment. These \n69 are significant indicators for rising maternal mortality cases in rural areas [7]. Unmet nutritional \n70 needs, heavy physical labour, infections, and some other primary chronic conditions like being \n71 overweight and diabetes further deteriorate pregnancy outcomes [10].\n72 Maternal mortality can be prevented with access to increased professionally delivered \n73 interventions, more specifically, coverage of crucial obstetric care, access to safe abortion \n74 services, active management during the third stage of labour and the application of \n75 anticonvulsants for women with pre-eclampsia [11]. The knowledge and implementation of \n76 Antenatal Care (ANC) can save the lives of many women. For this, routine antenatal nutrition, \n77 maternal and foetal checkups, preventive measures, intervention for managing common \n78 physiologic symptoms in pregnancy, and health-related interventions significantly improve the \n79 quality of ANC and its utilisation [12]. \n80 Pakistan is a signatory of the Sustainable Development Goals (SDGs) Agenda 2030, but it still \n81 lags as the MMR is higher in rural settings. The quality of healthcare is a crucial concern for the \n82 coverage of universal health and equity and for reducing the occurrence of maternal and newborn \n83 mortalities [13]. National programmes and interventions often fail due to distance and poor \n84 infrastructure, more specifically for the people living in rural areas [14]. Therefore, it is essential \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n5\n85 to understand the existing ANC practices that lead to Maternal Health Vulnerabilities (MHV), \n86 particularly in less privileged areas. This study was designed to understand how poverty and \n87 gender inequality influence maternal health outcomes in rural areas of Pakistan and to suggest \n88 the areas where interventions are needed. This is a quantitative study on women of reproductive \n89 age that assesses the existing ANC-related practices, women’s access to healthcare services, and \n90 the barriers they experience in accessing these services in rural areas in Sindh, Pakistan. \n91 We aimed to identify socio-cultural and geographical barriers to maternal health in rural areas of \n92 Sindh. Research in these areas has not explored and analysed these factors. The study sought to \n93 evaluate the prevalent knowledge and practices of antenatal care and the impact of low-income \n94 and gender inequality on maternal health in rural areas of Pakistan.\n95 Methods\n96 This is a cross-sectional study exploring MHV in underserved areas of Sindh. The study \n97 was conducted between November 2023 and mid-February 2024 in five villages of Taluka \n98 Sukkur. A random sampling technique was used to select households in the villages. We \n99 recorded the recent and ongoing ANC practices followed by rural women and how their \n100 household income and gender inequality influenced those practices.\n101 Theoretical framework\n102 The Socio-Ecological Model (SEM) has been applied to this study to assess MHV in \n103 rural areas of Sindh, Pakistan. This model has been used extensively to understand individuals’ \n104 behaviours about health [15, 16, 17]. According to SEM, an individual has a reciprocal \n105 relationship with their environment. The model acknowledges social, cultural, and environmental \n106 factors and their associations with biological factors [18]. The model used in this study was \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n6\n107 borrowed from the [19, 20] ecological model, which consists of four levels influencing the \n108 conditions and behaviours about health. The SEM suggests four levels, i.e., microsystem, \n109 mesosystem, exosystem and macrosystem. It considers the interplay between individuals and \n110 their settings and recognises the dynamic network of factors that shape an individual’s behaviour \n111 on the individual, community, and societal levels [21]. SEM is applied to this study to record and \n112 analyse the different barriers women experience at these four levels in accessing ANC services.\n113  Fig 1. Application of (SEM) Socio-Ecological Model to assess maternal health vulnerabilities.\n114 Data collection \n115 For this study, we surveyed 360 households and collected data from 352 women of \n116 reproductive age. Participants who met the inclusion criteria were selected, i.e., a) women of \n117 reproductive age, b) delivered babies within the last two years, and c) residents of rural and less \n118 privileged areas. A well-structured, closed-ended questionnaire was prepared after reviewing the \n119 literature on the subject. The questionnaire included various themes, including demographic \n120 characteristics, child-related variables, and knowledge and practices of ANC-related questions. \n121 The first part included demographic variables such as age, marital status, husband and wife’s \n122 education, occupation, monthly income, and total number of children. The child-related factors \n123 were also included in the first part, such as the child who died after birth (yes/no), the number of \n124 children who died after birth, the cause of child mortality, and the age of the children at death. \n125 The second part included a 24-item scale which included questions related to knowledge and \n126 practices of ANC among women. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n7\n127 Ethical approval \n128 The Research Ethics Committees of Aga Khan University, Karachi, and Sheffield Hallam \n129 University approved this study. We followed all ethical protocols mentioned in the proposal \n130 during the data collection. For example, prior informed and verbal consent was sought from the \n131 participants as most of the women (49%) were not literate at all, and 19% had only primary-level \n132 education. All the participants were briefed about the study before collecting the data. They were \n133 assured of keeping their identity confidential and anonymising all identifiable information.\n134 Statistical analysis\n135 Data was analysed using SPSS version 24. This study carried out three variables, \n136 comprised of 24 questions in which demographic, descriptive reliability and regression \n137 techniques were used to test the hypotheses.\n138 Results\n139 Descriptive Analysis\n140 Table 1 summarises the demographic characteristics of the study participants. Out of the 352 \n141 women of reproductive age, most (21%) belonged to the age group of 18-22, 22% were between \n142 23-27, 24% were between 28-32, and 18% belonged to the age group of 33-37. The marital \n143 status variable was taken as married, divorced, or widowed. \n144\n145\n146 Table 1. Demographics of participants and child-related factors.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n8\nTotal N=352 (100%) \nVariable\n \nCategory Frequency (n) Percentage (%)\nAge 18-22 73 20.7\n 23-27 77 21.9\n 28-32 85 24.1\n 33-37 63 17.9\n 38-42 31 8.8\n 43-above 23 6.5\n Total 352  \nMarital status Married 310 88.1\n Divorced 34 9.7\n Widow 8 2.3\n Total 352  \nEducation Not literate 173 49.1\n Primary 66 18.8\n Secondary 20 5.7\n Matric 23 6.5\n Intermediate 15 4.3\n Bachelors 23 6.5\n Masters 32 9.1\n Total 352  \nHusband’s education Not literate 108 30.7\n Primary 48 13.6\n Secondary 45 12.8\n Matric 32 9.1\n Intermediate 18 5.1\n Bachelors 32 9.1\n Masters 69 19.6\n Total 352  \nOccupation Animal Husbandry 80 22.7\n Craftsmanship 83 23.6\n House help 66 18.8\n Stitching 59 16.8\n Total 352  \nHusband’s occupation Formal job 80 22.7\n Informal job 85 24.1\n Agriculture 71 20.2\n Animal Husbandry 65 18.5\n Jobless 51 14.5\n Total 352  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n9\nThe monthly income of the family 5k-10k 35 9.9\n 11k-15k 38 10.8\n 16k-20k 44 12.5\n 21k-25k 70 19.9\n 26k-30k 74 21\n 31-above 91 25.9\n Total 352  \nTotal number of children 2-Jan 89 25.3\n 4-Mar 163 46.3\n 6-May 62 17.6\n 7-above 38 10.8\n Total 352  \nChild related factors    \nChildren died after birth Yes 119 33.8\n No 233 66.2\n Total 352  \nNumber of children died after birth One 21 17.6\n Two 85 71.4\n Three 10 8.4\n Four 3 2.5\n Total 119  \nCause of child mortality Pneumonia 45 37.8\n Diarrhea 33 27.7\n Malaria 29 24.4\n Congenital anomalies 4 3.4\n Malnourishment 8 6.7\n Total 119  \nAge of children at death 1-2 months 39 32.8\n 3-4 months 23 19.3\n 5-6 months 26 21.8\n 7-8 months 14 11.8\n 9-10 months 10 8.4\n 11-12 months 7 5.9\n Total 348  \n147 Reliability\n148 The reliability of the knowledge and practices questionnaire was assessed by using Cronbach’s \n149 alpha. Table 2 represents the cumulative alpha value as .844, suggesting a relatively acceptable \n150 internal consistency as the Cronbach alpha results at 0.7 and 0.8 are considered excellent. All the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n10\n151 items had corrected item-total correlations. However, .95 or greater values are creating a \n152 disturbance in internal consistency [22]. The Cronbach alpha value exists between 0-1.\n153 Table 2. Corrected item-total correlation and Cronbach’s alpha values of the 24 items of \n154 Knowledge and Practices of ANC.\nItem-Total Statistics\nScale \nMean if \nItem \nDeleted\nScale \nVariance if \nItem \nDeleted\nCorrected \nItem-Total \nCorrelation\nCronbach's \nAlpha if \nItem \nDeleted\nI have less consumption of milk during my last pregnancy. 123.8182 329.112 0.225 0.843\nI did not take a proper diet during my last pregnancy. 124.4176 325.281 0.315 0.841\nI have to ask for money needed for my treatment from my \nhusband.\n124.1506 329.325 0.203 0.844\nI am exposed to violence due to my husband’s \nunemployment during pregnancy.\n124.3324 327.288 0.253 0.842\nMy household responsibilities do not change during \npregnancy.\n124.1903 330.616 0.156 0.845\nHousehold responsibilities quickly made me tired during \npregnancy.\n124.2102 307.158 0.573 0.833\nI prefer homebirths due to the lack of money. 124.3097 310.14 0.495 0.835\nHealthcare facilities are affordable in government hospitals. 123.8324 315.815 0.432 0.837\nAccess to standard healthcare services is difficult. 124.2301 303.511 0.606 0.831\nThe source of water and access to sanitation is poor. 124.0256 307.119 0.586 0.832\nI get permission to visit the hospital from my husband \nduring pregnancy.\n124.2216 308.264 0.531 0.834\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n11\nI do not know much about modern healthcare facilities. 124.25 305.556 0.552 0.833\nMy husband decides about family planning. 124.0653 307.457 0.559 0.833\nI do not seek healthcare facilities during pregnancy if there \nis no companion.\n124.2585 309.098 0.508 0.835\nI do not make the decision as to which hospital to go to for \na checkup during pregnancy.\n123.6932 331 0.197 0.844\nI cannot visit the health facility alone due to distance. 123.4233 324.456 0.362 0.84\nI have to take public transportation to visit healthcare. \nFacility, but there is often a lack of transportation.\n123.2869 332.427 0.133 0.846\nI do not have post-delivery follow-up support. 124.0057 319.345 0.351 0.84\nHigh-quality health services are not present in public \nhospitals.\n124.1193 320.613 0.314 0.841\nThe pressure to have a son makes my pregnancies difficult. 123.3835 323.565 0.376 0.839\nI was unable to read the brochures given by doctors about \nmaternal healthcare during pregnancy.\n123.2131 320.704 0.45 0.838\nI do not know different methods of contraception. 123.2699 326.044 0.303 0.841\nI was unaware of the significance of multivitamins during \npregnancy.\n123.2131 320.362 0.429 0.838\nMen in the family are not concerned about women’s health \nduring pregnancy.\n123.8381 341.515 -0.065 0.852\n Cronbach's alpha 0.844\n155\n156 Regression Analysis\n157 Table 3 represents the model summary and ANOVA results. The model summary shows the \n158 strength of the relationship between the model and the dependent variable, namely the model’s \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n12\n159 fitness, which is 44.90%. In this connection, several factors leading to maternal and perinatal \n160 health vulnerabilities include poverty and gender inequality. However, there is a significant \n161 variance between MHV and gender inequality and poverty. 05 p-value is a cutoff value that \n162 shows the possibility of acceptance of the null hypothesis. MHV and gender inequality and \n163 poverty are two separate things, but they are interdependent in the context of women.\n164 Table 3. The Multiple Regression Analysis (Model summary and ANOVA)\nModel Summary\nR R Square Adjusted R Square\nStd. Error of the \nEstimate\n.672a 0.452 0.449 0.74240223\nANOVA\n Sum of Squares df Mean Square F Sig.\nRegression 158.645 2 79.322 143.919 .000b\nResidual 192.355 349 0.551   \nTotal 351 351    \n165 a. Predictors: (Constant), Gender Inequality, Poverty. \n166 b. Dependent Variable: Maternal Health Vulnerabilities.\n167 Table 4 represents the results of regression Coefficients, showing the significant level of poverty \n168 and gender inequality in the prediction of MHV. The Beta value shows the contribution of each \n169 independent variable separately. In this study, poverty predicts MHV positive and significant \n170 (65.60% and .000). In contrast, gender inequality predicts MHV positive and significant (10.50% \n171 and .000). Thus, in MHV, gender inequality and poverty are two different terms that tend to \n172 complement each other by acting as risk or protective factors, respectively, both at the individual \n173 level and at the health system—further sig. Values also explain the status of hypotheses H1 and \n174 H2, which are supported in the study. \n175 Table 4. Unstandardised and standardised Coefficients.\nCoefficients\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n13\n \nUnstandardised \nCoefficients Std. Error\nStandardised \nCoefficients t Sig.\n(Constant) -5.92E-17 0.04  0 1\nPoverty 0.656 0.04 0.656 16.517 0\nGender \nInequality 0.105 0.04 0.105 2.637 0.009\n176 Discussion and conclusion\n177 Reducing maternal mortality has become a global health priority as it affects women \n178 disproportionately in low and middle-income countries. Many of these deaths are preventable \n179 [23]. Maternal health has become a challenge for Pakistan, which faces a maternal health crisis \n180 with a high MMR. The prevalent societal beliefs and perceptions, household power structures \n181 and misinformation significantly impact maternal health [24]. The results of this study reveal that \n182 different levels within the SEM influence factors affecting maternal health vulnerabilities. These \n183 factors include sociodemographic characteristics of the women and social and community \n184 aspects.\n185 Women’s vulnerabilities in rural areas begin from the micro and mesosystem: poverty, gender \n186 inequality, and cultural practices disempower women and pose numerous barriers to enhancing \n187 their social status. The women lack education and awareness about reproductive health. This is \n188 even though education and awareness about reproductive and maternal health can play a central \n189 role in smoothing ANC, which is central to promoting a positive pregnancy experience and \n190 improving maternal and child survival [25]. The critical steps of ANC include risk diagnosis, \n191 pregnancy management and prevention of pregnancy-related diseases, health education and \n192 health promotion [26]. The participants in this study showed a lack of health awareness and \n193 information about ANC. Most participants, i.e., 49%, were not literate, while 19% had primary-\n194 level education. Only 6% of participants had matric, and 4% had intermediate-level education. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n14\n195 Thus, most of the women were unable to read and comprehend information about ANC, the use \n196 of contraceptives, the importance of follow-ups, maintaining diet plans, reading and \n197 understanding brochures, knowledge about modern healthcare facilities, and the extent of \n198 contraceptives.  \n199 Patriarchy, supported by socio-cultural norms, is another element within the micro, meso and \n200 exosystem impacting MHV. In rural areas, the uptake of ANC is widely influenced by social and \n201 cultural norms. Inadequate and poor-quality services and social and cultural orientations limit \n202 women’s access to quality maternal health services [4]. Results of this study also reflect that \n203 women’s regular visits to healthcare facilities and follow-ups were greatly influenced by the \n204 distance of the health facility from their residence; a more significant distance complicated the \n205 situation further. Since men make substantial decisions, women’s access to ANC services was \n206 also subject to men’s approval.\n207 Women’s low status, poverty, limited literacy, and inaccessible, inadequate and costly healthcare \n208 services influence MHV [27]. Results of this study show that poverty is the main factor \n209 influencing ANC practices in the villages; the women in this study were less likely to maintain \n210 the healthy diet required during pregnancy due to financial constraints such as milk consumption, \n211 proper food, or vitamin intake. Women also preferred home delivery because their families could \n212 not afford hospital expenses. Poverty is a significant factor in the micro, meso, and exosystems \n213 of SEM that influence MHV. \n214 The growing population and poor maternal health outcomes in Pakistan require immediate \n215 response and improved strategies. For example, gains cannot be made by investing in the health \n216 sector alone; social indicators of women also need close attention. Fundamental issues about \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n15\n217 women’s status, empowerment, education, hygiene and sanitation must also be considered [28, \n218 29].\n219 There is a lack of gender-sensitive policies and initiatives on the macro level to address MHV in \n220 rural areas and remote communities where women are in disadvantageous positions. Maternal \n221 health outcomes can be improved with robust interventions targeted to reduce gender inequality \n222 in accessing healthcare. The World Health Organization has set a goal to decrease the global \n223 MMR to 70 maternal deaths per 100,000 live births by 2030 [30]. For this, WHO is working to \n224 record maternal mortality through increased research evidence, setting global standards, \n225 providing evidence-based clinical and pragmatic guidance, and giving technical support to \n226 member countries in developing and implementing effective policies and programs [4]. \n227 Moreover, pregnancy-related awareness programs, the provision of skilled birth attendants and \n228 access to antenatal care contribute to safer pregnancies and childbirth. To address the needs and \n229 priorities of women and girls, inequalities must be removed in accessing quality reproductive, \n230 maternal, and healthcare services for newborn children, along with the factors causing maternal \n231 mortalities, morbidities, and related disabilities.\n232 The SEM helped to enhance an understanding of how different factors at personal, community \n233 and societal levels influence individuals’ health-seeking behaviour and increase vulnerabilities. \n234 This study concludes that gender inequality and poverty are well entrenched in rural areas, \n235 resulting in poor ANC practices. We suggest addressing the needs and priorities of the women \n236 residing in less privileged areas. This can only be possible if socio-economic and geographical \n237 factors are considered and women are given improved access to financial and physical resources. \n238 This study is limited to some villages in northern Sindh; more research on MHV is required in \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n16\n239 other less privileged areas of Pakistan where patriarchy is well entrenched and women’s access \n240 to public spheres is restricted. \n241 Disclaimer: None \n242 Conflict of interest: None\n243 Acknowledgement: We would like to thank our funders, the Academy of Medical \n244 Sciences UK, for their support of the study and Dr Zahid Memon for helping us obtain ethics \n245 approval. \n246 References\n247 1. Sule F. A., Uthman, O. A., Olamijuwon, E. O., Ichegbo, N. K., Mgbachi, I. C., \n248 Okusanya, B., & Makinde, O. A. (2022). 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New global targets to prevent maternal deaths. Available at: \n349 https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal-\n350 deaths (Accessed 13 February 2023).\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}