Maternal health in rural Pakistan: An analysis of knowledge and practices of antenatal care using the socio-ecological model

1 1 Maternal health in rural Pakistan: An analysis of 2 knowledge and practices of antenatal care using the 3 socio-ecological model. 4 5 Nadia Agha1#a, Rahim Dad Rind1#a, Shoukat Ali Mahar2#b, Moomal Mendhri Channa3#c, Fizza Ansar4, Sadiq 6 Bhanbhro4#e* 7 1Department of Sociology, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 8 2Department of Public Administration, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 9 3Institute of Gender Studies, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 10 4Department of Community Health Sciences, Aga Khan University, Karachi 11 5Centre for Applied Health and Social Care Research, Sheffield Hallam University, United Kingdom 12 #aCurrent Address: Department of Sociology, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 13 #bCurrent Address: Department of Public Administration, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 14 #cCurrent Address: Institute of Gender Studies, Shah Abdul Latif University, Khairpur, Sindh, Pakistan 15 #eCurrent Address: Centre for Applied Health and Social Care Research, College of Health, Wellbeing and Life 16 Sciences, Robert Winston Building, Collegiate Campus, Sheffield Hallam University, UK. 17 *Corresponding author 18 Email: [email protected] 19 All authors contributed equally to this work. 20 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2 21 Abstract 22 Background 23 Pakistan carries a heavy burden of maternal and child health vulnerabilities. Maternal health can 24 be prevented with culturally specific interventions and women’s enhanced access to healthcare 25 facilities, yet women in rural areas in Pakistan are deprived of such interventions. In this study, 26 we assessed the prevalent knowledge and practices of antenatal care and the impact of low- 27 income and gender inequalities on maternal health in rural areas of Pakistan. 28 Method 29 We conducted a cross-sectional study using the Socio-Ecological Model (SEM) in five villages 30 in the Sindh province of Pakistan. We tested hypotheses using descriptive reliability and 31 regression techniques. 32 Results 33 Findings show that the socio-geographical and cultural factors influencing maternal health were 34 embedded within the different levels of SEM. The prevalence of Maternal Health Vulnerabilities 35 (MHV) was high in villages where women had limited literacy and awareness. Of the 352 36 participants, 173 (49%) women were not literate and could not read pregnancy-related 37 information imparted through leaflets or brochures. Data showed that women consumed less 38 milk, multivitamins, and proper food due to poverty. At the same time, they had restricted access 39 to health facilities: 119 (34%) women had lost their babies after birth. In this study, poverty and 40 gender inequality correlate with MHV (significant 65.60% and .000 and 10.50% and .000, 41 respectively) and exacerbate the situation by complementing each other. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 3 42 Conclusion 43 Culturally appropriate and evidence-based interventions are needed to reduce gender inequality 44 and prioritise women’s and girls’ maternal health needs. This study has considered cultural, 45 social, geographical, and economic factors influencing maternal health. It provides a nuanced 46 account of a complex web of barriers to attaining Sustainable Development Goals (SDGs), 47 particularly goals 3, ‘Good health and well-being’ and 5 ‘, Gender equality’. 48 Keywords: Maternal health, Antenatal care, poverty, gender inequality, Pakistan, Socio- 49 Ecological Model (SEM) 50 51 Introduction 52 Background 53 Maternal and child mortality is a crucial health challenge prevailing in many low and 54 middle-income countries (LMICs) [1]. Worldwide, around 800 women died every day in 2020 55 from pregnancy and childbirth-related complications [2], making the global Maternal Mortality 56 Rate (MMR) 216 deaths per 100,000 births [3]. It is estimated that 94% of maternal mortality 57 occurs in LMICs [4]. 58 Globally, South Asia and Sub-Saharan African countries carry the burden of maternal deaths [5]. 59 Maternal mortality in these regions reached up to 87% of the total global burden [2]. About 80% 60 of these cases could have been prevented if women were given access to basic healthcare 61 facilities [6]. Pakistan is one of the leading South Asian countries in terms of high MMR [7]. It . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 4 62 carries a more significant burden of maternal, foetal and child mortality rates [8]. The MMR in 63 Pakistan is 186 deaths per 100,000 live births, which is 26% higher in rural than in urban areas 64 [9]. 65 There are myriad factors contributing to maternal and perinatal health vulnerabilities. The 66 leading factors of pregnancy-related mortality and morbidity are low household income, low 67 education, poor healthcare services, gender-based disparities, socio-cultural values, more 68 considerable distance, malnutrition, unfair resource distribution and political environment. These 69 are significant indicators for rising maternal mortality cases in rural areas [7]. Unmet nutritional 70 needs, heavy physical labour, infections, and some other primary chronic conditions like being 71 overweight and diabetes further deteriorate pregnancy outcomes [10]. 72 Maternal mortality can be prevented with access to increased professionally delivered 73 interventions, more specifically, coverage of crucial obstetric care, access to safe abortion 74 services, active management during the third stage of labour and the application of 75 anticonvulsants for women with pre-eclampsia [11]. The knowledge and implementation of 76 Antenatal Care (ANC) can save the lives of many women. For this, routine antenatal nutrition, 77 maternal and foetal checkups, preventive measures, intervention for managing common 78 physiologic symptoms in pregnancy, and health-related interventions significantly improve the 79 quality of ANC and its utilisation [12]. 80 Pakistan is a signatory of the Sustainable Development Goals (SDGs) Agenda 2030, but it still 81 lags as the MMR is higher in rural settings. The quality of healthcare is a crucial concern for the 82 coverage of universal health and equity and for reducing the occurrence of maternal and newborn 83 mortalities [13]. National programmes and interventions often fail due to distance and poor 84 infrastructure, more specifically for the people living in rural areas [14]. Therefore, it is essential . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 5 85 to understand the existing ANC practices that lead to Maternal Health Vulnerabilities (MHV), 86 particularly in less privileged areas. This study was designed to understand how poverty and 87 gender inequality influence maternal health outcomes in rural areas of Pakistan and to suggest 88 the areas where interventions are needed. This is a quantitative study on women of reproductive 89 age that assesses the existing ANC-related practices, women’s access to healthcare services, and 90 the barriers they experience in accessing these services in rural areas in Sindh, Pakistan. 91 We aimed to identify socio-cultural and geographical barriers to maternal health in rural areas of 92 Sindh. Research in these areas has not explored and analysed these factors. The study sought to 93 evaluate the prevalent knowledge and practices of antenatal care and the impact of low-income 94 and gender inequality on maternal health in rural areas of Pakistan. 95 Methods 96 This is a cross-sectional study exploring MHV in underserved areas of Sindh. The study 97 was conducted between November 2023 and mid-February 2024 in five villages of Taluka 98 Sukkur. A random sampling technique was used to select households in the villages. We 99 recorded the recent and ongoing ANC practices followed by rural women and how their 100 household income and gender inequality influenced those practices. 101 Theoretical framework 102 The Socio-Ecological Model (SEM) has been applied to this study to assess MHV in 103 rural areas of Sindh, Pakistan. This model has been used extensively to understand individuals’ 104 behaviours about health [15, 16, 17]. According to SEM, an individual has a reciprocal 105 relationship with their environment. The model acknowledges social, cultural, and environmental 106 factors and their associations with biological factors [18]. The model used in this study was . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 6 107 borrowed from the [19, 20] ecological model, which consists of four levels influencing the 108 conditions and behaviours about health. The SEM suggests four levels, i.e., microsystem, 109 mesosystem, exosystem and macrosystem. It considers the interplay between individuals and 110 their settings and recognises the dynamic network of factors that shape an individual’s behaviour 111 on the individual, community, and societal levels [21]. SEM is applied to this study to record and 112 analyse the different barriers women experience at these four levels in accessing ANC services. 113 Fig 1. Application of (SEM) Socio-Ecological Model to assess maternal health vulnerabilities. 114 Data collection 115 For this study, we surveyed 360 households and collected data from 352 women of 116 reproductive age. Participants who met the inclusion criteria were selected, i.e., a) women of 117 reproductive age, b) delivered babies within the last two years, and c) residents of rural and less 118 privileged areas. A well-structured, closed-ended questionnaire was prepared after reviewing the 119 literature on the subject. The questionnaire included various themes, including demographic 120 characteristics, child-related variables, and knowledge and practices of ANC-related questions. 121 The first part included demographic variables such as age, marital status, husband and wife’s 122 education, occupation, monthly income, and total number of children. The child-related factors 123 were also included in the first part, such as the child who died after birth (yes/no), the number of 124 children who died after birth, the cause of child mortality, and the age of the children at death. 125 The second part included a 24-item scale which included questions related to knowledge and 126 practices of ANC among women. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 7 127 Ethical approval 128 The Research Ethics Committees of Aga Khan University, Karachi, and Sheffield Hallam 129 University approved this study. We followed all ethical protocols mentioned in the proposal 130 during the data collection. For example, prior informed and verbal consent was sought from the 131 participants as most of the women (49%) were not literate at all, and 19% had only primary-level 132 education. All the participants were briefed about the study before collecting the data. They were 133 assured of keeping their identity confidential and anonymising all identifiable information. 134 Statistical analysis 135 Data was analysed using SPSS version 24. This study carried out three variables, 136 comprised of 24 questions in which demographic, descriptive reliability and regression 137 techniques were used to test the hypotheses. 138 Results 139 Descriptive Analysis 140 Table 1 summarises the demographic characteristics of the study participants. Out of the 352 141 women of reproductive age, most (21%) belonged to the age group of 18-22, 22% were between 142 23-27, 24% were between 28-32, and 18% belonged to the age group of 33-37. The marital 143 status variable was taken as married, divorced, or widowed. 144 145 146 Table 1. Demographics of participants and child-related factors. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 8 Total N=352 (100%) Variable Category Frequency (n) Percentage (%) Age 18-22 73 20.7 23-27 77 21.9 28-32 85 24.1 33-37 63 17.9 38-42 31 8.8 43-above 23 6.5 Total 352 Marital status Married 310 88.1 Divorced 34 9.7 Widow 8 2.3 Total 352 Education Not literate 173 49.1 Primary 66 18.8 Secondary 20 5.7 Matric 23 6.5 Intermediate 15 4.3 Bachelors 23 6.5 Masters 32 9.1 Total 352 Husband’s education Not literate 108 30.7 Primary 48 13.6 Secondary 45 12.8 Matric 32 9.1 Intermediate 18 5.1 Bachelors 32 9.1 Masters 69 19.6 Total 352 Occupation Animal Husbandry 80 22.7 Craftsmanship 83 23.6 House help 66 18.8 Stitching 59 16.8 Total 352 Husband’s occupation Formal job 80 22.7 Informal job 85 24.1 Agriculture 71 20.2 Animal Husbandry 65 18.5 Jobless 51 14.5 Total 352 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 9 The monthly income of the family 5k-10k 35 9.9 11k-15k 38 10.8 16k-20k 44 12.5 21k-25k 70 19.9 26k-30k 74 21 31-above 91 25.9 Total 352 Total number of children 2-Jan 89 25.3 4-Mar 163 46.3 6-May 62 17.6 7-above 38 10.8 Total 352 Child related factors Children died after birth Yes 119 33.8 No 233 66.2 Total 352 Number of children died after birth One 21 17.6 Two 85 71.4 Three 10 8.4 Four 3 2.5 Total 119 Cause of child mortality Pneumonia 45 37.8 Diarrhea 33 27.7 Malaria 29 24.4 Congenital anomalies 4 3.4 Malnourishment 8 6.7 Total 119 Age of children at death 1-2 months 39 32.8 3-4 months 23 19.3 5-6 months 26 21.8 7-8 months 14 11.8 9-10 months 10 8.4 11-12 months 7 5.9 Total 348 147 Reliability 148 The reliability of the knowledge and practices questionnaire was assessed by using Cronbach’s 149 alpha. Table 2 represents the cumulative alpha value as .844, suggesting a relatively acceptable 150 internal consistency as the Cronbach alpha results at 0.7 and 0.8 are considered excellent. All the . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 10 151 items had corrected item-total correlations. However, .95 or greater values are creating a 152 disturbance in internal consistency [22]. The Cronbach alpha value exists between 0-1. 153 Table 2. Corrected item-total correlation and Cronbach’s alpha values of the 24 items of 154 Knowledge and Practices of ANC. Item-Total Statistics Scale Mean if Item Deleted Scale Variance if Item Deleted Corrected Item-Total Correlation Cronbach's Alpha if Item Deleted I have less consumption of milk during my last pregnancy. 123.8182 329.112 0.225 0.843 I did not take a proper diet during my last pregnancy. 124.4176 325.281 0.315 0.841 I have to ask for money needed for my treatment from my husband. 124.1506 329.325 0.203 0.844 I am exposed to violence due to my husband’s unemployment during pregnancy. 124.3324 327.288 0.253 0.842 My household responsibilities do not change during pregnancy. 124.1903 330.616 0.156 0.845 Household responsibilities quickly made me tired during pregnancy. 124.2102 307.158 0.573 0.833 I prefer homebirths due to the lack of money. 124.3097 310.14 0.495 0.835 Healthcare facilities are affordable in government hospitals. 123.8324 315.815 0.432 0.837 Access to standard healthcare services is difficult. 124.2301 303.511 0.606 0.831 The source of water and access to sanitation is poor. 124.0256 307.119 0.586 0.832 I get permission to visit the hospital from my husband during pregnancy. 124.2216 308.264 0.531 0.834 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 11 I do not know much about modern healthcare facilities. 124.25 305.556 0.552 0.833 My husband decides about family planning. 124.0653 307.457 0.559 0.833 I do not seek healthcare facilities during pregnancy if there is no companion. 124.2585 309.098 0.508 0.835 I do not make the decision as to which hospital to go to for a checkup during pregnancy. 123.6932 331 0.197 0.844 I cannot visit the health facility alone due to distance. 123.4233 324.456 0.362 0.84 I have to take public transportation to visit healthcare. Facility, but there is often a lack of transportation. 123.2869 332.427 0.133 0.846 I do not have post-delivery follow-up support. 124.0057 319.345 0.351 0.84 High-quality health services are not present in public hospitals. 124.1193 320.613 0.314 0.841 The pressure to have a son makes my pregnancies difficult. 123.3835 323.565 0.376 0.839 I was unable to read the brochures given by doctors about maternal healthcare during pregnancy. 123.2131 320.704 0.45 0.838 I do not know different methods of contraception. 123.2699 326.044 0.303 0.841 I was unaware of the significance of multivitamins during pregnancy. 123.2131 320.362 0.429 0.838 Men in the family are not concerned about women’s health during pregnancy. 123.8381 341.515 -0.065 0.852 Cronbach's alpha 0.844 155 156 Regression Analysis 157 Table 3 represents the model summary and ANOVA results. The model summary shows the 158 strength of the relationship between the model and the dependent variable, namely the model’s . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 12 159 fitness, which is 44.90%. In this connection, several factors leading to maternal and perinatal 160 health vulnerabilities include poverty and gender inequality. However, there is a significant 161 variance between MHV and gender inequality and poverty. 05 p-value is a cutoff value that 162 shows the possibility of acceptance of the null hypothesis. MHV and gender inequality and 163 poverty are two separate things, but they are interdependent in the context of women. 164 Table 3. The Multiple Regression Analysis (Model summary and ANOVA) Model Summary R R Square Adjusted R Square Std. Error of the Estimate .672a 0.452 0.449 0.74240223 ANOVA Sum of Squares df Mean Square F Sig. Regression 158.645 2 79.322 143.919 .000b Residual 192.355 349 0.551 Total 351 351 165 a. Predictors: (Constant), Gender Inequality, Poverty. 166 b. Dependent Variable: Maternal Health Vulnerabilities. 167 Table 4 represents the results of regression Coefficients, showing the significant level of poverty 168 and gender inequality in the prediction of MHV. The Beta value shows the contribution of each 169 independent variable separately. In this study, poverty predicts MHV positive and significant 170 (65.60% and .000). In contrast, gender inequality predicts MHV positive and significant (10.50% 171 and .000). Thus, in MHV, gender inequality and poverty are two different terms that tend to 172 complement each other by acting as risk or protective factors, respectively, both at the individual 173 level and at the health system—further sig. Values also explain the status of hypotheses H1 and 174 H2, which are supported in the study. 175 Table 4. Unstandardised and standardised Coefficients. Coefficients . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 13 Unstandardised Coefficients Std. Error Standardised Coefficients t Sig. (Constant) -5.92E-17 0.04 0 1 Poverty 0.656 0.04 0.656 16.517 0 Gender Inequality 0.105 0.04 0.105 2.637 0.009 176 Discussion and conclusion 177 Reducing maternal mortality has become a global health priority as it affects women 178 disproportionately in low and middle-income countries. Many of these deaths are preventable 179 [23]. Maternal health has become a challenge for Pakistan, which faces a maternal health crisis 180 with a high MMR. The prevalent societal beliefs and perceptions, household power structures 181 and misinformation significantly impact maternal health [24]. The results of this study reveal that 182 different levels within the SEM influence factors affecting maternal health vulnerabilities. These 183 factors include sociodemographic characteristics of the women and social and community 184 aspects. 185 Women’s vulnerabilities in rural areas begin from the micro and mesosystem: poverty, gender 186 inequality, and cultural practices disempower women and pose numerous barriers to enhancing 187 their social status. The women lack education and awareness about reproductive health. This is 188 even though education and awareness about reproductive and maternal health can play a central 189 role in smoothing ANC, which is central to promoting a positive pregnancy experience and 190 improving maternal and child survival [25]. The critical steps of ANC include risk diagnosis, 191 pregnancy management and prevention of pregnancy-related diseases, health education and 192 health promotion [26]. The participants in this study showed a lack of health awareness and 193 information about ANC. Most participants, i.e., 49%, were not literate, while 19% had primary- 194 level education. Only 6% of participants had matric, and 4% had intermediate-level education. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 14 195 Thus, most of the women were unable to read and comprehend information about ANC, the use 196 of contraceptives, the importance of follow-ups, maintaining diet plans, reading and 197 understanding brochures, knowledge about modern healthcare facilities, and the extent of 198 contraceptives. 199 Patriarchy, supported by socio-cultural norms, is another element within the micro, meso and 200 exosystem impacting MHV. In rural areas, the uptake of ANC is widely influenced by social and 201 cultural norms. Inadequate and poor-quality services and social and cultural orientations limit 202 women’s access to quality maternal health services [4]. Results of this study also reflect that 203 women’s regular visits to healthcare facilities and follow-ups were greatly influenced by the 204 distance of the health facility from their residence; a more significant distance complicated the 205 situation further. Since men make substantial decisions, women’s access to ANC services was 206 also subject to men’s approval. 207 Women’s low status, poverty, limited literacy, and inaccessible, inadequate and costly healthcare 208 services influence MHV [27]. Results of this study show that poverty is the main factor 209 influencing ANC practices in the villages; the women in this study were less likely to maintain 210 the healthy diet required during pregnancy due to financial constraints such as milk consumption, 211 proper food, or vitamin intake. Women also preferred home delivery because their families could 212 not afford hospital expenses. Poverty is a significant factor in the micro, meso, and exosystems 213 of SEM that influence MHV. 214 The growing population and poor maternal health outcomes in Pakistan require immediate 215 response and improved strategies. For example, gains cannot be made by investing in the health 216 sector alone; social indicators of women also need close attention. Fundamental issues about . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 15 217 women’s status, empowerment, education, hygiene and sanitation must also be considered [28, 218 29]. 219 There is a lack of gender-sensitive policies and initiatives on the macro level to address MHV in 220 rural areas and remote communities where women are in disadvantageous positions. Maternal 221 health outcomes can be improved with robust interventions targeted to reduce gender inequality 222 in accessing healthcare. The World Health Organization has set a goal to decrease the global 223 MMR to 70 maternal deaths per 100,000 live births by 2030 [30]. For this, WHO is working to 224 record maternal mortality through increased research evidence, setting global standards, 225 providing evidence-based clinical and pragmatic guidance, and giving technical support to 226 member countries in developing and implementing effective policies and programs [4]. 227 Moreover, pregnancy-related awareness programs, the provision of skilled birth attendants and 228 access to antenatal care contribute to safer pregnancies and childbirth. To address the needs and 229 priorities of women and girls, inequalities must be removed in accessing quality reproductive, 230 maternal, and healthcare services for newborn children, along with the factors causing maternal 231 mortalities, morbidities, and related disabilities. 232 The SEM helped to enhance an understanding of how different factors at personal, community 233 and societal levels influence individuals’ health-seeking behaviour and increase vulnerabilities. 234 This study concludes that gender inequality and poverty are well entrenched in rural areas, 235 resulting in poor ANC practices. We suggest addressing the needs and priorities of the women 236 residing in less privileged areas. This can only be possible if socio-economic and geographical 237 factors are considered and women are given improved access to financial and physical resources. 238 This study is limited to some villages in northern Sindh; more research on MHV is required in . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 16 239 other less privileged areas of Pakistan where patriarchy is well entrenched and women’s access 240 to public spheres is restricted. 241 Disclaimer: None 242 Conflict of interest: None 243 Acknowledgement: We would like to thank our funders, the Academy of Medical 244 Sciences UK, for their support of the study and Dr Zahid Memon for helping us obtain ethics 245 approval. 246 References 247 1. Sule F. A., Uthman, O. A., Olamijuwon, E. O., Ichegbo, N. K., Mgbachi, I. C., 248 Okusanya, B., & Makinde, O. A. (2022). Examining vulnerability and resilience in 249 maternal, newborn and child health through a gender lens in low-income and middle- 250 income countries: a scoping review. BMJ Global Health, 7 (4), p. e007426. 251 https://doi: 10.1186/s12961-015-0036-5. 252 2. WHO (2023). Maternal mortality. Geneva, Switzerland. Available at 253 https://www.who.int/news-room/fact-sheets/detail/maternal-mortality (Accessed 2 May 254 2023) 255 3. Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A.B., Gemmill, A., & Say, L. 256 (2016). Global, regional, and national levels and trends in maternal mortality between 257 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 17 258 Maternal Mortality Estimation Inter-Agency Group. The Lancet, 387, No. 10017, 462– 259 474. http://dx.doi.org/10.1016/ S0140-6736(15)00838-7. 260 4. WHO (2019). Maternal mortality. Geneva, Switzerland. Available at 261 https://apps.who.int/iris/bitstream/handle/10665/329886/WHO-RHR-19.20-eng.pdf. 262 (Accessed 12 March 2023) 263 5. UNICEF (2020). Maternal mortality: Data and statistics. New York, USA. Available at: 264 https://gdc.unicef.org/resource/maternal- 265 mortality#:~:text=Sub%2DSaharan%20Africans%20suffer%20from,maternal%20deaths 266 %20per%20year%20worldwide (Accessed 12 February 2023) 267 6. UNICEF (2009). The State of the World’s Children 2009: Maternal and Newborn Health. 268 (United Nations publication, Sales No. E.09.XX.1), New York, USA. Available at 269 https://www.unicef.org/media/84866/file/SOWC-2009.pdf (Accessed 23 March 2023) 270 7. Hanif, M., Khalid, S., Rasul, A., & Mahmood, K. (2021). Maternal mortality in rural 271 areas of Pakistan: challenges and prospects. Rural Health, 27, 1040–1047. https://doi: 272 10.5772/intechopen.96934. 273 8. Bhutta, Z. A., Hafeez, A., Rizvi, A., Ali, N., Khan, A., Ahmad, F., & Jafarey, S. N. 274 (2013). Reproductive, maternal, newborn, and child health in Pakistan: challenges and 275 opportunities. The Lancet, 381, No. 9884, 2207–2218. https://doi: 10.1016/S0140- 276 6736(12)61999-0. 277 9. Pakistan Maternal Mortality Survey (2019). National Institute of Population Studies 278 (NIPS) [Pakistan] and ICF. 2020: Key Indicators Report. Islamabad, Pakistan, and . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 18 279 Rockville, Maryland, USA. NIPS and ICF. Available at: 280 https://dhsprogram.com/pubs/pdf/SR267/SR267.pdf. 281 10. Roos, N., Kovats, S., Hajat, S., Filippi, V., Chersich, M., Luchters, S., & Wright, C. Y. 282 (2021). Maternal and newborn health risks of climate change: a call for awareness and 283 global action. Acta obstetricia et gynecologica Scandinavica, 100 (4), 566–570. 284 https://doi.org/10.1111/aogs.14124. 285 11. World Bank (2004). The Millennium Development Goals for Health: Rising to the 286 Challenges”, Washington, DC, World Bank, pp. xi, 6, 51 and 52. Available at: The 287 Millennium Development Goals for Health: Rising to the Challenges (worldbank.org) 288 (Accessed 22 March 2023) 289 12. WHO (2018). WHO Recommendations on Antenatal Care for a Positive Pregnancy 290 Experience: Summary Highlights and Key Messages from the World Health 291 Organization’s 2016 Global Recommendations for Routine Antenatal Care. Available at 292 https://apps.who.int/iris/bitstream/handle/10665/259947/WHO-RHR-18.02-eng.pdf 293 (Accessed 2 May 2023) 294 13. WHO (2021a). Why we need to focus on quality care for women and newborns. Geneva, 295 Switzerland. Available at: https://www.who.int/news/item/04-05-2021-why-we-need-to- 296 focus-on-quality-care-for-women-and-newborns (Accessed 23 January 2023) 297 14. Jimenez Soto, E., La Vincente, S., Clark, A., Firth, S., Morgan, A., Dettrick, Z., 298 &Widiati, Y. (2013). Investment case for improving maternal and child health: results 299 from four countries. BMC Public Health, 13 (1), 1–14. https://doi:10.1186/1471-2458-13- 300 601 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 19 301 15. Townsend, N., & Foster, C. (2013). Developing and applying a socio-ecological model to 302 the promotion of healthy eating in the school. Public Health Nutrition, 16 (6), 1101– 303 1108. https://doi:10.1017/S1368980011002655. 304 16. Sallis, J. F., Owen, N., & Fisher, E. (2015). Ecological models of health 305 behaviour. Health behaviour: Theory, research, and practice, 5, 43–64. 306 17. Centers for Disease Control and Prevention (CDC) (2022). The Social-Ecological Model: 307 A Framework for Prevention. Available at: The Social-Ecological Model: A Framework 308 for Prevention |Violence Prevention|Injury Center|CDC (Accessed 20 July 2023) 309 18. Salihu, H. M., Wilson, R. E., King, L. M., Marty, P. J., & Whiteman, V. E. (2015). 310 Socio-ecological model as a framework for overcoming barriers and challenges in 311 randomised control trials in minority and underserved communities. International 312 Journal of MCH and AIDS, 3 (1), p. 85. 313 19. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature 314 and design. Harvard University Press. 315 20. Bronfenbrenner U (1977). Toward an experimental ecology of human development. 316 American Psychologist, 32(7), 513–531. 317 21. Martínez-Andrés, M., Bartolomé-Gutiérrez, R., Rodríguez-Martín, B., Pardo-Guijarro, 318 M. J., Garrido-Miguel, M., & Martínez-Vizcaíno, V. (2020). Barriers and facilitators to 319 leisure physical activity in children: a qualitative approach using the socio-ecological 320 model. International Journal of Environmental Research and Public Health, 17 (9), p. 321 3033. https://doi: 10.3390/ijerph17093033. . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 20 322 22. Hulin, C. (2001). Can a reliability coefficient be too high? Journal of Consumer 323 Psychology, (1–2), p. 55. https://doi:10.2307/1480474. 324 23. Ozimek, J. A., & Kilpatrick, S. J. (2018). Maternal mortality in the twenty-first 325 century. Obstetrics and Gynecology Clinics, 45 (2), 175–186. 326 https://doi: 10.1016/j.ogc.2018.01.004. 327 24. Mustafa, M., Batool, A., Fatima, B., Nawaz, F., Toyama, K., & Raza, A.A. (2020). 328 Patriarchy, maternal health and spiritual healing: Designing maternal health interventions 329 in Pakistan. In Proceedings of the 2020 CHI Conference on Human Factors in 330 Computing Systems, 1–13. https://doi.org/10.1145/3313831.3376294. 331 25. Kumar, G., Choudhary, T.S., Srivastava, A., Upadhyay, R.P., Taneja, S., Bahl, R., & 332 Mazumder, S. (2019). Utilisation, equity and determinants of full antenatal care in India: 333 analysis from the National Family Health Survey 4. BMC Pregnancy and Childbirth, 19 334 (1), 1–9. https://doi.org/10.1186/s12884-019-2473-6. 335 26. WHO (2016). WHO recommendations on antenatal care for a positive pregnancy 336 experience: summary. Geneva, Switzerland. Available at: 337 https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912- 338 eng.pdf?sequence=1 (Accessed 12 March 2023) 339 27. WHO (2014). Maternal Mortality, Fact sheet. Geneva, Switzerland. Available at 340 https://apps.who.int/iris/bitstream/handle/10665/112318/WHO_RHR_14.06_eng.pdf 341 (Accessed 22 February 2023) . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint 21 342 28. Bhutta, Z.A., & Hafeez, A. (2015). What can Pakistan do to address maternal and child 343 health over the next decade? Health Research Policy and Systems, 13 (1), 13–16. 344 https://doi 10.1186/s12961-015-0036-5. 345 29. Requejo, J.H., & Bhutta, Z.A. (2015). The post-2015 agenda: staying the course in 346 maternal and child survival. Archives of disease in childhood, 100 (Suppl 1), S76–S81. 347 https://doi: 10.1136/archdischild-2013-305737. 348 30. WHO (2021b). New global targets to prevent maternal deaths. Available at: 349 https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal- 350 deaths (Accessed 13 February 2023). . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 1, 2024. ; https://doi.org/10.1101/2024.03.31.24305141doi: medRxiv preprint