"Missed Prenatal Ultrasounds" unspoken issue of women having Antenatal care at Primary health care settings: A qualitative exploratory study in District Hazro, Pakistan

"Missed Prenatal Ultrasounds" unspoken issue of women having Antenatal care at Primary health care settings: A qualitative exploratory study in District Hazro, Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "Missed Prenatal Ultrasounds" unspoken issue of women having Antenatal care at Primary health care settings: A qualitative exploratory study in District Hazro, Pakistan Bushra Asif Ali Khan, Jawaria Mukhtar Ahmed, Rawshan Jabeen, Humaira Mahmood, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3973396/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background This qualitative study aimed to explore women's experiences and perceptions regarding barriers to accessing ultrasound scans at primary healthcare level. Method Altogether, four focus group discussions (FGDs) involving 36 pregnant women who had received prenatal care at facilities between February and September 2021 were conducted. Using a purposive sampling technique participants provided informed consent before data collection during guided FGDs. Result Thematic analysis of the data using NVivo 12 revealed recurring themes explaining underutilization of ultrasound scans at this level of healthcare. The study highlighted challenges faced by women at primary health care facilities, emphasizing the potential gaps in caregivers' ability to provide comprehensive counseling about the importance and safety of ultrasound scans in fetal growth monitoring. Addressing staff training and accountability emerged as essential areas requiring attention. Additionally, allocating more resources to alleviate financial burdens associated with accessing ultrasound services was a key recommendation. Conclusion In conclusion, this study revealed diverse barriers hindering women's access to ultrasound services at primary healthcare . It suggests targeted interventions focusing on staff training, improving facility support, and addressing financial constraints to enhance accessibility and utilization of ultrasound scans among pregnant women attending Primary Health Care facilities. Pregnant women Ultrasound Primary Health Care and Antenatal care Figures Figure 1 Background Antenatal care (ANC) is a vital component of women's health, and its importance cannot be overstated in achieving the Sustainable Development Goals (SDGs) 3.1 and 3.2 by 2030. These targets aim to reduce global maternal mortality to less than 70 per 100,000 live births and eliminate preventable deaths of newborns and children under five years of age [ 1 ]. In the broader context, the World Health Organization (WHO) recommends a minimum of four antenatal visits to improve maternal and neonatal outcomes [ 1 ]. Ultrasound, a key component of antenatal care, helps assess fetal development, detect abnormalities, and guide timely decisions during pregnancy. However, its widespread use faces challenges in low and middle-income settings, such as high equipment costs and a shortage of trained personnel [ 2 ]. WHO 2020 High income countries (HICs) recommendations advocate at least two ultrasound scans during pregnancy, one in the first trimester for confirmation and another between 18 and 22 weeks to assess the normal anatomy of the fetus [ 3 ]. In Europe, mid-trimester routine ultrasounds in ANC clinics detected around 56% of malformations and fetal anomalies before 24 weeks of gestational age [ 4 ]. However, accessibility remains challenging in many regions, for instance, in the United States, an average of 3–4 ultrasound test are conducted per pregnancy, indicating its prevalence and importance [ 5 ] and further, the WHO 2013, emphasizes ultrasound as an important diagnostic test during pregnancy, advocating at least one scan before 24 weeks of pregnancy [ 6 , 7 ].Studies suggest that integrating ultrasound in ANC could proactively identify complications, enabling appropriate timely referrals before labor, potentially reducing mortality rates. Despite its proven benefits, the impediments to its widespread implementation in resource-constrained settings persist [ 8 ]. In Pakistan, the provision of adequate prenatal services remains an urgent issue and just over half of women (51%) receive care during pregnancy, and the standard of care often falls below of guidelines [ 9 ]. Furthermore, previous studies reported many barriers that stand in the way of women living in low-income and rural regions, especially when it comes to obtaining these essential services [ 6 ]. Factors including costly transportation, ignorance, and cultural reluctance pose significant obstacles that prevent women from accessing critical healthcare. Furthermore, the nation's general maternal care service quality is below par, which influences women's poor conduct when it comes to seeking medical attention [ 10 ]. An additional barrier to the adoption of antenatal ultrasonography screening is patient and healthcare provider misinterpretation, abuse, and overuse [ 11 ]. Cultural resistance is another important factor. Owing to some cultural views, it is disrespectful or indecent to visualize a pregnant woman's insides or project a fetus. In order to provide comprehensive and easily available maternity healthcare for every woman in Pakistan, it is essential to tackle these complex issues [ 12 , 13 ]. Another study highlighted the significance of ultrasound in estimating fetal weight. They emphasized the importance of selecting an appropriate model tailored to the local population for an accurate assessment. Precision in these estimations is crucial for effective care in Pakistan [ 14 ]. A cluster-randomized trial suggested that the impact of introducing ultrasound during antenatal care have potential benefits of ultrasound in enhancing prenatal care and outcomes for women in underserved regions [ 15 ]. Nevertheless, understanding how women perceive ultrasound use at the Primary Healthcare level (PHC) level is crucial. This insight helps pinpoint perceived advantages and challenges, providing valuable insights for healthcare professionals to address them effectively. This study aimed to reveal the underlying causes of noncompliance, such as cultural norms, financial constraints, or lack of awareness. Further, understanding these factors enables healthcare systems to design targeted interventions and strategies for improved compliance rates and ensure optimal utilization of ultrasound services at the Primary Healthcare levels (PHC). Methodology The study prioritized rigor and trustworthiness through a multifaceted approach. To enhance rigor, various measures were implemented at different stages of the research process. Firstly, the utilization of a descriptive research design provided a systematic framework for exploring barriers faced by women in accessing prenatal ultrasound services. This methodological choice facilitated a comprehensive understanding of the phenomenon under investigation. Purposive sampling was employed to ensure the selection of 36 participants who met specific inclusion criteria presented in Table 1 , thereby enriching the depth and relevance of the gathered data. Additionally, the exclusion of non-pregnant women helped maintain the study's focus and relevance to the targeted research area. Table 1 Participants Inclusion & Exclusion Criteria Eligibility Criteria • Pregnant women utilizing prenatal care, attending at least three antenatal visits at the respective study locations (BHU Khagwani & the Hazro urban area dispensary). • Women aged 18 years and above. • Pregnant women who willingly provided consent to take part in the research. Exclusion Criteria: Those who did not meet this criterion were excluded. To enhance the depth and breadth of our insights, we employed FGDs held at BHU Khagwani and the Hazro urban area dispensary in district Attock. Our approach aimed to gather comprehensive information and provide a holistic understanding of the subject. The interview guide, initially designed in a semi-structured format by a qualitative expert, underwent revisions following pilot testing by the research team. These discussions were expertly facilitated by trained professionals, fostering open and candid conversations among participants. During interviews, which typically lasted around 60–90 minutes each, recordings were made to ensure accuracy. Additionally, a note-taker was present to collect field notes, providing valuable contextual information that added depth to our dataset. This meticulous approach aimed to ensure the reliability and completeness of our findings. To ensure data rigor and thoroughness, a summary of the information was shared and discussed with the participants. The interviews were conducted in Urdu language, with subsequent translation and transcription of the four FGDs into English for analysis. Ethical considerations were paramount, with informed consent obtained from participants, and ethical approval secured from the Armed Forces Post Graduate Medical Institute (Re: 208-AAA-ERC-AFPGMI). The study strictly adhered to established ethical guidelines, notably the Declaration of Helsinki, safeguarding the rights and welfare of all participating individuals. Conceptual Framework: We used Multilevel Prenatal Ultrasound Access Framework (MPUAF)" as a deductive approach with emphasis on multiple levels of influence—individual, interpersonal, community and systemic—pertaining to access to prenatal ultrasound services [ 16 , 17 ]. The framework is derived from various frameworks to provide a comprehensive structure tailored to the exploration of missed prenatal ultrasounds in resource -constrained healthcare settings. Data Analysis: In the thematic data analysis for this manuscript, a deductive approach was employed to systematically organize and analyze the collected data regarding reasons for missed prenatal ultrasounds in District Hazro, Pakistan. The analysis process was facilitated using NVivo 12 software. Bilingual experts proficient in the local language and English collaborated in the analysis, ensuring a nuanced understanding of the cultural context and accurate interpretation of participants' responses. The deductive approach involved pre-defined codes aligned with the study's research questions and established theoretical frameworks. These codes were systematically applied to the transcripts, allowing for the identification of patterns and themes related to reasons for missed prenatal ultrasounds. Regular discussions and consensus-building among the analysis team were conducted to ensure reliability and consistency in the interpretation of data, enhancing the credibility of the study's findings. Rigor of the study was ensured by using Lincoln- Guba framework, such as thematic coding aligned with established frameworks and involved multiple independent researchers to ensure inter-coder reliability and credibility. Regular discussions among the analysis team members facilitated consensus-building and mitigated biases. Additionally, peer debriefing sessions and an audit trail were maintained to document decisions and ensure transparency in analytical steps. Reflexivity: The research team engaged in reflexive practices to acknowledge and address potential biases and subjectivities that might influence the research process. Reflexivity involved continuous self-awareness among researchers regarding their assumptions, perspectives, and possible influences on data collection and analysis. Result We conducted a study involving thirty-six pregnant women, all residing in rural areas. The study highlights a predominant presence of joint family structures and lower levels of education among pregnant women in rural areas. Additionally, a significant portion of the participants had multiple children, suggesting varying experiences in terms of childbirth and family size. Table 2 Socio-demographic characteristics of the study participants Socio demographic profile (n = 36) n (%) Type of family Nuclear 6 (17%) Joint 30 (83%) Occupation of female Working 16 (44%) Non-working 20 (55%) Education of female Illiterate or read and write 10 (27%) Primary 14 (38%) Secondary 12 (33%) Current Pregnancy Primigravida 8 (22%) 2–3 18 (50%) More than three 10 (27%) Table 3 presents the predetermined themes and corresponding sub-themes utilized for data analysis. The overarching themes encompassed individual-level factors, interpersonal factors, community-level factors, and systemic factors. A comprehensive breakdown of each theme and its associated sub-themes is elaborated upon in subsequent sections. Table 3 Predefined themes and corresponding sub-theme Themes Sub-themes Individual level factors Limited knowledge of ultrasound technology Personal beliefs Financial constraints Concerns regarding ultrasound procedure Interpersonal factors Communication with HCPs Partner involvement & support Community level factors Cultural and societal norms Concerns Regarding Ultrasound Procedure/Perceptions related to ultrasound use/ Stigma or taboos associated with ultrasound/ Perceptions of ultrasound's benefits and risks Systemic factors Human resource and infrastructure issues Theme I: Individual level factors: Exploring these individual-level factors uncovers how these personal aspects influence a woman's decision-making process regarding seeking and utilizing prenatal ultrasound services, contributing to a comprehensive understanding of the barriers or facilitators at the individual level within the broader framework of prenatal ultrasound access. Personal beliefs: The sub-theme "Personal Beliefs" emerged as a pivotal category, encompassing diverse codes reflecting pregnant women's individual convictions and perceptions regarding prenatal ultrasound services. The finding revealed such as perceived importance, showing, how women valued prenatal ultrasounds in monitoring fetal health and identifying potential complications. During FGD 1, a pregnant participant, referred to as Pregnant Woman 2, emphasized the significance of ultrasounds in ensuring her baby's well-being. She expressed, "I've had three ultrasounds so far, and I'm seven months pregnant. I always wanted reassurance that my baby is healthy and progressing well, especially after experiencing two miscarriages and one stillbirth previously." While in FGD 4, Pregnant Woman 5 conveyed a sense of reassurance and emotional attachment when discussing the importance of ultrasounds. She expressed, "Since this is my first pregnancy, I went for an ultrasound. I feel a strong emotional connection when I see my baby on the screen, it makes me feel more bonded to my pregnancy." In FGD 3, a pregnant participant 3 expressed skepticism regarding the necessity of ultrasounds during pregnancy. She conveyed a belief that ultrasounds are not always essential and viewed them as optional procedures. Furthermore, she articulated a lack of trust in healthcare providers (HCPs), suggesting a perception that HCPs might prescribe ultrasounds primarily for financial gain. Her statement reflected a strong reliance on her body's intuition, stating, "I don’t think ultrasound is always needed. I trust my body to tell me if something is wrong." This viewpoint highlights a personal conviction in her ability to sense any potential issues without relying on medical imaging procedures during pregnancy. In the same discussion, another participant, labeled Participant 6 from FGD 2, echoed a similar sentiment by stating, "I trust my intuitions and instincts." This concise statement highlighted a deep-seated confidence in her instincts and inner feelings, indicating a preference for relying on personal intuition in decision-making, potentially extending to matters related to prenatal care and healthcare choices. During FGD 2, Pregnant Woman 1 expressed a perspective asserting pregnancy as a natural process. She conveyed a reluctance toward relying excessively on technology, stating that “undergoing ultrasounds might foster an undue dependency on technology” . Additionally, she highlighted concerns about the potential for ultrasounds to induce unnecessary anxiety, expressing a desire to focus solely on the emotions and experience of motherhood. Other participant from FGD 4 pregnant woman 6 shared her views, suggesting that “ultrasounds are often perceived as a means to determine the baby's gender”. They indicated societal pressures, mentioning instances where families insist on ultrasounds to know the baby's gender for the purpose of planning and shopping accordingly. Moreover, these participants highlighted situations where females might feel compelled to undergo ultrasounds due to familial expectations to fulfill specific gender preferences, potentially influencing family size and dynamics. Limited knowledge about ultrasound : This sub-theme illuminated the widespread knowledge deficit surrounding prenatal ultrasounds among participants. Their understanding varied greatly, ranging from incomplete information to outright misconceptions about the purpose, importance, and implications of these scans. Exploring this sub-theme provided valuable insights into the diverse perspectives and levels of awareness among participants concerning the use and impact of ultrasounds in the context of prenatal care. When questioned about their understanding of ultrasound and its relevance in pregnancy, Pregnant Woman 2 from FGD 1 expressed a viewpoint considering “ ultrasound as an unnecessary intervention ”, citing that, “it tends to induce anxiety among expecting mothers ”. On the other hand, another pregnant women 3 from FGD 3 conveyed uncertainty regarding the widespread need for ultrasounds, expressing, "I don’t know why everyone needs ultrasound; it seems necessary only in complex pregnancies or for females experiencing recurrent miscarriages." She added further, "Ultrasound releases harmful radiation, which isn't safe for the baby. That's why expecting mothers should limit unnecessary exposure to these radiations." Amidst a landscape of limited knowledge about ultrasounds in focus group 4, one pregnant woman 5 understanding stood out. She confidently explained the value of ultrasounds in “monitoring a baby's heartbeat, size, and overall growth”. When asked how she learned this, she credited her healthcare provider. " My doctor told me this multiple times during antenatal visits, really emphasizing its importance ," she explained. Notably, she further shared that, “ultrasounds can reveal potential issues like a lack of heartbeat or delayed growth, which, if identified, might necessitate prompt pregnancy termination to safeguard both mother and baby from potential health complications”. Most participants of FGDs mentioned that they did not have a set schedule for ultrasounds during their pregnancies. Instead, they underwent one or two scans based on the necessity arising from the baby's condition. Doctors usually advise having an ultrasound scan sometime between the first and fourth months of pregnancy. However, participants often chose to schedule these scans based on their convenience rather than following this suggested timeline. During the discussions (FGDs 1–4), participants mentioned that “their doctors suggested having ultrasounds in the first and fourth months of pregnancy. However, they didn't consider it urgent and chose to delay these scans. Instead, they decided to have the ultrasounds during later visits or whenever it was convenient for them”. This decision to postpone the scans might indicate a lack of immediate concern or perceived urgency about the suggested timing for ultrasounds during specific stages of pregnancy as advised by their doctors. This suggests that there's a lack of adherence to a structured ultrasound schedule recommended by healthcare professionals. Instead, participants arranged scans based on their own perceived need. This approach might result in variations in the timing of important scans, especially during the early stages of pregnancy. During FGD 3, a woman shared a distressing experience by stating, “ I missed the chance for an anomaly scan because of a delay caused by insufficient information”. Sadly, healthcare professionals didn't advise her in time, revealing a significant lack of their support. Financial constraints This sub-theme encapsulated the various financial challenges and limitations faced by participants when accessing ultrasound services during pregnancy. Exploring this sub-theme sheds light on the impact of financial constraints, which hindered participants' ability to access and afford essential ultrasound services, ultimately affecting their prenatal care experiences. Many women expressed their intention to use the ultrasound system at the Primary Healthcare level (PHC) for diagnostic purposes. They explained that the lack of maintenance in the public sector caused this issue with the equipment. As a result, their doctors advised them to go to private hospitals, which came with significant costs. This situation caused delays in getting important tests done within the required time. The unreliable public healthcare system's machinery created financial barriers, forcing women to opt for expensive alternatives and causing delays in their diagnostic processes. Participants across all four FGDs shared a similar feeling: "Managing expenses is tough, but our health is crucial, and seeking medical care is the only viable choice." This indicates their understanding of the financial challenges but emphasizes the importance they place on health; despite the difficulties they encounter in paying for necessary healthcare. Theme II: Interpersonal factors Interpersonal factors refer to the influence of social relationships, interactions, and communication among individuals within the context of accessing prenatal ultrasound services. This theme explores the interpersonal relationships and interactions that influenced participants' perspectives, decisions, and experiences regarding prenatal ultrasound services, highlighting the role of communication and social influences in shaping their choices. Communication with healthcare providers: When asked about how healthcare providers communicate the importance of ultrasounds, participants had mixed responses. Participants from FGD 2 and 4 mentioned that their doctors and antenatal nurses were attentive listeners, addressing all their concerns and making them feel heard and comfortable. They specifically highlighted that “these healthcare professionals listened to our worries and provided clear explanations, which significantly improved our understanding of ultrasound scans”. This positive communication experience enhanced their comprehension of the importance of undergoing ultrasound examinations during pregnancy. Participants from FGD 1 and 3 mentioned that “their antenatal care providers do listen to them, but they often feel rushed during appointments.” Due to a large number of patients waiting in the lounge, the healthcare providers sometimes suggest discussing queries outside the ultrasound room. Partner involvement & support: Overall, the sub-theme emphasizes the crucial role of partners in the decision-making process, their emotional support, and their involvement in discussions regarding ultrasounds, highlighting the impact of their presence and support on the pregnant woman's ultrasound experience and decision-making. Although family members and husbands possess a good understanding of pregnant women's experiences, a lasting concern exists regarding the safety of ultrasound procedures and their possible connection to miscarriages. This worry stems from a prevalent misconception or fear within the family and among husbands about the safety of these imaging techniques. As a result, it acts as a barrier, preventing their complete support for pregnant women undergoing ultrasounds during pregnancy. During FGD 1, a participant shared, "I can visit the ANC only when I'm unwell, and I'm always accompanied by my mother-in-law or other family members for support. However, if the doctor recommends an ultrasound test, I need to call and ask for permission from my husband." This means that while she has some freedom to seek care when feeling unwell, decisions about undergoing ultrasounds specifically require her husband's approval, indicating a different level of decision-making authority in her pregnancy care. During FGD 3, one participant mentioned “her doctor referred her to a specialized hospital for an advanced scan due to concerns about potential genetic issues in her child.” This referral suggests the necessity for a detailed examination to thoroughly evaluate and potentially identify any genetic conditions or abnormalities in the baby. During FGD 4, a participant mentioned that "the doctor recommended a Doppler ultrasound at another hospital, despite the cost, stressing the importance of checking for potential illnesses in the child. " She further said, "My partner expects me to follow doctor's orders without question." The participant followed the doctor's advice, accompanied by her husband, highlighting their shared concern for their child's health. This instance underscores the participant's commitment to prioritizing the doctor's recommendation for the Doppler ultrasound, despite the expense, showing a deep care for their child's well-being. Theme III: Community level factors This theme explores societal attitudes towards pregnancy and healthcare, prevailing cultural beliefs regarding ultrasound safety or necessity, and the influence of community members, such as family, friends, or community elders, in shaping perceptions about ultrasounds. Concerns Regarding Ultrasound Procedure The women in the community expressed fear and reluctance towards undergoing ultrasound procedures early in their pregnancies, preferring to visit the ANC clinic after the third month instead. Most of the pregnant women mentioned that “while most women typically go through the initial months or trimesters of pregnancy, they hadn't personally encountered this”. Their hesitation seemed to stem from a belief held by a few participants that “ultrasound or x-ray procedures could potentially harm the health and growth of the child” . This perception contributed to their reluctance to undergo these scans during the early stages of pregnancy. This reluctance to engage with ultrasound procedures at the onset of pregnancy, coupled with a preference to seek ANC care later, highlights a significant barrier in their approach to prenatal health. The fear and misconception surrounding the perceived harms of ultrasound or x-rays impacted their decision-making about when to initiate prenatal care and undergo necessary medical procedures. During FGD 2, a participant mentioned that “her mother-in-law strongly suggested keeping the pregnancy confidential until three months, fearing that an early ANC clinic visit might involve an ultrasound, which she believed could lead to a miscarriage.” This advice exposes a prevalent misconception within society and family circles about the safety of early ultrasounds during pregnancy. It underscores the existence of myths and misunderstandings regarding the potential risks associated with undergoing ultrasounds in the early stages, contributing to the delay in seeking crucial prenatal care. During FGD 4, a participant expressed the belief that “X-rays aren't helpful for a child's growth” . This viewpoint highlights a common misunderstanding among some people that procedures like X-rays, and sometimes even ultrasounds, might negatively impact a child's development during pregnancy. This misconception often leads to fear and hesitation among expectant mothers when it comes to undergoing these imaging procedures, even though they're essential for monitoring the baby's health and growth. The concern specifically relates to myths and misconceptions surrounding X-rays and their potential effects during pregnancy, contributing to apprehension about these medical imaging procedures. Cultural & Societal Norms According to a participant in FGD 1, in her community, “women who opt for ultrasounds are viewed as neglecting their babies.” This perception sheds light on the societal attitude prevalent in her community, where seeking ultrasounds might be seen as neglectful or unnecessary care for the unborn child. Conversely, participants in FGD 3 expressed a different perspective. They shared that “their families anticipate at least one ultrasound to confirm the pregnancy.” This view highlights the contrasting societal expectation within their families, emphasizing the importance placed on undergoing at least one ultrasound for pregnancy confirmation. This suggests variations in community perceptions regarding the necessity or neglectfulness of ultrasounds during pregnancy. Theme IV Systemic factors: Human resource and infrastructure issues Pregnant women shared their challenges in accessing ultrasound services within the community. They mentioned that doctors were available at the facility for scans only a few days per week, leaving technicians responsible for conducting the tests. This led to longer waiting times to complete their examinations. During FGD 2, A participant mentioned that “Most doctors were unavailable, so we had to wait for them”. Furthermore, the lack of sufficient restroom facilities and access to water made the women feel uncomfortable during their visits. The combination of limited doctor availability, reliance on technicians, and inadequate amenities at the facility created a less-than-ideal experience for women seeking ultrasounds. During FGD 4, “Participants decided against undergoing the test at the ultrasound room due to extended waiting periods and the unavailability of a clean restroom”. This prolonged their waiting periods and negatively impacted their overall comfort and convenience during these important medical appointments. Accessibility and availability of the services: The subtheme within systemic factors pertains to the difficulties women face when trying to access ultrasound services in healthcare settings. It covers challenges related to physically reaching these facilities, the availability of services when needed, and the logistical barriers that pregnant women encounter in obtaining ultrasound examinations. This subtheme highlights the struggles women undergo to physically reach healthcare centers providing ultrasounds and the issues they face regarding the timing and availability of these essential services. When asked about clinic timings, every participant from all FGDs mentioned that “Primary Healthcare level (PHC)s (BHUs) offered basic ultrasound services only from 9 am to 2 pm. However, they frequently experienced issues with the machine being out of order, leading to delays in getting it repaired, sometimes taking days or even weeks. This situation compelled them to seek fetal anomaly scans at private clinics, which posed financial burdens. The process involved visiting a doctor first to get a referral for the ultrasound and then scheduling the appointment, often requiring accompaniment by their husband or mother-in-law. If these family members weren't available, it would have caused further delays in accessing the ultrasound services”. Primary Healthcare level (PHC) Discussion This study found a variety of hurdles to women's access to ultrasonography services in primary care. It proposes focused interventions that focus on staff training, increasing facility support, and addressing financial constraints in order to improve the accessibility and utilization of ultrasound scans among pregnant women visiting Primary Health Care institutions. However, participants lacked awareness regarding the frequency and scheduling of these scans. A similar study reported that 93.5% of women recognized the necessity of ultrasound scans but were uncertain about the ideal timing, feeling it should occur at least twice during pregnancy [ 18 ]. Our findings revealed that women had fears about undergoing ultrasounds during the first trimester, mirroring results from another study where 95% of women admitted that ultrasounds contributed to their anxieties about fetal health [ 19 ]. This emphasizes the necessity for healthcare providers to address and alleviate concerns surrounding early trimester ultrasounds, ensuring that expectant mothers feel more comfortable and informed about this essential aspect of prenatal care. Traditionally, cost has been seen as the main barrier to widespread adoption of medical technology and Lack of training is identified as a major impediment to the routine use of ultrasonography in poor countries by health care providers. Equipment requirements, including maintenance and machine costs, are also key issues [ 20 ]. However, the reality is more nuanced [ 21 ]. A standard ultrasound machine is both expensive and bulky, taking up the space of a refrigerator and costing around $ 19,000 directly [ 22 ]. Our study emphasized the importance of addressing equipment maintenance issues to ensure quality care at primary healthcare (PHC) levels. Missed prenatal ultrasound is a common issue in LMICs such as a study in Nepal found that the women has no knowledge of ultrasound who received ANC clinics [ 23 ]. Only 6% of the women received prenatal ultrasound in rural South Africa [ 13 ]. Another study in Kenya found that uncertainty regarding pregnancy status linked to delays in ANC attendance; more than 78% of women were more than 20 weeks pregnant at their initial visit. Healthcare staff found it difficult to detect pregnancies below 16 weeks' gestation, and reliable assessment of gestational age below 20 weeks' gestation may be challenging [ 24 ]. The provision of services relies on detecting the pregnancy and determining the gestational age. Healthcare providers were unfamiliar with Doppler technology and its use to guide clinical decisions but due to shortage of educated local staff, inadequate equipment, a lengthy distance to and from the hospital, and frequent power outages [ 25 ]. This highlights the significance of not only technological aspects but also the need for support systems that enable effective utilization of these technologies in remote or resource-limited areas. Improving communication channels and support networks can enhance the practicality and effectiveness of portable scanning tools in the hands of healthcare workers in such settings. This qualitative study centered on the perceptions and experiences of mothers visiting primary healthcare centers. However, to bolster the findings, incorporating viewpoints from healthcare providers and management would add depth. Additionally, these findings help to understand mothers' profiles could augment community-based data by providing a more structured and measurable foundation for understanding the challenges, needs, and characteristics of mothers within a community. Furthermore, in future the data-driven approach can lead to more targeted and effective interventions, policy changes, and community programs. Primary Healthcare level (PHC) Expanding the Sehat Sahulat national insurance system to cover antenatal ultrasound scans at private clinics could alleviate the financial burden on the community. This comprehensive approach aims to enhance ANC services, increase access to essential ultrasound screenings, and ease financial strains for pregnant women in resource-limited settings. Conclusion The study identified challenges faced by women at primary healthcare (PHC) levels, where caregivers often struggle to provide sufficient counseling on the importance of ultrasound scans for fetal growth. Many women lacked awareness about the significance of ultrasounds and had limited understanding about their safety compared to x-rays. Several factors contributed to the underutilization of ultrasounds at PHC levels, including insufficient awareness, fears about the procedure, decision-making delays, facility-related issues, and budget constraints. To address these gaps, the report recommends integrating ultrasound training into primary healthcare professionals' curricula. It also suggests allocating more resources to lower-level healthcare facilities to establish functional ultrasound services and extending coverage through national insurance programs. Declarations Ethical consideration & consent to participate: The research presented in this manuscript received ethical approval from the Ethical Review Committee of the Armed Forces Post Graduate Medical Institute under the reference number 208-AAA-ERC-AFPGMI. Prior to enrollment in the study, written informed consent was obtained from all participants. The consent process involved a comprehensive explanation of the study's background, rationale, as well as the associated advantages and disadvantages to the mothers. It is important to note that throughout the entire research process, adherence to ethical principles was maintained in accordance with the guidelines outlined in the Declaration of Helsinki. Consent for Publication: Not applicable Conflict of Interest: The authors declared no compelling interest. Availability of data and materials: Data will be available upon reasonable request from the corresponding author. Funding: Not Applicable Authors Contribution: BK was the Principal Investigator (PI) who conceptualized the study and was involved in study design; BK, HM, and JMA designed the study protocol and obtained IRB approval. BK, JMA, and HM were involved in formulating the study methodology, developing study tools, and finalizing the data analysis plan; JMA, RJ and UJ were involved in article writing. BK and HM conducted a review of the literature and were involved in reviewing and editing the study tools. JMA, AM, UR and RJ were involved in editing manuscripts. All authors reviewed the manuscript several times and provided critical feedback. All authors read and approved the final version of the manuscript. Acknowledgement: This study stands as a testament to the invaluable guidance and unwavering support provided by our co-authors, to whom we extend our deepest appreciation. Additionally, our heartfelt gratitude goes to the participants whose time and insights were generously shared, playing a pivotal role in the success of this research. Their contributions were instrumental in shaping the study's outcomes and significance. References WHO. WHO reference number: WHO/RHR/1801 . 2020; Salomon L, Alfirevic Z, Berghella V, et al. Practice guidelines for performance of the routine mid‐trimester fetal ultrasound scan. Ultrasound in Obstetrics & Gynecology . 2011;37(1):116-126. Organization WH. WHO antenatal care recommendations for a positive pregnancy experience: nutritional interventions update: multiple micronutrient supplements during pregnancy. 2020; Grandjean H, Larroque D, Levi S. The performance of routine ultrasonographic screening of pregnancies in the Eurofetus Study. 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Reducing maternal mortality: an ultrasound system for village midwives. IEEE; 2011:84-90. Schulman KA RB. Toward an effective innovation agenda. 2019;380(10):900-901. Greenfield F, Lynch M, Maharjan N, et al. Antenatal care in Nepal: a qualitative study into missed opportunities in the first trimester. 2022;2(4):100127. Oluoch DA, Mwangome N, Kemp B, et al. “You cannot know if it’sa baby or not a baby”: uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya. 2015;15(1):1-11. Ali S, Kabajaasi O, Kawooya MG, et al. Antenatal Doppler ultrasound implementation in a rural sub-Saharan African setting: exploring the perspectives of women and healthcare providers. 2021;18:1-12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 07 May, 2024 Reviews received at journal 07 May, 2024 Reviews received at journal 07 May, 2024 Reviews received at journal 30 Apr, 2024 Reviewers agreed at journal 04 Apr, 2024 Reviews received at journal 04 Apr, 2024 Reviewers agreed at journal 03 Apr, 2024 Reviewers invited by journal 03 Apr, 2024 Editor assigned by journal 01 Apr, 2024 Submission checks completed at journal 01 Apr, 2024 First submitted to journal 20 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3973396","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287205691,"identity":"e5b8767b-1f76-4109-b8ca-4d456e39fea8","order_by":0,"name":"Bushra Asif Ali Khan","email":"","orcid":"","institution":"National University of Medical Sciences (NUMS)","correspondingAuthor":false,"prefix":"","firstName":"Bushra","middleName":"Asif Ali","lastName":"Khan","suffix":""},{"id":287205692,"identity":"5f28d1ed-1620-4c9b-8f7b-54d0c84380e9","order_by":1,"name":"Jawaria Mukhtar Ahmed","email":"data:image/png;base64,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","orcid":"","institution":"Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Jawaria","middleName":"Mukhtar","lastName":"Ahmed","suffix":""},{"id":287205693,"identity":"1a188698-46ed-4ef7-8120-162855e470a6","order_by":2,"name":"Rawshan Jabeen","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Rawshan","middleName":"","lastName":"Jabeen","suffix":""},{"id":287205694,"identity":"285c3985-ff9f-49db-ab71-9a85705f3c11","order_by":3,"name":"Humaira Mahmood","email":"","orcid":"","institution":"National University of Medical Sciences (NUMS)","correspondingAuthor":false,"prefix":"","firstName":"Humaira","middleName":"","lastName":"Mahmood","suffix":""},{"id":287205695,"identity":"60541e1c-0a11-445b-ac15-9ba3ec669785","order_by":4,"name":"Muhammad Arif Khan","email":"","orcid":"","institution":"CHPE, Healthcare Administrator \u0026 Public Health Advisor, Officer Commanding PAF Hospital Lahore","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Arif","lastName":"Khan","suffix":""},{"id":287205696,"identity":"db9e3509-4174-4ede-8443-a94fcb34a7bb","order_by":5,"name":"Unaib Rabbani","email":"","orcid":"","institution":"Qassim Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Unaib","middleName":"","lastName":"Rabbani","suffix":""},{"id":287205697,"identity":"b60efb6b-7943-483a-b334-d5738dc3c8a8","order_by":6,"name":"Ameer Muhammad","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Ameer","middleName":"","lastName":"Muhammad","suffix":""}],"badges":[],"createdAt":"2024-02-20 17:06:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3973396/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3973396/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54182056,"identity":"277991d6-f9bd-4b9a-99df-c09976436eed","added_by":"auto","created_at":"2024-04-05 16:39:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":680019,"visible":true,"origin":"","legend":"\u003cp\u003eDerived framework name is Multilevel Prenatal Ultrasound Access Framework (MPUAF) with recommendation.\u003c/p\u003e","description":"","filename":"Figure1Ultrasoundpaper.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3973396/v1/c742a1f7f310acbdc7bdb3d0.jpg"},{"id":54182486,"identity":"7690a7f3-b31d-496e-8abe-0012db65d954","added_by":"auto","created_at":"2024-04-05 16:47:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434219,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3973396/v1/8fe26965-e6af-4068-a9b1-182f87f06274.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\"Missed Prenatal Ultrasounds\" unspoken issue of women having Antenatal care at Primary health care settings: A qualitative exploratory study in District Hazro, Pakistan","fulltext":[{"header":"Background","content":"\u003cp\u003e Antenatal care (ANC) is a vital component of women's health, and its importance cannot be overstated in achieving the Sustainable Development Goals (SDGs) 3.1 and 3.2 by 2030. These targets aim to reduce global maternal mortality to less than 70 per 100,000 live births and eliminate preventable deaths of newborns and children under five years of age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the broader context, the World Health Organization (WHO) recommends a minimum of four antenatal visits to improve maternal and neonatal outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Ultrasound, a key component of antenatal care, helps assess fetal development, detect abnormalities, and guide timely decisions during pregnancy. However, its widespread use faces challenges in low and middle-income settings, such as high equipment costs and a shortage of trained personnel [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWHO 2020 High income countries (HICs) recommendations advocate at least two ultrasound scans during pregnancy, one in the first trimester for confirmation and another between 18 and 22 weeks to assess the normal anatomy of the fetus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Europe, mid-trimester routine ultrasounds in ANC clinics detected around 56% of malformations and fetal anomalies before 24 weeks of gestational age [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, accessibility remains challenging in many regions, for instance, in the United States, an average of 3\u0026ndash;4 ultrasound test are conducted per pregnancy, indicating its prevalence and importance [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and further, the WHO 2013, emphasizes ultrasound as an important diagnostic test during pregnancy, advocating at least one scan before 24 weeks of pregnancy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].Studies suggest that integrating ultrasound in ANC could proactively identify complications, enabling appropriate timely referrals before labor, potentially reducing mortality rates. Despite its proven benefits, the impediments to its widespread implementation in resource-constrained settings persist [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Pakistan, the provision of adequate prenatal services remains an urgent issue and just over half of women (51%) receive care during pregnancy, and the standard of care often falls below of guidelines [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, previous studies reported many barriers that stand in the way of women living in low-income and rural regions, especially when it comes to obtaining these essential services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Factors including costly transportation, ignorance, and cultural reluctance pose significant obstacles that prevent women from accessing critical healthcare. Furthermore, the nation's general maternal care service quality is below par, which influences women's poor conduct when it comes to seeking medical attention [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. An additional barrier to the adoption of antenatal ultrasonography screening is patient and healthcare provider misinterpretation, abuse, and overuse [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Cultural resistance is another important factor. Owing to some cultural views, it is disrespectful or indecent to visualize a pregnant woman's insides or project a fetus. In order to provide comprehensive and easily available maternity healthcare for every woman in Pakistan, it is essential to tackle these complex issues [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Another study highlighted the significance of ultrasound in estimating fetal weight. They emphasized the importance of selecting an appropriate model tailored to the local population for an accurate assessment. Precision in these estimations is crucial for effective care in Pakistan [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A cluster-randomized trial suggested that the impact of introducing ultrasound during antenatal care have potential benefits of ultrasound in enhancing prenatal care and outcomes for women in underserved regions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Nevertheless, understanding how women perceive ultrasound use at the Primary Healthcare level (PHC) level is crucial. This insight helps pinpoint perceived advantages and challenges, providing valuable insights for healthcare professionals to address them effectively. This study aimed to reveal the underlying causes of noncompliance, such as cultural norms, financial constraints, or lack of awareness. Further, understanding these factors enables healthcare systems to design targeted interventions and strategies for improved compliance rates and ensure optimal utilization of ultrasound services at the Primary Healthcare levels (PHC).\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThe study prioritized rigor and trustworthiness through a multifaceted approach. To enhance rigor, various measures were implemented at different stages of the research process. Firstly, the utilization of a descriptive research design provided a systematic framework for exploring barriers faced by women in accessing prenatal ultrasound services. This methodological choice facilitated a comprehensive understanding of the phenomenon under investigation. Purposive sampling was employed to ensure the selection of 36 participants who met specific inclusion criteria presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, thereby enriching the depth and relevance of the gathered data. Additionally, the exclusion of non-pregnant women helped maintain the study's focus and relevance to the targeted research area.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants Inclusion \u0026amp; Exclusion Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEligibility Criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Pregnant women utilizing prenatal care, attending at least three antenatal visits at the respective study locations (BHU Khagwani \u0026amp; the Hazro urban area dispensary).\u003c/p\u003e \u003cp\u003e\u0026bull; Women aged 18 years and above.\u003c/p\u003e \u003cp\u003e\u0026bull; Pregnant women who willingly provided consent to take part in the research.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusion Criteria: Those who did not meet this criterion were excluded.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo enhance the depth and breadth of our insights, we employed FGDs held at BHU Khagwani and the Hazro urban area dispensary in district Attock. Our approach aimed to gather comprehensive information and provide a holistic understanding of the subject. The interview guide, initially designed in a semi-structured format by a qualitative expert, underwent revisions following pilot testing by the research team. These discussions were expertly facilitated by trained professionals, fostering open and candid conversations among participants. During interviews, which typically lasted around 60\u0026ndash;90 minutes each, recordings were made to ensure accuracy. Additionally, a note-taker was present to collect field notes, providing valuable contextual information that added depth to our dataset. This meticulous approach aimed to ensure the reliability and completeness of our findings. To ensure data rigor and thoroughness, a summary of the information was shared and discussed with the participants. The interviews were conducted in Urdu language, with subsequent translation and transcription of the four FGDs into English for analysis. Ethical considerations were paramount, with informed consent obtained from participants, and ethical approval secured from the Armed Forces Post Graduate Medical Institute (Re: 208-AAA-ERC-AFPGMI). The study strictly adhered to established ethical guidelines, notably the Declaration of Helsinki, safeguarding the rights and welfare of all participating individuals.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eConceptual Framework:\u003c/h2\u003e \u003cp\u003eWe used Multilevel Prenatal Ultrasound Access Framework (MPUAF)\" as a deductive approach with emphasis on multiple levels of influence\u0026mdash;individual, interpersonal, community and systemic\u0026mdash;pertaining to access to prenatal ultrasound services [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The framework is derived from various frameworks to provide a comprehensive structure tailored to the exploration of missed prenatal ultrasounds in resource -constrained healthcare settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eIn the thematic data analysis for this manuscript, a deductive approach was employed to systematically organize and analyze the collected data regarding reasons for missed prenatal ultrasounds in District Hazro, Pakistan. The analysis process was facilitated using NVivo 12 software. Bilingual experts proficient in the local language and English collaborated in the analysis, ensuring a nuanced understanding of the cultural context and accurate interpretation of participants' responses. The deductive approach involved pre-defined codes aligned with the study's research questions and established theoretical frameworks. These codes were systematically applied to the transcripts, allowing for the identification of patterns and themes related to reasons for missed prenatal ultrasounds. Regular discussions and consensus-building among the analysis team were conducted to ensure reliability and consistency in the interpretation of data, enhancing the credibility of the study's findings. Rigor of the study was ensured by using Lincoln- Guba framework, such as thematic coding aligned with established frameworks and involved multiple independent researchers to ensure inter-coder reliability and credibility. Regular discussions among the analysis team members facilitated consensus-building and mitigated biases. Additionally, peer debriefing sessions and an audit trail were maintained to document decisions and ensure transparency in analytical steps.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eReflexivity:\u003c/h2\u003e \u003cp\u003eThe research team engaged in reflexive practices to acknowledge and address potential biases and subjectivities that might influence the research process. Reflexivity involved continuous self-awareness among researchers regarding their assumptions, perspectives, and possible influences on data collection and analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eWe conducted a study involving thirty-six pregnant women, all residing in rural areas. The study highlights a predominant presence of joint family structures and lower levels of education among pregnant women in rural areas. Additionally, a significant portion of the participants had multiple children, suggesting varying experiences in terms of childbirth and family size.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of the study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocio demographic profile (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eType of family\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (83%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOccupation of female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEducation of female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate or read and write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCurrent Pregnancy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimigravida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than three\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the predetermined themes and corresponding sub-themes utilized for data analysis. The overarching themes encompassed individual-level factors, interpersonal factors, community-level factors, and systemic factors. A comprehensive breakdown of each theme and its associated sub-themes is elaborated upon in subsequent sections.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredefined themes and corresponding sub-theme\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual level factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited knowledge of ultrasound technology\u003c/p\u003e \u003cp\u003ePersonal beliefs\u003c/p\u003e \u003cp\u003eFinancial constraints\u003c/p\u003e \u003cp\u003eConcerns regarding ultrasound procedure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication with HCPs\u003c/p\u003e \u003cp\u003ePartner involvement \u0026amp; support\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity level factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCultural and societal norms\u003c/p\u003e \u003cp\u003eConcerns Regarding Ultrasound Procedure/Perceptions related to ultrasound use/ Stigma or taboos associated with ultrasound/ Perceptions of ultrasound's benefits and risks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHuman resource and infrastructure issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTheme I: Individual level factors:\u003c/h2\u003e \u003cp\u003eExploring these individual-level factors uncovers how these personal aspects influence a woman's decision-making process regarding seeking and utilizing prenatal ultrasound services, contributing to a comprehensive understanding of the barriers or facilitators at the individual level within the broader framework of prenatal ultrasound access.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePersonal beliefs:\u003c/h2\u003e \u003cp\u003eThe sub-theme \"Personal Beliefs\" emerged as a pivotal category, encompassing diverse codes reflecting pregnant women's individual convictions and perceptions regarding prenatal ultrasound services. The finding revealed such as perceived importance, showing, how women valued prenatal ultrasounds in monitoring fetal health and identifying potential complications.\u003c/p\u003e \u003cp\u003eDuring FGD 1, a pregnant participant, referred to as Pregnant Woman 2, emphasized the significance of ultrasounds in ensuring her baby's well-being. She expressed, \u003cem\u003e\"I've had three ultrasounds so far, and I'm seven months pregnant. I always wanted reassurance that my baby is healthy and progressing well, especially after experiencing two miscarriages and one stillbirth previously.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhile in FGD 4, Pregnant Woman 5 conveyed a sense of reassurance and emotional attachment when discussing the importance of ultrasounds. She expressed, \u003cem\u003e\"Since this is my first pregnancy, I went for an ultrasound. I feel a strong emotional connection when I see my baby on the screen, it makes me feel more bonded to my pregnancy.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn FGD 3, a pregnant participant 3 expressed skepticism regarding the necessity of ultrasounds during pregnancy. She conveyed a belief that ultrasounds are not always essential and viewed them as optional procedures. Furthermore, she articulated a lack of trust in healthcare providers (HCPs), suggesting a perception that HCPs might prescribe ultrasounds primarily for financial gain. Her statement reflected a strong reliance on her body's intuition, stating, \u003cem\u003e\"I don\u0026rsquo;t think ultrasound is always needed. I trust my body to tell me if something is wrong.\"\u003c/em\u003e This viewpoint highlights a personal conviction in her ability to sense any potential issues without relying on medical imaging procedures during pregnancy.\u003c/p\u003e \u003cp\u003eIn the same discussion, another participant, labeled Participant 6 from FGD 2, echoed a similar sentiment by stating, \u003cem\u003e\"I trust my intuitions and instincts.\"\u003c/em\u003e This concise statement highlighted a deep-seated confidence in her instincts and inner feelings, indicating a preference for relying on personal intuition in decision-making, potentially extending to matters related to prenatal care and healthcare choices.\u003c/p\u003e \u003cp\u003eDuring FGD 2, Pregnant Woman 1 expressed a perspective asserting pregnancy as a natural process. She conveyed a reluctance toward relying excessively on technology, stating \u003cem\u003ethat \u0026ldquo;undergoing ultrasounds might foster an undue dependency on technology\u0026rdquo;\u003c/em\u003e. Additionally, she highlighted concerns about the potential for ultrasounds to induce unnecessary anxiety, expressing a desire to focus solely on the emotions and experience of motherhood. Other participant from FGD 4 pregnant woman 6 shared her views, suggesting that \u003cem\u003e\u0026ldquo;ultrasounds are often perceived as a means to determine the baby's gender\u0026rdquo;.\u003c/em\u003e They indicated societal pressures, mentioning instances where families insist on ultrasounds to know the baby's gender for the purpose of planning and shopping accordingly. Moreover, these participants highlighted situations where females might feel compelled to undergo ultrasounds due to familial expectations to fulfill specific gender preferences, potentially influencing family size and dynamics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eLimited knowledge about ultrasound\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThis sub-theme illuminated the widespread knowledge deficit surrounding prenatal ultrasounds among participants. Their understanding varied greatly, ranging from incomplete information to outright misconceptions about the purpose, importance, and implications of these scans. Exploring this sub-theme provided valuable insights into the diverse perspectives and levels of awareness among participants concerning the use and impact of ultrasounds in the context of prenatal care.\u003c/p\u003e \u003cp\u003eWhen questioned about their understanding of ultrasound and its relevance in pregnancy, Pregnant Woman 2 from FGD 1 expressed a viewpoint considering \u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eultrasound as an unnecessary intervention\u003c/span\u003e\u0026rdquo;, citing that, \u003cem\u003e\u0026ldquo;it tends to induce anxiety among expecting mothers\u003c/em\u003e\u0026rdquo;. On the other hand, another pregnant women 3 from FGD 3 conveyed uncertainty regarding the widespread need for ultrasounds, expressing, \u003cem\u003e\"I don\u0026rsquo;t know why everyone needs ultrasound; it seems necessary only in complex pregnancies or for females experiencing recurrent miscarriages.\"\u003c/em\u003e She added further, \u003cem\u003e\"Ultrasound releases harmful radiation, which isn't safe for the baby. That's why expecting mothers should limit unnecessary exposure to these radiations.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAmidst a landscape of limited knowledge about ultrasounds in focus group 4, one pregnant woman 5 understanding stood out. She confidently explained the value of ultrasounds in \u0026ldquo;monitoring a baby's heartbeat, size, and overall growth\u0026rdquo;. When asked how she learned this, she credited her healthcare provider. \"\u003cem\u003eMy doctor told me this multiple times during antenatal visits, really emphasizing its importance\u003c/em\u003e,\" she explained. Notably, she further shared that, \u003cem\u003e\u0026ldquo;ultrasounds can reveal potential issues like a lack of heartbeat or delayed growth, which, if identified, might necessitate prompt pregnancy termination to safeguard both mother and baby from potential health complications\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMost participants of FGDs mentioned that they did not have a set schedule for ultrasounds during their pregnancies. Instead, they underwent one or two scans based on the necessity arising from the baby's condition. Doctors usually advise having an ultrasound scan sometime between the first and fourth months of pregnancy. However, participants often chose to schedule these scans based on their convenience rather than following this suggested timeline. During the discussions (FGDs 1\u0026ndash;4), participants mentioned that \u003cem\u003e\u0026ldquo;their doctors suggested having ultrasounds in the first and fourth months of pregnancy. However, they didn't consider it urgent and chose to delay these scans. Instead, they decided to have the ultrasounds during later visits or whenever it was convenient for them\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis decision to postpone the scans might indicate a lack of immediate concern or perceived urgency about the suggested timing for ultrasounds during specific stages of pregnancy as advised by their doctors.\u003c/p\u003e \u003cp\u003eThis suggests that there's a lack of adherence to a structured ultrasound schedule recommended by healthcare professionals. Instead, participants arranged scans based on their own perceived need. This approach might result in variations in the timing of important scans, especially during the early stages of pregnancy.\u003c/p\u003e \u003cp\u003eDuring FGD 3, a woman shared a distressing experience by stating, \u0026ldquo;\u003cem\u003eI missed the chance for an anomaly scan because of a delay caused by insufficient information\u0026rdquo;.\u003c/em\u003e Sadly, healthcare professionals didn't advise her in time, revealing a significant lack of their support.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eFinancial constraints\u003c/h2\u003e \u003cp\u003eThis sub-theme encapsulated the various financial challenges and limitations faced by participants when accessing ultrasound services during pregnancy. Exploring this sub-theme sheds light on the impact of financial constraints, which hindered participants' ability to access and afford essential ultrasound services, ultimately affecting their prenatal care experiences.\u003c/p\u003e \u003cp\u003eMany women expressed their \u003cem\u003eintention to use the ultrasound system at the Primary Healthcare level (PHC) for diagnostic purposes.\u003c/em\u003e They explained that the lack of maintenance in the public sector caused this issue with the equipment. As a result, their doctors advised them to go to private hospitals, which came with significant costs. This situation caused delays in getting important tests done within the required time. The unreliable public healthcare system's machinery created financial barriers, forcing women to opt for expensive alternatives and causing delays in their diagnostic processes.\u003c/p\u003e \u003cp\u003eParticipants across all four FGDs shared a similar feeling: \u003cem\u003e\"Managing expenses is tough, but our health is crucial, and seeking medical care is the only viable choice.\"\u003c/em\u003e This indicates their understanding of the financial challenges but emphasizes the importance they place on health; despite the difficulties they encounter in paying for necessary healthcare.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme II: Interpersonal factors\u003c/h2\u003e \u003cp\u003eInterpersonal factors refer to the influence of social relationships, interactions, and communication among individuals within the context of accessing prenatal ultrasound services. This theme explores the interpersonal relationships and interactions that influenced participants' perspectives, decisions, and experiences regarding prenatal ultrasound services, highlighting the role of communication and social influences in shaping their choices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCommunication with healthcare providers:\u003c/h2\u003e \u003cp\u003eWhen asked about how healthcare providers communicate the importance of ultrasounds, participants had mixed responses. Participants from FGD 2 and 4 mentioned that their doctors and antenatal nurses were attentive listeners, addressing all their concerns and making them feel heard and comfortable. They specifically highlighted that \u003cem\u003e\u0026ldquo;these healthcare professionals listened to our worries and provided clear explanations, which significantly improved our understanding of ultrasound scans\u0026rdquo;.\u003c/em\u003e This positive communication experience enhanced their comprehension of the importance of undergoing ultrasound examinations during pregnancy.\u003c/p\u003e \u003cp\u003eParticipants from FGD 1 and 3 mentioned that \u003cem\u003e\u0026ldquo;their antenatal care providers do listen to them, but they often feel rushed during appointments.\u0026rdquo;\u003c/em\u003e Due to a large number of patients waiting in the lounge, the healthcare providers sometimes suggest discussing queries outside the ultrasound room.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePartner involvement \u0026amp; support:\u003c/h2\u003e \u003cp\u003eOverall, the sub-theme emphasizes the crucial role of partners in the decision-making process, their emotional support, and their involvement in discussions regarding ultrasounds, highlighting the impact of their presence and support on the pregnant woman's ultrasound experience and decision-making.\u003c/p\u003e \u003cp\u003eAlthough family members and husbands possess a good understanding of pregnant women's experiences, a lasting concern exists regarding the safety of ultrasound procedures and their possible connection to miscarriages. This worry stems from a prevalent misconception or fear within the family and among husbands about the safety of these imaging techniques. As a result, it acts as a barrier, preventing their complete support for pregnant women undergoing ultrasounds during pregnancy.\u003c/p\u003e \u003cp\u003eDuring FGD 1, a participant shared, \u003cem\u003e\"I can visit the ANC only when I'm unwell, and I'm always accompanied by my mother-in-law or other family members for support. However, if the doctor recommends an ultrasound test, I need to call and ask for permission from my husband.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis means that while she has some freedom to seek care when feeling unwell, decisions about undergoing ultrasounds specifically require her husband's approval, indicating a different level of decision-making authority in her pregnancy care.\u003c/p\u003e \u003cp\u003eDuring FGD 3, one participant mentioned \u003cem\u003e\u0026ldquo;her doctor referred her to a specialized hospital for an advanced scan due to concerns about potential genetic issues in her child.\u0026rdquo;\u003c/em\u003e This referral suggests the necessity for a detailed examination to thoroughly evaluate and potentially identify any genetic conditions or abnormalities in the baby.\u003c/p\u003e \u003cp\u003eDuring FGD 4, a participant mentioned that \u003cem\u003e\"the doctor recommended a Doppler ultrasound at another hospital, despite the cost, stressing the importance of checking for potential illnesses in the child. \"\u003c/em\u003e She further said, \u003cem\u003e\"My partner expects me to follow doctor's orders without question.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe participant followed the doctor's advice, accompanied by her husband, highlighting their shared concern for their child's health. This instance underscores the participant's commitment to prioritizing the doctor's recommendation for the Doppler ultrasound, despite the expense, showing a deep care for their child's well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme III: Community level factors\u003c/h2\u003e \u003cp\u003eThis theme explores societal attitudes towards pregnancy and healthcare, prevailing cultural beliefs regarding ultrasound safety or necessity, and the influence of community members, such as family, friends, or community elders, in shaping perceptions about ultrasounds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConcerns Regarding Ultrasound Procedure\u003c/h2\u003e \u003cp\u003eThe women in the community expressed fear and reluctance towards undergoing ultrasound procedures early in their pregnancies, preferring to visit the ANC clinic after the third month instead. Most of the pregnant women mentioned that \u003cem\u003e\u0026ldquo;while most women typically go through the initial months or trimesters of pregnancy, they hadn't personally encountered this\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTheir hesitation seemed to stem from a belief held by a few participants that \u003cem\u003e\u0026ldquo;ultrasound or x-ray procedures could potentially harm the health and growth of the child\u0026rdquo;\u003c/em\u003e. This perception contributed to their reluctance to undergo these scans during the early stages of pregnancy.\u003c/p\u003e \u003cp\u003eThis reluctance to engage with ultrasound procedures at the onset of pregnancy, coupled with a preference to seek ANC care later, highlights a significant barrier in their approach to prenatal health. The fear and misconception surrounding the perceived harms of ultrasound or x-rays impacted their decision-making about when to initiate prenatal care and undergo necessary medical procedures.\u003c/p\u003e \u003cp\u003eDuring FGD 2, a participant mentioned that \u003cem\u003e\u0026ldquo;her mother-in-law strongly suggested keeping the pregnancy confidential until three months, fearing that an early ANC clinic visit might involve an ultrasound, which she believed could lead to a miscarriage.\u0026rdquo;\u003c/em\u003e This advice exposes a prevalent misconception within society and family circles about the safety of early ultrasounds during pregnancy. It underscores the existence of myths and misunderstandings regarding the potential risks associated with undergoing ultrasounds in the early stages, contributing to the delay in seeking crucial prenatal care.\u003c/p\u003e \u003cp\u003eDuring FGD 4, a participant expressed the belief that \u003cem\u003e\u0026ldquo;X-rays aren't helpful for a child's growth\u0026rdquo;\u003c/em\u003e. This viewpoint highlights a common misunderstanding among some people that procedures like X-rays, and sometimes even ultrasounds, might negatively impact a child's development during pregnancy. This misconception often leads to fear and hesitation among expectant mothers when it comes to undergoing these imaging procedures, even though they're essential for monitoring the baby's health and growth. The concern specifically relates to myths and misconceptions surrounding X-rays and their potential effects during pregnancy, contributing to apprehension about these medical imaging procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCultural \u0026amp; Societal Norms\u003c/h2\u003e \u003cp\u003eAccording to a participant in FGD 1, in her community, \u003cem\u003e\u0026ldquo;women who opt for ultrasounds are viewed as neglecting their babies.\u0026rdquo;\u003c/em\u003e This perception sheds light on the societal attitude prevalent in her community, where seeking ultrasounds might be seen as neglectful or unnecessary care for the unborn child.\u003c/p\u003e \u003cp\u003eConversely, participants in FGD 3 expressed a different perspective. They shared that \u003cem\u003e\u0026ldquo;their families anticipate at least one ultrasound to confirm the pregnancy.\u0026rdquo;\u003c/em\u003e This view highlights the contrasting societal expectation within their families, emphasizing the importance placed on undergoing at least one ultrasound for pregnancy confirmation. This suggests variations in community perceptions regarding the necessity or neglectfulness of ultrasounds during pregnancy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme IV Systemic factors:\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eHuman resource and infrastructure issues\u003c/h2\u003e \u003cp\u003ePregnant women shared their challenges in accessing ultrasound services within the community. They mentioned that doctors were available at the facility for scans only a few days per week, leaving technicians responsible for conducting the tests. This led to longer waiting times to complete their examinations.\u003c/p\u003e \u003cp\u003eDuring FGD 2, A participant mentioned that \u003cem\u003e\u0026ldquo;Most doctors were unavailable, so we had to wait for them\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFurthermore, the lack of sufficient restroom facilities and access to water made the women feel uncomfortable during their visits. The combination of limited doctor availability, reliance on technicians, and inadequate amenities at the facility created a less-than-ideal experience for women seeking ultrasounds.\u003c/p\u003e \u003cp\u003eDuring FGD 4, \u003cem\u003e\u0026ldquo;Participants decided against undergoing the test at the ultrasound room due to extended waiting periods and the unavailability of a clean restroom\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis prolonged their waiting periods and negatively impacted their overall comfort and convenience during these important medical appointments.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAccessibility and availability of the services:\u003c/h2\u003e \u003cp\u003eThe subtheme within systemic factors pertains to the difficulties women face when trying to access ultrasound services in healthcare settings. It covers challenges related to physically reaching these facilities, the availability of services when needed, and the logistical barriers that pregnant women encounter in obtaining ultrasound examinations. This subtheme highlights the struggles women undergo to physically reach healthcare centers providing ultrasounds and the issues they face regarding the timing and availability of these essential services.\u003c/p\u003e \u003cp\u003eWhen asked about clinic timings, every participant from all FGDs mentioned that \u003cem\u003e\u0026ldquo;Primary Healthcare level (PHC)s (BHUs) offered basic ultrasound services only from 9 am to 2 pm. However, they frequently experienced issues with the machine being out of order, leading to delays in getting it repaired, sometimes taking days or even weeks. This situation compelled them to seek fetal anomaly scans at private clinics, which posed financial burdens. The process involved visiting a doctor first to get a referral for the ultrasound and then scheduling the appointment, often requiring accompaniment by their husband or mother-in-law. If these family members weren't available, it would have caused further delays in accessing the ultrasound services\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePrimary Healthcare level (PHC)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found a variety of hurdles to women's access to ultrasonography services in primary care. It proposes focused interventions that focus on staff training, increasing facility support, and addressing financial constraints in order to improve the accessibility and utilization of ultrasound scans among pregnant women visiting Primary Health Care institutions. However, participants lacked awareness regarding the frequency and scheduling of these scans. A similar study reported that 93.5% of women recognized the necessity of ultrasound scans but were uncertain about the ideal timing, feeling it should occur at least twice during pregnancy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our findings revealed that women had fears about undergoing ultrasounds during the first trimester, mirroring results from another study where 95% of women admitted that ultrasounds contributed to their anxieties about fetal health [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This emphasizes the necessity for healthcare providers to address and alleviate concerns surrounding early trimester ultrasounds, ensuring that expectant mothers feel more comfortable and informed about this essential aspect of prenatal care. Traditionally, cost has been seen as the main barrier to widespread adoption of medical technology and Lack of training is identified as a major impediment to the routine use of ultrasonography in poor countries by health care providers. Equipment requirements, including maintenance and machine costs, are also key issues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, the reality is more nuanced [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A standard ultrasound machine is both expensive and bulky, taking up the space of a refrigerator and costing around \u003cspan\u003e$\u003c/span\u003e19,000 directly [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our study emphasized the importance of addressing equipment maintenance issues to ensure quality care at primary healthcare (PHC) levels.\u003c/p\u003e \u003cp\u003eMissed prenatal ultrasound is a common issue in LMICs such as a study in Nepal found that the women has no knowledge of ultrasound who received ANC clinics [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Only 6% of the women received prenatal ultrasound in rural South Africa [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Another study in Kenya found that uncertainty regarding pregnancy status linked to delays in ANC attendance; more than 78% of women were more than 20 weeks pregnant at their initial visit. Healthcare staff found it difficult to detect pregnancies below 16 weeks' gestation, and reliable assessment of gestational age below 20 weeks' gestation may be challenging [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The provision of services relies on detecting the pregnancy and determining the gestational age. Healthcare providers were unfamiliar with Doppler technology and its use to guide clinical decisions but due to shortage of educated local staff, inadequate equipment, a lengthy distance to and from the hospital, and frequent power outages [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This highlights the significance of not only technological aspects but also the need for support systems that enable effective utilization of these technologies in remote or resource-limited areas. Improving communication channels and support networks can enhance the practicality and effectiveness of portable scanning tools in the hands of healthcare workers in such settings. This qualitative study centered on the perceptions and experiences of mothers visiting primary healthcare centers. However, to bolster the findings, incorporating viewpoints from healthcare providers and management would add depth. Additionally, these findings help to understand mothers' profiles could augment community-based data by providing a more structured and measurable foundation for understanding the challenges, needs, and characteristics of mothers within a community. Furthermore, in future the data-driven approach can lead to more targeted and effective interventions, policy changes, and community programs. Primary Healthcare level (PHC) Expanding the Sehat Sahulat national insurance system to cover antenatal ultrasound scans at private clinics could alleviate the financial burden on the community. This comprehensive approach aims to enhance ANC services, increase access to essential ultrasound screenings, and ease financial strains for pregnant women in resource-limited settings.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eThe study identified challenges faced by women at primary healthcare (PHC) levels, where caregivers often struggle to provide sufficient counseling on the importance of ultrasound scans for fetal growth. Many women lacked awareness about the significance of ultrasounds and had limited understanding about their safety compared to x-rays. Several factors contributed to the underutilization of ultrasounds at PHC levels, including insufficient awareness, fears about the procedure, decision-making delays, facility-related issues, and budget constraints. To address these gaps, the report recommends integrating ultrasound training into primary healthcare professionals' curricula. It also suggests allocating more resources to lower-level healthcare facilities to establish functional ultrasound services and extending coverage through national insurance programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthical consideration\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u0026amp; consent to participate:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research presented in this manuscript received ethical approval from the Ethical Review Committee of the Armed Forces Post Graduate Medical Institute under the reference number 208-AAA-ERC-AFPGMI. Prior to enrollment in the study, written informed consent was obtained from all participants. The consent process involved a comprehensive explanation of the study\u0026apos;s background, rationale, as well as the associated advantages and disadvantages to the mothers. It is important to note that throughout the entire research process, adherence to ethical principles was maintained in accordance with the guidelines outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for Publication:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of Interest:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no compelling interest.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors Contribution:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBK was the Principal Investigator (PI) who conceptualized the study and was involved in study design; BK, HM, and JMA designed the study protocol and obtained IRB approval. BK, JMA, and HM were involved in formulating the study methodology, developing study tools, and finalizing the data analysis plan; JMA, RJ and UJ were involved in article writing. BK and HM conducted a review of the literature and were involved in reviewing and editing the study tools. JMA, AM, UR and RJ were involved in editing manuscripts. All authors reviewed the manuscript several times and provided critical feedback. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgement:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study stands as a testament to the invaluable guidance and unwavering support provided by our co-authors, to whom we extend our deepest appreciation. Additionally, our heartfelt gratitude goes to the participants whose time and insights were generously shared, playing a pivotal role in the success of this research. Their contributions were instrumental in shaping the study\u0026apos;s outcomes and significance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. \u003cem\u003eWHO reference number: WHO/RHR/1801\u003c/em\u003e. 2020;\u003c/li\u003e\n\u003cli\u003eSalomon L, Alfirevic Z, Berghella V, et al. Practice guidelines for performance of the routine mid‐trimester fetal ultrasound scan. \u003cem\u003eUltrasound in Obstetrics \u0026amp; Gynecology\u003c/em\u003e. 2011;37(1):116-126. \u003c/li\u003e\n\u003cli\u003eOrganization WH. WHO antenatal care recommendations for a positive pregnancy experience: nutritional interventions update: multiple micronutrient supplements during pregnancy. 2020;\u003c/li\u003e\n\u003cli\u003eGrandjean H, Larroque D, Levi S. The performance of routine ultrasonographic screening of pregnancies in the Eurofetus Study. \u003cem\u003eAmerican journal of obstetrics and gynecology\u003c/em\u003e. 1999;181(2):446-454. \u003c/li\u003e\n\u003cli\u003eWastlund D, Moraitis AA, Dacey A, Sovio U, Wilson EC, Smith GC. Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis. \u003cem\u003ePLoS medicine\u003c/em\u003e. 2019;16(4):e1002778. \u003c/li\u003e\n\u003cli\u003eFinlayson K, Downe SJPm. Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies. 2013;10(1):e1001373. \u003c/li\u003e\n\u003cli\u003eLaGrone LN, Sadasivam V, Kushner AL, Groen RS. A review of training opportunities for ultrasonography in low and middle income countries. \u003cem\u003eTropical Medicine \u0026amp; International Health\u003c/em\u003e. 2012;17(7):808-819. \u003c/li\u003e\n\u003cli\u003eFranklin HL, Mirza W, Swanson DL, et al. Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries. \u003cem\u003eReproductive health\u003c/em\u003e. 2018;15(1):204. \u003c/li\u003e\n\u003cli\u003eAsim M, Saleem S, Ahmed ZH, et al. We won\u0026rsquo;t go there: barriers to accessing maternal and newborn care in District Thatta, Pakistan. MDPI; 2021:1314.\u003c/li\u003e\n\u003cli\u003eMalik M, Prescott K, Khalid M, Hashmi A, Kiani AJJoPP, Practice. Expectations and experiences of women regarding maternal healthcare services in Pakistan: challenges and lessons to be learnt. 2021;14(1):1-9. \u003c/li\u003e\n\u003cli\u003eKim ET, Singh K, Moran A, Armbruster D, Kozuki NJRh. Obstetric ultrasound use in low and middle income countries: a narrative review. 2018;15:1-26. \u003c/li\u003e\n\u003cli\u003eSwanson D, Lokangaka A, Bauserman M, et al. Challenges of implementing antenatal ultrasound screening in a rural study site: a case study from the Democratic Republic of the Congo. 2017;5(2):315-324. \u003c/li\u003e\n\u003cli\u003eIbrahimi J, Mumtaz ZJIJoG, Obstetrics. Ultrasound imaging and the culture of pregnancy management in low‐and middle‐income countries: A systematic review. 2023;\u003c/li\u003e\n\u003cli\u003eMunim S, Figueras F, Shah SM, Khan F, Gardosi JJJoO, Research G. Ultrasound estimation of fetal weight: a formula for a Pakistani population. 2010;36(3):479-483. \u003c/li\u003e\n\u003cli\u003eMcClure EM, Nathan RO, Saleem S, et al. First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings. 2014;14(1):1-8. \u003c/li\u003e\n\u003cli\u003eAwiti JOJHer. A multilevel analysis of prenatal care and birth weight in Kenya. 2014;4(1):1-16. \u003c/li\u003e\n\u003cli\u003eCurci SG, Luecken LJ, Hern\u0026aacute;ndez JC, Winstone LK, Perez MJHP. Multilevel prenatal socioeconomic predictors of Mexican American children\u0026rsquo;s cardiometabolic health in preschool and school age. 2023;42(11):788. \u003c/li\u003e\n\u003cli\u003eMunim S, Khawaja N, Qureshi RJJoPMA. Knowledge and awareness of pregnant women about ultrasounsd scanning and prenatal diagnosis. 2004;54(11):553. \u003c/li\u003e\n\u003cli\u003ePatterson K. An exploration of the parental experience of diagnosis of foetal abnormalities during routine antenatal ultrasound screening. 2023;\u003c/li\u003e\n\u003cli\u003eEnsor T, Cooper SJHp, planning. Overcoming barriers to health service access: influencing the demand side. 2004;19(2):69-79. \u003c/li\u003e\n\u003cli\u003eBrunette W, Hicks M, Hope A, Ruddy G, Anderson RE, Kolko B. Reducing maternal mortality: an ultrasound system for village midwives. IEEE; 2011:84-90.\u003c/li\u003e\n\u003cli\u003eSchulman KA RB. Toward an effective innovation agenda. 2019;380(10):900-901. \u003c/li\u003e\n\u003cli\u003eGreenfield F, Lynch M, Maharjan N, et al. Antenatal care in Nepal: a qualitative study into missed opportunities in the first trimester. 2022;2(4):100127. \u003c/li\u003e\n\u003cli\u003eOluoch DA, Mwangome N, Kemp B, et al. \u0026ldquo;You cannot know if it\u0026rsquo;sa baby or not a baby\u0026rdquo;: uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya. 2015;15(1):1-11. \u003c/li\u003e\n\u003cli\u003eAli S, Kabajaasi O, Kawooya MG, et al. Antenatal Doppler ultrasound implementation in a rural sub-Saharan African setting: exploring the perspectives of women and healthcare providers. 2021;18:1-12. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnant women, Ultrasound, Primary Health Care, and Antenatal care","lastPublishedDoi":"10.21203/rs.3.rs-3973396/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3973396/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis qualitative study aimed to explore women's experiences and perceptions regarding barriers to accessing ultrasound scans at \u003cb\u003eprimary healthcare level.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAltogether, four focus group discussions (FGDs) involving 36 pregnant women who had received prenatal care at facilities between February and September 2021 were conducted. Using a purposive sampling technique participants provided informed consent before data collection during guided FGDs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResult\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThematic analysis of the data using NVivo 12 revealed recurring themes explaining underutilization of ultrasound scans at this level of healthcare. The study highlighted challenges faced by women at primary health care facilities, emphasizing the potential gaps in caregivers' ability to provide comprehensive counseling about the importance and safety of ultrasound scans in fetal growth monitoring. Addressing staff training and accountability emerged as essential areas requiring attention. Additionally, allocating more resources to alleviate financial burdens associated with accessing ultrasound services was a key recommendation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn conclusion, this study revealed diverse barriers hindering women's access to ultrasound services at \u003cem\u003eprimary healthcare\u003c/em\u003e. It suggests targeted interventions focusing on staff training, improving facility support, and addressing financial constraints to enhance accessibility and utilization of ultrasound scans among pregnant women attending Primary Health Care facilities.\u003c/p\u003e","manuscriptTitle":"\"Missed Prenatal Ultrasounds\" unspoken issue of women having Antenatal care at Primary health care settings: A qualitative exploratory study in District Hazro, Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-05 16:39:11","doi":"10.21203/rs.3.rs-3973396/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-07T08:24:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-07T08:23:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-07T08:22:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-30T19:45:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7e6b67c6-d279-4e70-9412-55ee37fcfa7d","date":"2024-04-04T14:02:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-04T06:38:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b2dc6d45-fa36-4220-947f-6e25c501de6e","date":"2024-04-04T01:28:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-03T16:27:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-01T09:23:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-01T09:23:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2024-02-20T16:40:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5cd8e933-a749-4796-abee-e20b3e9a572b","owner":[],"postedDate":"April 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2024-07-30T05:32:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-05 16:39:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3973396","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3973396","identity":"rs-3973396","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}