title: Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study.
abstract: BACKGROUND
  Pakistan has alarmingly high numbers of maternal mortality along with suboptimal care-seeking behaviour. It is essential to identify the barriers and facilitators that women and families encounter, when deciding to seek maternal care services. This study aimed to understand health-seeking patterns of pregnant women in rural Sindh, Pakistan.
  
  
  METHODS
  A qualitative study was undertaken in rural Sindh, Pakistan as part of a large multi-country study in 2012. Thirty three focus group discussions and 26 in-depth interviews were conducted with mothers [n = 173], male decision-makers [n = 64], Lady Health Workers [n = 64], Lady Health Supervisors [n = 10], Women Medical Officers [n = 9] and Traditional Birth Attendants [n = 7] in the study communities. A set of a priori themes regarding care-seeking during pregnancy and its complications as well as additional themes as they emerged from the data were used for analysis. Qualitative analysis was done using NVivo version 10.
  
  
  RESULTS
  Women stated they usually visited health facilities if they experienced pregnancy complications or danger signs, such as heavy bleeding or headache. Findings revealed the importance of husbands and mothers-in-law as decision makers regarding health care utilization. Participants expressed that poor availability of transport, financial constraints and the unavailability of chaperones were important barriers to seeking care. In addition, private facilities were often preferred due to the perceived superior quality of services.
  
  
  CONCLUSIONS
  Maternal care utilization was influenced by social, economic and cultural factors in rural Pakistani communities. The perceived poor quality care at public hospitals was a significant barrier for many women in accessing health services. If maternal lives are to be saved, policy makers need to develop processes to overcome these barriers and ensure easily accessible high-quality care for women in rural communities.
  
  
  BACKGROUND
  NCT01911494.
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan. rahat.qureshi@aku.edu.
authors.forename: Rahat Najam
authors.initials: RN
authors.lastname: Qureshi
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.
authors.forename: Sana
authors.initials: S
authors.lastname: Sheikh
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.|Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Asif Raza
authors.initials: AR
authors.lastname: Khowaja
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.
authors.forename: Zahra
authors.initials: Z
authors.lastname: Hoodbhoy
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.
authors.forename: Shujaat
authors.initials: S
authors.lastname: Zaidi
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Sawchuck
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Marianne
authors.initials: M
authors.lastname: Vidler
authors.affiliation: Division of Women & Child Health, Aga Khan University, Karachi, Pakistan.|Program for Global Pediatric Research, Hospital for Sick Children, Toronto, Canada.
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.affiliation: Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: von Dadeslzen
mesh_terms: D000328:Adult; D003657:Decision Making; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D010154:Pakistan; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000517:prevention & control*; D036301:Qualitative Research; D012424:Rural Population; D012959:Socioeconomic Factors
keywords: Antenatal care; Associated factors; Health facilities; Health seeking behaviour; Pakistan; Patient acceptance of health care; Pregnancy; Pregnancy complications