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Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study Qureshi, Rahat N; Sheikh, Sana; Khowaja, Asif R; Hoodbhoy, Zahra; Zaidi, Shujaat; Sawchuck, Diane; Vidler, Marianne; Bhutta, Zulfiqar A; von Dadeslzen, Peter Jun 8, 2016

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RESEARCH Open AccessHealth care seeking behaviours inpregnancy in rural Sindh, Pakistan:a qualitative studyRahat Najam Qureshi1*, Sana Sheikh1, Asif Raza Khowaja1,2, Zahra Hoodbhoy1, Shujaat Zaidi1, Diane Sawchuck2,Marianne Vidler2, Zulfiqar A. Bhutta1,3, Peter von Dadeslzen2 and CLIP Working GroupAbstractBackground: Pakistan has alarmingly high numbers of maternal mortality along with suboptimal care-seekingbehaviour. It is essential to identify the barriers and facilitators that women and families encounter, when decidingto seek maternal care services. This study aimed to understand health-seeking patterns of pregnant women in ruralSindh, 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], maledecision-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 regardingcare-seeking during pregnancy and its complications as well as additional themes as they emerged from thedata 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 ordanger signs, such as heavy bleeding or headache. Findings revealed the importance of husbands andmothers-in-law as decision makers regarding health care utilization. Participants expressed that poor availability oftransport, 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.Conclusion: Maternal care utilization was influenced by social, economic and cultural factors in rural Pakistanicommunities. The perceived poor quality care at public hospitals was a significant barrier for many women inaccessing health services. If maternal lives are to be saved, policy makers need to develop processes to overcomethese barriers and ensure easily accessible high-quality care for women in rural communities.Trial Registration: NCT01911494Keywords: Health seeking behaviour, Pregnancy, Antenatal care, Associated factors, Pakistan, Health facilities, Patientacceptance of health care, Pregnancy complications* Correspondence: rahat.qureshi@aku.edu1Division of Women & Child Health, Aga Khan University, Karachi, PakistanFull list of author information is available at the end of the article© 2016 Qureshi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Qureshi et al. Reproductive Health 2016, 13(Suppl 1):34DOI 10.1186/s12978-016-0140-1BackgroundAppropriate and timely care seeking is essential forhealthy outcomes for individuals and communities [1].Understanding health seeking behaviour in a communityis necessary for the development of appropriate healthpolicies, health systems and educational strategies to fa-cilitate access. The decision to seek care is complex anddriven by many determinants [1]. The behaviour maydiffer depending on the nature of the complaint as wellas the social circumstances of the patient [2].Behavioural models can be used to illustrate the dy-namics of the individual, community and care providersin such decisions [1]. Andersen’s behavioural model de-scribes three categories of determinants at play in healthcare decision making: predisposing characteristics, enab-ling characteristics, and need [1]. Predisposing character-istics include the individual’s demographics, their socialstructure as well as their beliefs regarding the benefits ofhealth services. Enabling characteristics encompass per-sonal and community resources that encourage usage ofhealth services. Finally, the third category relates to theperceived and actual need for services.Theories used to explain health care utilization assumethat the recognition of symptoms suggests illness; how-ever, in regions with poor living conditions such astemperature extremes, lack of potable water and fuel,women’s perception of feeling unwell may be unique [3],particularly when they have low social status and theirsense of ‘feeling unwell’ may not be validated by familymembers [4].During pregnancy, the choice of provider and facility isoften dependent on women’s social and physical environ-ment. Women with greater autonomy, which is measuredby control over finances, decision making power and free-dom of movement, have a greater preponderance foraccessing care during pregnancy [5]. Health services maybe accessed for routine antenatal care, for delivery, fortreatment, or emergencies.The Pakistan Demographic and Health Survey (PDHS)2006–07 revealed that only 65 % of women seek routinecare during pregnancy, and amongst these, 4 % seek careoutside the formal health system. Sixty five percent ofwomen delivered at home, and only 39 % of deliveriestook place in presence of a skilled birth attendant (doc-tor, nurse, midwife or lady health visitor) [6]. Postpartumcare was less common than antenatal care (43 vs. 61 %respectively) [6].Pakistan is the 6th most populous country and giventhe current fertility rate it is likely to maintain this pos-ition [7]. Overall 65 % of the population resides in ruralareas. Many have limited education and only 24 % ofwomen and 65 % of men have formal education. Inaddition, household conditions are often substandard,where only 22 % of households have piped water, and88 % of households have no latrine connected to a pipedsewerage system. Living conditions are particularly chal-lenging in Sindh province where average temperaturesare 30–40 °C [8].Most rural homes are at least 10 km from the districthospital or maternal and child health centre. The mostreadily available health care providers in these commu-nities are traditional birth attendants (TBA), alternativemedicine practitioners or pharmacists [6]. The healthcare system of Pakistan comprises of public and privatesectors. The public sector delivers services at the pri-mary, secondary and tertiary level. The primary levelincludes rural health centres, basic health units, primaryhealth care centres, dispensaries, first aid posts, motherand child health centres, and community health workersknown as Lady Health Workers (LHW). The secondarylevel includes the district and Tehsil Headquarter hospi-tals whereas the tertiary level care is delivered throughthe teaching hospitals. The private sector consists ofallopathic as well spiritual/traditional healers [9].Pakistan has been unable to achieve a substantial re-duction in the maternal mortality ratio (MMR), theWorld Health Organization (WHO) estimated the MMRin Pakistan at 260 deaths per 100,000 live births [10].Although there has been progress in the reduction ofmaternal mortality, trends indicate that Pakistan lagsbehind many South Asian countries. Haemorrhage, pre-eclampsia and puerperal sepsis account for 57 % ofmaternal deaths in Pakistan [6, 7]. The vast majority ofthese deaths could be prevented through access to basicantenatal care services [10]. Inadequate access andunder-utilization of the health care system are major fac-tors for poor health indicators of developing countries[10]. These numbers reflect the suboptimal care seekingbehaviour during pregnancy in Pakistani women.The aim of this study was to assess the perception ofpregnant women and their families regarding healthseeking behavior during pregnancy and its complica-tions, and to evaluate the barriers and facilitators duringthis process.MethodsA qualitative study was undertaken between February-July2012 in Pakistan, as part of a large multi-country study, adetailed description of the methods has been published.This study served as the formative research for an upcom-ing international trial, Community Level Interventions forPre-eclampsia (CLIP) (NCT01911494) [11]. This studywas conducted in two districts, Matiari and Hyderabad,where 23 % of the population of Sindh province resides.Hyderabad is located on the east bank of the Indus River,and contains the second largest city in Sindh province,while Matiari is a rural district located 25 km north fromHyderabad. Over 90 % of the population is Muslim, andQureshi et al. Reproductive Health 2016, 13(Suppl 1):34 Page 76 of 97Sindhi is the main dialect. The provincial literacy rate is40 % (25 % male and 15 % female), and nearly half of thepopulation is engaged in the agricultural sector [12].Data was collected through 33 focus group discussionsand 26 one-to-one in-depth interviews. Purposive samplingwas used during regular household visits and communityactivities to identify married women of reproductive ageand male decision-makers,. Male decision-makers includedhusbands, teachers, religious leaders, and communityleaders. Traditional Birth Attendants (TBA) were few innumber and were identified through snowball sam-pling. Lady Health Workers (LHWs) and Lady HealthSupervisors (LHS) were identified through the officeof the National LHWs Programme. LHS were selectedthrough contact lists and were recruited at theirmonthly meetings. Woman Medical Officers (WMO)were identified and approached during visits to healthfacilities in the study catchment areas.Participants were considered eligible, if they expressedwillingness to participate in the study and were availablefor at least 60 min. All study participation was voluntary,and the background and purpose of the study wereexplained prior to obtaining consent. Participant charac-teristics are enumerated in Table 1.Focus group and interview guides were developedfor set of a priori themes informed by the literature.The topics were related to care during pregnancy andits complications, perceived severity of hypertensionand seizures during pregnancy, and community basedpractices in pregnancy. The themes included, know-ledge and perceptions/beliefs/experiences about preg-nancy associated common illnesses, perceptions andbeliefs for prevention of pregnancy complications,delays in care seeking for the management of compli-cations during pregnancy and cost of care (direct andin-direct). All focus groups and interviews were con-ducted in Sindhi or Urdu languages to best fit theneeds of participants. To respect local preferences,focus groups were held separately for women and menat the local venues. Data saturation was confirmedthough regular reviews of the focus groups and inter-views conducted.Each focus group was conducted by one facilitator, twonote takers, one observer; and discussions were audio-recorded. Interviews were conducted by native Sindhi/Urdu speaking, gender specific staff, with a medical orsocial science background. Project staff were locallyrecruited and trained by a senior faculty member and asocial scientist with first-hand knowledge and expertise inqualitative research. The field staff then developed localSindhi languages transcriptions based on the recordedinformation. Reflexive notes were maintained for all FGDsand IDIs to capture field observations. Quality control wasensured through random observation of FGDs and IDIsby the field co-ordinator, and an audit-trail of 20 % ofFGD transcripts. The audit-trail process included verifyingcontent of transcripts with audio-recordings, and biweeklydebriefing sessions with moderators/transcribers led bythe senior project staff. Data were typed in Sindhi andreviewed to ensure that all the information had beenrecorded accurately. The data was analysed in Sindhilanguage using NVivo version 10 [QSR, Doncaster Vic,Australia] to develop the themes and subthemes from anethnographic approach. After verbatim transcription inlocal language, the transcripts were translated intoEnglish, with back-translation to ensure data quality.This study received ethical approval from Ethics ReviewCommittee of Aga Khan University, Karachi Pakistan,National Bioethics Committee of Pakistan [1917-Obs-ERC-11] and Institutional Review Board of University ofBritish Columbia, Vancouver Canada [H12-00132].ResultsThe findings from this study have been categorized inseven thematic areas. These include the women andmen’s perspectives, as well as that of community-levelcare providers, LHW, TBA, and WMO.Theme one-Knowledge, perceptions, beliefs, experiencesabout common pregnancy complicationsMost women claimed not to seek regular antenatal care(ANC); however, those that did followed-up as instructedby their health care provider. The perception was thatANC is only needed in the event of complications: “Ifthere is no problem then why should we go, but if there issome problem then one should go” [mother]. Womenaccessed ANC from public and private facilities.Theme two-Perceptions and beliefs for prevention ofpregnancy complicationsMajority of women stated “Vertigo, headache, weaknessand excessive bleeding are the reasons we visit doctor whilewe are pregnant” as they are ‘danger signs’ or complicationsof pregnancy. Some women also included ‘high bloodTable 1 Distribution of FGDs/IDIsStakeholder group Data collectionmethodNumber ofFGD/IDINumber ofparticipantsMothers Focus group 19 173Male decision-makers Focus group 7 64Lady health workers Focus group 7 64Lady health supervisor Interview 10 10Women medical officer Interview 9 9Traditional birth attendants Interview 7 7Qureshi et al. Reproductive Health 2016, 13(Suppl 1):34 Page 77 of 97pressure and seizures’ as danger signs after probing. Whenasked directly all women knew the terminology of highblood pressure and, stated that high blood pressure canoccur during pregnancy. Women also stated that this maylead to “weakness, headaches and palpitations in themother; child could be born weak” [mothers]. They furtherstated that they knew they had high blood pressurewhen they experienced headache, weakness, dizziness,pain in back and legs, and swelling of the feet. They didnot state measurement of blood pressure as a way toidentify the problem. When they experienced thesesymptoms they would self-medicate with drugs pur-chased over the counter.Women believed that when these symptoms weresevere, they should seek care in health facility.Male decision-makers stated that weakness/anaemiaand the lack of foetal movements were indications of aproblem requiring a health care provider: “Mostly thereis anaemia” [male decision-makers].Community health care providers-LHS and TBAs -reported that it is a lack of knowledge and awarenessabout pregnancy complications that ultimately delaywomen from accessing services. LHS and TBAsclaimed this deficient knowledge exists amongst preg-nant women and their families. In addition, there werepotentially harmful misconceptions held by womenand families regarding the severity of pregnancy com-plications. Women stated “stress and poverty” as acause for their raised blood pressure and did not statethe connection between pregnancy and high bloodpressure. This was further confirmed by the followingstatement “People do not take blood pressure seriously;they think it will get better if they take rest and do nottake salt” [LHS and TBAs].Theme three - Delays in care seeking for themanagement of pregnancy complicationsBarriers to care seeking in pregnancySeveral barriers were identified by women that hinderedaccess to health care services. These barriers includedlack of child care, poor access to transport, significantdistance to facility, and the lack of a male chaperone. Insome instances an elderly female took on the role ofchaperone when men were not available.There are many problems; sometimes we havemoney sometimes we don’t. […] If husband is homehe will take us otherwise we stay at home (Mothers)The hospital is far away and our husbands are alsonot at home. It takes time to arrange transport. It isvery difficult to reach the hospital on time (Mothers)Decision-making power as a determinant for care seekingin pregnancyThe majority of the respondents agreed that the principaldecision-maker for health care is the husband: “Obviouslymy husband decides” [mother]. Some men preferred TBAswhen their wives accessed services, because they believedthat TBAs were readily available to deliver care at home ata decreased cost. These preferences influenced women’scare seeking due to the influential role of the husband.Nevertheless, in some cases the mother-in-law, withwhom the woman is residing, will make decisions: “Weagree on what our husbands say, we also do what ourmother-in-law says” [mothers]. There were only a fewwomen who stated that they were able to make thedecision on their own: “I myself decide, I visit doctors formedication when I am ill” [mothers].Theme four - Cost and the perceived burden of careMale decision-makers described that they took loanswhen money was needed for transport and health services.Such loans could be repaid in installments or by sellinggoods such as cattle:If any animal bull etc. is at home, we sell it in halfprice to return the money [Male Decision-Makers].Theme five - The role of traditional and spiritual healersin pregnancyThe community claims not to be using alternative medi-cines or providers (homeopathic, ayurvedic or herbal).One mother described how these types of services areno longer chosen: “People of our community don’t useany other alternative medicines because they don’t trustthem, we take English medicines only” [Mothers].LHWs confirmed that allopathic medicine was preferredover homeopathic or herbal medicine in their community:“Scientific medicines are used. No other” [LHW]. However,there were home remedies which pregnant women takeon recommendation by community elders and LHWthemselves: “For this salt intake can be decreased, oilintake can also be decreased, spicy foods intake can also bedecreased. This is very beneficial” [LHW].Aside from these traditional practices, some menreported that women consulted ‘local religious leaders’because of concerns of supernatural involvement. Faith-based treatments were described as an adjunct to formalhealth care services and not as a replacement.She should be given treatment, made to consult doctor.In home remedy, she is given massage on her head. Itoften occurs in rural areas. Spiritual healing is alsodone in order to see if she is under some supernaturalinfluence. We take her there. The ‘faqir’(spiritualhealer) treats through ‘jhaar, phoonk”(chanting andQureshi et al. Reproductive Health 2016, 13(Suppl 1):34 Page 78 of 97blowing on the person or afflicted part of the body)and also do ‘jhaar, phoonk’ on water and give her todrink. They also give ‘taveez’ (amulet) to wear. This isa practice in rural areas.(Male Decision-Makers)Theme six - Community support during pregnancyThe family plays an important role in assisting womenin pregnancy. Family mainly consists of the husband andthe in-laws living in the same house or compound.Rarely family may include the natal members of thewoman’s family. Respondents described the integral rolefamily support plays in maternal health care serviceutilization. The family may assist in arranging transportor contributing funds: “My husband and my motherarranged transport and took me to the hospital on theright time” [Mothers].The community may also play a role in assisting fam-ilies to access health care services. In some cases whereprivate vehicles are available in the neighborhood, thiswas used for transport to facility. In-kind support wasalso described by respondents, such as providing cookedmeals. In spite of these examples, many women claimedthe community was not involved in providing assistance:“They don’t help. The community can’t do anything tosave the woman” [Mothers].Theme seven - Preferred health care providersIn emergency cases, private health facilities were oftenpreferred if the family can afford them. This preferencewas due to greater availability of physicians, timely careand availability of services. Private facilities were alsopreferred as they have a greater number of female pro-viders, which is more culturally acceptable for care inpregnancy and postpartum. In the absence of adequatefunds families were forced to patronize public facilities,where the quality of care is felt to be inferior - “Thepeople there are just not good, so we go to private. Ingovernment you also don’t know anything when checkingthe BP. They don’t do that well either” [Mother]. Inaddition to the perceived low quality of services, somerespondents stated that health care providers treatwomen poorly in public facilities: “Private hospitals havemore facilities and the attitude of doctors in governmenthospitals is also very rude” [LHW]. Women complainedthat government facilities have long wait times: “Theyhave to stand in a long queue. The doctors give slipsand make them stand for long hours. The doctor doesnot give them time and the condition of the womangets worse” [LHW].DiscussionThis study’s findings present the reported health seekingbehaviour of rural women in Sindh Province, Pakistan aswell as the barriers. This study reported that women anddecision-makers are often not familiar with the import-ance of routine antenatal care. They believe that womenshould seek health services only when there is a com-plaint or complication. Women’s’ beliefs regarding ante-natal care has been evaluated by Mumtaz et al [13],which found that most rural residents in the Punjabstrongly believed that pregnancy is meant to lead tochildbirth and hence should not be interfered with. Thisstudy also showed that villagers believed medical inter-ventions during pregnancy can be harmful [13], andsome symptoms are common and acceptable, and there-fore did not seek care [14].Headache is one such symptom that is commonlyregarded as a sign of high blood pressure. Kruszewski etal. reported that in people with mild or moderate hyper-tension, headache was not significantly associated withraised blood pressure [15]. Further, Sperling et al. re-ported that headache as diagnostic criteria for pre-eclampsia is unreliable, nonspecific, and does notaccurately predict adverse maternal and fetal outcomes[16]. The female participants in our study were alsonoted to report high blood pressure if they experienceda headache, without any objective measurements. Stressand family issues were commonly expressed by the par-ticipants as the cause of the headache and hence raisedblood pressure.Similar observations have been noted for other ill-nesses as well. Galloway et al. explored women’s percep-tions of anemia from eight developing countries. It wasnoted that 90 % of women assumed that they hadanemia based on the symptoms of weakness, headache,pale look and feelings of light headedness [17]. Most ofthese were the perception of the participants rather thanobjective measurements. This finding is consistent withour results as well.The study results demonstrated a strong preferencefor private facilities for reasons that included availabilityof doctors, better equipment and facilities. Women’sperception of the quality of care available at the facilitysignificantly influenced their choice [18]. Sheikh et alreported that in the northern Pakistan, the gender ofhealth care providers, quality of service provided at thehealth facility and the associated financial cost were im-portant factors in considering whom to consult [19].Anwar et al also reported that in Pakistan, usage ofpublic facilities was lower in rural areas due to re-stricted hours of operation, non-availability of drugs,distant locations and lack of female providers [20].Women are frequently forbidden to visit the govern-ment facilities as there are mostly male doctors onduty [19]. It is unfortunate that this tendency alsoinhibits them from seeking care when resources arelimited as private facilities are expensive. This percep-tion and its associated health care behaviour are seenQureshi et al. Reproductive Health 2016, 13(Suppl 1):34 Page 79 of 97in many countries where public health systems are oflow quality [21].Results showed women generally are looked after andfollow decisions of the husband and/or elder women intheir community. Similar patterns of care seeking inpregnancy have been shown in rural Haiti [22] and inBangladesh where the husband and mother-in-lawwere the main decision-makers for antenatal care [23].A study done by Fatmi et al in rural Sindh concludedthat husband’s educational status and occupation weresignificantly associated with utilization of antenatalcare [24].Resources are available within the immediate familiesand community to support women in accessing healthcare services. Social support from the husband, family orfriends had the potential to influence care seeking behav-iour. Social support in pregnancy is crucial for women indeveloped as well as developing countries [25, 26]. Mobil-ity of some women is restricted, in some tribes this maybe a self-imposed restriction i.e. ‘Brohi’ tribe in this study.Similar findings were reported by Mumtaz et al. wherepregnant women avoided public places and travelling toaccess antenatal care due to the association of pregnancywith sexual activity [27]. The need for a companion is thenorm in Pakistan, if the woman is admitted the compan-ion is required to purchase any required materials or med-ications [13]. Women in Sindh use local resources to gethelp before approaching a health facility. Community re-sources such as TBAs as well as advice from the localpharmacists are utilized by pregnant women and theirfamilies. This phenomenon has also been observed instudies in Bangladesh where majority of women (68 %)purchased medicine from the store to use at home [28].Finlayson et al.’s meta-synthesis of antenatal care ser-vices in low and middle income countries [29], reportedthat antenatal care was delayed because pregnancy wasconsidered a healthy state which did not require interven-tion, access was further limited by financial constraints ordistance. It was also reported that unprofessional attitudeof the staff and unavailability of resources at the healthfacility further hindered health seeking [29]. Our studycorroborates these findings. Further, it adds to the litera-ture by exploring the community support available to thefamily in times of need as well as the use of alternativemedicine during pregnancy.The province of Sindh has a multi-ethnic population,which may not be fully represented in these results;however, the findings have shown similar themesacross groups. Nevertheless, there may be subtle dif-ferences in the way these people perceive antenatalcare which may have not surfaced in this study. Fur-ther, this study does not explore the deficiencies in thecare process and infrastructure of the various healthcare facilities.ConclusionThis study revealed that health care has to be sought withthe permission of and accompanied by a male familymember or female elder in rural Sindh. Pregnancy wasnot considered a high-risk situation and therefore womenpresented infrequently for antenatal care. Women need tohave clear concepts about symptoms that indicate emer-gencies during pregnancy and childbirth, as misconcep-tions regarding the severity of various conditions werereported. The community recognized that emergenciescan arise during childbirth and in these cases womenshould access health services. Nevertheless, socio-culturalfactors came into play causing delays. In addition, lack ofhigh quality facilities at the public level prevented womenfrom accessing appropriate and timely care.There are policy implications for such findings. Firstly,it is important to educate the community regarding thebenefits of regular antenatal care as well as the dangersigns of pregnancy. LHWs should reinforce health andeducational messages to women as well as the commu-nity during routine visits. Educational messages can behighlighted at primary health facilities along with radioor television messaging. It is also essential that thepublic sector ensure quality of services at all levels; thiscan be achieved by ensuring availability of qualified,competent, caring and preferably female staff at publicand private facilities. Procedures and policies for man-agement and referral of high risk obstetric cases need tobe in place so that treatment delays are reduced. Im-proving the standard of care available to the pregnantwomen during emergencies is essential if maternalmortality is to be reduced.Peer reviewPeer review reports for this article can be found inAdditional file 1.Additional fileAdditional file 1: Peer review reports. (PDF 616 kb)AbbreviationsANC: antenatal care; CLIP: Community Level Interventions for Pre-eclampsia;LHS: lady health supervisors; LHW: lady health workers; MMR: maternalmortality ratio; PDHS: Pakistan Demographic and Health Survey;TBA: traditional birth attendants; TBA: traditional birth attendants;WHO: World Health Organization; WMO: woman medical officer.Competing interestsThe authors declare they have no competing interests.Authors’ contributionsRNQ served as Principal Investigators of this study and prepared themanuscript. RNQ, DS, PvD, ZAB were involved in the conception anddesign of the study. SS contributed in the development of focus groupguides, data analysis and reviewed the manuscript. SZ was a senior socialscientist involved in the development of focus group guides, superviseddata collection, and reviewed the manuscript. ZH and ARK reviewed theQureshi et al. Reproductive Health 2016, 13(Suppl 1):34 Page 80 of 97manuscript and provided intellectual input. MV was involved in the conceptionand review of the manuscript for important content. Members of the CLIPFeasibility Pakistan Working Group were involved in development of focusgroup guides, and intellectual contributions in design of the manuscript.All authors read and approved the final manuscript.AcknowledgmentsThe authors thank all the study participants for their time and willinglysharing their personal experiences of pregnancy related illnesses and careseeking practices. We acknowledge the dedicated efforts of local communityhealth care providers who voluntarily helped in approaching study participants,and the field staff for their efforts to have organized focus group discussionsand excellent record keepings. We would also like to thank the CLIP PakistanFeasibility Working Group: Ata Jamali, Aadil Qureshi, Anila Sajid, Bushra Memon,Hassan Murad Shah, Kiran Saba, Buhsra Memon, Beth Payne, Sharla Drebit,Chirag Kariya and Laura Magee. This work is part of the University of BritishColumbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention andTreatment) initiative supported by the Bill & Melinda Gates Foundation.DeclarationsPublication charges for this supplement were funded by the University ofBritish Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Preventionand Treatment) initiative supported by the Bill & Melinda Gates Foundation.This article has been published as part of Reproductive Health Volume 13Supplement 1, 2016: Community insights from four low- and middle-incomecountries into normal and complicated pregnancies. 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