By Shahina Maqbool
Effective care in pregnancy is the first step towards newborn care. Newborn care starts before childbirth so that the mother’s requirements in terms of adequate nourishment, safety from infections, and monitoring to detect the emergence of complications, can be met. This is how far theory goes. In reality, however, antenatal care-seeking behaviour in developing countries like Pakistan largely depends on availability of money, education and support of the family members, on the one hand, and illness and pregnancy-related complications, on the other.
An interesting study portraying patterns of antenatal care has recently been completed by Arjumand and Associates, an Islamabad-based group of consultants. Sponsored by Save the Children through funds from Gates Foundation, the study was conducted in 9 districts of the four provinces, and included Khuzdar and Pishin in Balochistan; Haripur, Charsadda and Lakki Marwat in NWFP; Jhelum and Dera Ghazi Khan in Punjab, and Dadu and Sukkur in Sindh.
In each of the 9 districts, 5 focus group discussions (FGDs) were conducted with mothers of children less than 2 years of age in 5 different union councils (UCs) — three rural and two urban. Ten in-depth interviews with mothers (two in each UC), ten with decision-makers (two in each UC with husband/mother-in-law in selected households), and five with key informants (Lady Health Visitor/Lady Health Worker/Dai) were also conducted.
A total of 404 mothers of children under 2 years of age participated in 45 FGDs in 9 districts; their age ranged from 16-45 years with a median of 26 years. More than 60% of the mothers were illiterate; only 8% had 10 or more years of education. A total of 90 household decision-makers (mothers-in-law, fathers-in-law and husbands of mothers) were interviewed.
The study showed that in only 3 out of 9 districts (i.e. Jhelum, Charsadda and Haripur) a majority of mothers mentioned that they usually go to doctors or LHVs for ante-natal care (ANC); however, the frequency of visits depends on two considerations namely, availability of money, and illness. For some, it was once every month and for a majority, it was at least 3-4 times during pregnancy. Hospitals, doctors, private clinics and LHVs were mentioned for seeking ANC.
Seeking ANC depends on affordability, and since a majority cannot afford it, they do not seek care unless there is illness or a pregnancy-related problem. It becomes clear that women do not give much value to the advice, iron tablet and tetanus toxoid (TT) immunization given by LHWs. For them, ANC means check-up by doctor and getting an ultrasound done.
In the other 6 out of 9 districts, women are mostly not seeking ANC, and those who are, belong to the urban areas. The main reasons for this contrast are lack of facilities and relatively more poverty in the rural areas. A number of participants of the study could not think of visiting a healthcare provider if everything was proceeding normally. The problems during pregnancy for which ANC is sought included giddiness, loss of appetite, indigestion, vomiting, turning pale or yellow, weight gain or swelling of body, high blood pressure, bleeding, pain in the uterus, and IV infusion for gaining strength and overcoming weakness.
Many mothers said that they if they go to a doctor in case of any problem, the doctors tell them to take iron tablets. Usually, doctors advise change in the diet of women to include items that can overcome the deficiency of iron, vitamin and calcium. Along with that, they also prescribe medicines for gaining strength. In one rural FGD (Arain, Sukkur), mothers reported having been advised by LHWs to take iron and calcium tablets. However, it is not always possible for mothers to buy medicines due to poverty and they do not take those regularly or at all.
Other women reported issues of accessibility or cultural restrictions for not seeking ANC. For example, one woman in Lakki Marvat stated: “Most people do not go for check up or ANC in our village because there is no facility in the village and the government hospital is also very much far away. The rich people also go only in case of some problem.”
Another woman from Pishin explained the problem as follows: “We cannot go outside for any check-up during pregnancy. Since we are a Pathan family, this is not the culture. Our husbands are very strict and so are our fathers-in-law and mothers-in-law. Dai is called at home but she doesn’t know much. When the woman is about to die, only then they take women to a health facility but only if the husband can arrange for transport. There is a doctor nearby but she charges a lot of money and poor can’t go there.”
In one district (Lakki Marwat), many mothers hesitate to tell about their pregnancy to other family members because of shyness, thus limiting their chances for seeking ANC. A woman describing this said: “Here men come to know that the woman is pregnant after 3, 4 or 7 months. It is a matter of shyness that is why we do not tell them.” Even if the pregnancy is known to the family members, some women feel very shy in sharing about the problems that they may be suffering from during pregnancy. A mother stated: “I used to have vomiting and pain in the uterus throughout nine months but I did not tell to anybody because I was shy.”
In one area in Sukkur, women reported that they do not go to any healthcare provider at all even in case of a problem: “Here, nobody goes to a doctor, no matter what happens, even if the woman dies.” Those who seek ANC in these 9 districts, mostly go for any of the following four reasons:
Firstly, they want to be sure about the position and condition of the fetus for determining whether they can deliver at home or not. It was stated that it is important for mothers to know the position/condition of fetus so that they can assess whether the delivery will be normal and could it take place at home or the mother will have to be taken to facility. Secondly, to know if the pregnancy is progressing normally. Thirdly, to seek treatment, if they suffer from some problem; and fourthly, to overcome weakness and improve their health for improving health (birth weight) of the newborn. Mothers mentioned that if the mother is weak, the fetus can die in her abdomen.
Some ‘dais’ reported that women also come to them for check-ups and to know about the position of the baby, especially in 8th month. Some advise women to go for an ultrasound and, those who can afford, act upon their advice. Lady Health Workers said that they advise women to go to the doctor for ANC during pregnancy but again only those who can afford do so.
In both rural and urban areas, some women stated having a role in decision-making about ANC, but they also emphasized that actions are taken with the permission of mothers-in-law in joint families and husbands in nuclear families. Very few mothers spoke of family support from their husbands and mothers-in-law for seeking ANC, and they were mostly from urban areas or belonging to relatively well-off families.
Thus, care seeking largely depends on availability of money, education and support of the family members, and problems or illness during pregnancy.