We investigated the social and cultural factors that have been contributing towards delayed decision-making in seeking healthcare for women during pregnancy. The themes derived from data analysis are presented below.
Low status of women
Despite many governmental efforts for gender mainstreaming, Pakistan is far behind in achieving gender equality in health, education, economic and political participation for women. Still women are subjected to different forms of discriminations and have little or no say in their personal or family matters [21]. The present study found that illiterate and socially isolated women were more vulnerable to poor reproductive and general health. There were certain social and cultural practises such as purdah (veil system), dependency on male guardian, and other social restrictions on independent mobility of women which deprived them to seek timely medical care during pregnancy and childbirth. A majority of women, particularly in rural areas, could not read or write as education was not considered necessary for women. A mother-in-law had a clear stance against women’s education as she opined:
“Why school or college education for girls? Ability to read and write is good but the most important thing is that they should be able to read Holy Quran. And she should have the skill of cooking and home making. This is what every Muslim woman must learn.”
While discussing the healthcare needs of women, especially during pregnancy, a wife of a retired military spy said:
“During pregnancy, the family – especially the husband and mother-in-law – must be careful and considerate. If there is a problem, it is the duty of husband to arrange a visit to a qualified care provider.”
Lack of autonomy and mobility
In the local culture of Pakistan, women generally lacked autonomy to seek care when they need it. It was noted that there were many “stakeholders” whose consent was necessary before a pregnant woman embarks to seek care from a health facility. One LHW explained:
“It is not the decision of pregnant woman when, why and from whom to seek healthcare. Usually, it is the joint decision of many players including mother-in-law, father-in-law, husband and sometimes the husband’s brother. They make the decision according to the perceived severity of illness, cost, nature of threat, availability and competence of care providers, and other conditions.”
Sometimes, the decision to travel to a healthcare facility is not based on women’s health condition but on availability of transport as well as on availability and willingness of her husband, father or brother to travel with the women. A gynaecologist pointed out the restrictions on mobility of women:
“Most of the time, mothers with pregnancy complications are brought to us [referring to gynaecologists] when they are near to death. Yesterday, I received a pregnant mother for delivery. She was in a critical condition with profuse bleeding. When I inquired the family for this delay, the family told me that they were waiting for her husband to bring her to hospital as culturally it is forbidden for woman to go alone.”
Another dimension of a lack in decision-making is illustrated by a LHW:
“Sometimes, women do not want to make their decisions independently as it has serious consequences if something went wrong. For example, if a woman selects a particular doctor for treatment and if the pregnancy is terminated by this treatment, the women will be in trouble. So, she needs to take other family members into confidence while making the decision.”
Low nutritional status
Due to the low social status of women they also experience discrimination at home. Sometimes, they are not provided with proper food which is required during pregnancy. Therefore, their dietary needs are frequently ignored. A healthy and balanced diet during pregnancy and after childbirth is one of the significant factors for women health. Absence of this can have adverse effect on mother’s health and can lead to maternal complications [22]. A gynaecologist in her early thirties expressed heir view on women’s poor nutritional status:
“I get horrified to see the pale ghostly faces of women who reach to us with maternal complications. Giving food to the men within the house and then children first is the cultural thing here. Women’s dietary needs are not their priority.”
The LHWs being close to rural households had their own observation on obstacles in the first delay of seeking healthcare for pregnant women. One of the main obstacles was poverty and powerlessness within the family power structure, as stated by a senior LHW:
“In poor families, pregnant women cannot get two times decent meal; not to talk of timely and proper medical care.”
Another middle-aged woman who retired as office attendant in the local middle school said:
“Here,the main issue is not poverty but priority and preference. Women from poor background – whose parents are poor and not influential – are not properly cared in their in-law’s homes. They are simply ignored; the issues of their health and illness are taken for granted.”
While probing families on any special focus on pregnant mother’s diet, a mother-in-law commented:
“I cannot feed pregnant mother first, if children are crying of hunger. Neither my mother-in-law paid special attention to me nor I did with my daughter-in-law. What is so special in giving birth?”
Early marriages
In Pakistan, especially in poor rural families, early marriage, forced marriage and cousin marriages are common and considered as normative cultural practice. A growing body of literature indicates the negative physical consequences of early marriages on young girls [23]. A girl married in young age is not mature enough to decide about her healthcare and she is more dependent on in-laws and husbands for her healthcare needs. In local culture, child marriage is justified by providing many reasons. One of the mothers-in-law expressed her strong beliefs on girl’s early marriages:
“Poor and powerless people are not safe here – so is the case with their daughters. We cannot afford keeping daughters unmarried for long at home.”
A LHW shared:
“This is a general perception here: The younger the girl is, the brighter are the chances of producing more children. Therefore, many people think that it is a cultural thing and they follow it.”
A female doctor in this regard shared her views:
“In this area, girls are married at an early age and they have multiple pregnancies before reaching and age of 25 years. Sometimes I refuse believing the age of the pregnant women when I am told about their age. The fact is they usually look ten to twenty years older than their actual age. They have been producing children every year and chances of maternal mortalities with such health condition are always higher.”
A LHW working in a village community for the past ten years added:
“The poor parents are always in hurry marrying their daughter to lessen their burden. Culturally, people think marrying daughter early prevent them of becoming characterless. If girls remain unmarried after attaining puberty, there is a risk of creating affairs or sex scandals.”
One female doctor emphasized the dependency which goes along with early marriages:
“I have assisted deliveries of many young mothers in this community. In many times they are brought to us with pregnancy complications when it is difficult to save her life. They [refereeing to young mothers] are not prepared to decide about themselves, about their family planning. And they do not know about their reproductive health. They are totally dependent on their in-law families for such decision-making.”
Lack of reproductive autonomy
Because of social exclusion and economic non-participation, women are less aware about their reproductive rights. In some areas, the birth of a baby girl is not welcomed; rather it disempowers the mother who gave birth to a daughter. Therefore, a woman pregnant with a baby girl is less likely to seek appropriate and timely care during pregnancy. The present study showed that the lack of family planning among married couples and the average family size in rural households is large. The study participants shared their belief that family planning is a sin in religion. Furthermore, the wish for a son is the primary factor of a large family size. A husband with very poor socioeconomic status admitted:
“My wife died during birth of the seventh child and I admit I never followed any family planning. I know very well it is a conspiracy against Muslims.”
The LHW shared her experience and added:
“I was once physically abused by a mother-in-law and husband when once a young married girl – who died in childbirth later – asked for a contraceptive pill, but tried to hide it from her family. Here, culturally and religious people think it is a sin to follow family planning methods.”
In household power structure, mothers-in-law have more power. They can influence the decisions related to reproductive life of the daughter-in-law, including their health seeking behaviour during pregnancy. When reproductive decisions are made by someone else but not by the mother, timely decision for healthcare is never done. The same observation was made by many participants in terms of the role of mothers-in-law in the life of their daughters-in-law. A female physician at a gynaecology ward revealed:
“The mothers-in-law are the one who decide the next course of action once a pregnant mother is brought to us. I have even seen them insisting saving the life of a baby in place of its mother, specifically if it is a baby boy.”
While commenting on the situation, one LHW noted:
“When things are decided by the mother-in-law regarding seeking care, she has her own ‘agenda’. She may delay the visit to save money, to avoid travel or simply to settle score with the pregnant mother. It is unfair and non-sense; but this is how it is.”
Poor understanding of pregnancy complications and risk factors
The present study found that women and their families were not well-aware of pregnancy complications and related risk factors. It is evident that a timely diagnosis of complications during pregnancy is possible, if antenatal visits are available for pregnant mothers [24]. However, the local culture has its own understanding of the phenomenon of pregnancy and its associated processes. Many pregnant women have no chance of visiting medical facilities for antenatal care. The LHWs and gynaecologists blamed families for this situation. It was also noted that there is a lack of trust in certain diagnostic medical procedures performed at healthcare facilities for pregnant women. One female physician observed the following:
“Sometimes, there is a serious lack of trust between doctor and patient. Some mothers are suspicious about ultrasound and think that it is family planning devise. Lack of trust is also a factor in delaying to seek formal care.”
While explaining the condition of rural women, one LHW stated:
“Poor women – which are the majority in this village – have no concept of prenatal care. They are taken to healthcare facilities when something visibly serious happened to them such as bleeding, fits or simply they lose their consciousness. For minor ailments, they are treated at home.”
While narrating the need for seeking healthcare during pregnancy, a mother-in-law stated:
“Problems in pregnancy are normal and natural. Why to rush to doctors for a natural process? For thousands of years, women have been delivering children at home. Doctors just complicate things to make money.”
One gynaecologist reported:
“Who cares for their treatment or antenatal check-ups? In the local culture, pregnancy is kept secret. A web of superstitious regulate the life of pregnant women. They come to us at a very critical stage.”
One of the sisters-in-law of a deceased mother revealed:
“My mother-in-law believes in keeping pregnant women inside home. Therefore, she could not expose to sunlight in the first three months of pregnancy. She did the same with my sister-in-law who died in the fifth month of pregnancy due to some complication, as she was not allowed to go to a doctor because of her [referring to her mother-in-law] superstitious beliefs.”
Seeking care in a plural medical system
Like other developing countries, Pakistan has a complex plural medical system where the biomedical system coexists and competes with a host of indigenous medical systems such as traditional hakeems, biomedical quacks, folk healers, or spiritual healers – to name a few. Depending on patient’s social class, level of education, affordability, and perceived nature of aliment, the patient selects a particular care provider or multiple care provider at a time. Getting multiple advices and treatment from multiple care providers can cause a delay in seeking treatment from a qualified care provider. One physician noted:
“Women come to us with long-term complications such as high blood pressure or gestational diabetes. Poor women fail to understand the long-term treatment and ask for quick remedy. Here come the quack and spiritual halers: They promise a quick relief.”
The South-Asian communities still attribute many physical and mental illness with the presence of supernatural powers and never hesitate consulting spiritual healers [8]. The role of spiritual religious leaders even in receiving consultation for medical care during pregnancy is common. One of the respondents who was a sister-in-law of a deceased mother and who also was pregnant informed:
“I have been advised by peer sahib [referring to spiritual healers] to keep a knife under pillow and avoid sunlight throughout my pregnancy. My mother-in-law believes that it could save me from future complications.”
While explaining the mechanism of delayed decision by spiritual healer a LHW added:
“I was once called upon to see a woman who had perfuse bleeding in her fifth month of pregnancy. While probing, I came to know she was stopped by a local peer [referring to a spiritual healer] to travel outside of her home and to consult a doctor as she had chances of being attacked by evil forces. She died on the same evening.”
A mother of a deceased women shared:
“Here, we have a strong belief of nazar lagna [evil eye] – especially during pregnancy. My daughter’s mother-in-law did not allow my daughter to go outside the home and consult a doctor. Always Dai [TBA] came to her home to provide the treatment. But she [referring to Dai] has done very bad with my daughter. She took the life of my daughter. She and my daughter’s in-law’s family are responsible for the death of my daughter.”
A physician at a gynaecology ward showed great disappointment regarding the large adverse impact of cultural and religious believes on pregnant women:
“These spiritual healers are part of the religious and cultural believes of rural people. Sometimes, a husband comes or not. But when a pregnant mother is close to death and brought to us, the local biomedical quack accompanies the family and even intervenes in our treatment methods.”
Spiritual healers of various types influence the health belief system of women during pregnancy which in turn regulates their care seeking behaviours [25]. Frequently, pregnant women and their families in villages are dependent on TBAs for healthcare. The families greatly preferred TBAs and sought help from them for women during pregnancy. A mother-in-law in her late seventies showed her great trust on these TBAs:
“Let us not break our tradition. In the four walls of our house we get great help from Dai [referring to TBAs] during pregnancy and for delivery. The poor Dai is happy to receive few kilos of Atta [wheat flour] as her fee even after delivering the baby. I am happy they are always available for us.”
An experienced LHW, however, showed her anger on the role of TBAs:
“I am helpless when I see these Dais to treat cases of preeclampsia and eclampsia [referring to high blood pressure during pregnancy] with herbal medicine. They don’t hesitate cutting umbilical cord of baby with a knife used for vegetables. Families blindly trust in them and no force can stop them.”
The gynaecologists shared their own experiences of dealing with complicated cases brought to them after treatment from untrained TBAs. One senior gynaecologist shared her views by commenting:
“The half-dead pregnant mothers are sometimes brought to us with serious complications. Most of the time, they are brought to us after wrong interventions by untrained Dais and Dais are unable to handle the delivery. In my eyes it is a killing, it is a murder.”