Why do women still give birth at home; perceptions of Pakistani women and decision-makers from marginalized communities.

In low- and middle-income countries (LMICs), maternal and newborn mortality is high due to the high prevalence of home births. Understanding the reasons behind this behavior is essential for improving maternal and newborn outcomes. Therefore, a qualitative exploratory study was conducted in a peri-urban community in Karachi, Pakistan to understand the perceptions of pregnant women who delivered at home despite receiving antenatal care and the perceptions of their decision-makers regarding this behavior. In-depth interviews were conducted with 15 randomly sampled women who chose to deliver at home after receiving antenatal care at a health facility, as well as 15 family members who were purposively identified as decision-makers by the women themselves. Thematic analysis was performed to explore the perceptions, myths, and cultural beliefs about homebirths as well as women's decision-making power related to childbirth. The three main themes identified showed that traditional beliefs and practices, poverty and gender inequality, and poor healthcare systems significantly influence the preference for childbirth. Traditional beliefs and practices, including religious and cultural beliefs, played a role in perceiving childbirth as a natural process best managed at home. The presence of traditional birth attendants who provide personalized care and emotional support further reinforced this preference. Gender inequalities, including limited access to mobile phones and women's caregiving roles, were identified as barriers to seeking formal healthcare at the time of delivery. Additionally, poor experiences with the formal healthcare system, such as the poor attitude of formal healthcare workers and fear of medical interventions, also contributed to the decision to deliver at home. The study highlighted the complex interplay between traditional/religious beliefs, gender inequalities, and healthcare experiences in shaping the decision to deliver at home despite receiving ANC services in marginalized settings. Addressing these factors is necessary for promoting facility-based delivery and improving maternal and neonatal outcomes in LMICs.

Feasibility of a peer-supported, WhatsApp-assisted, lifestyle modification intervention for weight reduction among adults in an urban slum of Karachi, Pakistan: a mixed-methods, single-group, pretest-post-test, quasi-experimental study.

OBJECTIVES: This pilot study assessed whether a peer-supported, WhatsApp-assisted lifestyle modification intervention for weight reduction is feasible to execute a definitive trial. DESIGN: A mixed-methods, single group, pretest and post-test, quasi-experimental study. SETTING: Azam Basti, an urban slum in Karachi, Pakistan. PARTICIPANTS: Fifty participants (males and females aged 20-60) with a body mass index of >23 kg/m2, along with their nominated peers from the same family. INTERVENTION: Using motivational interviewing techniques, a trained nutritionist delivered the lifestyle modification intervention to the participants and peers for 3 days after the baseline assessment and then once monthly for 1 year. The intervention was delivered in groups using WhatsApp voice calls. The education sessions mainly focused on dietary modifications, physical activity advice and peer-support assignments to achieve a 5% wt loss from the participant's initial body weight. OUTCOMES: The feasibility measures included screening, recruitment, retention and monthly interview response rates. At 1 year, in-depth interviews (IDIs) with participants and peers were conducted to explore the facilitators, barriers, acceptability and experiences of the intervention. Changes in weight, calorie intake/day and calorie expenditure/day were also assessed. RESULTS: The recruitment and retention rates were 32% (n=50/156) and 78% (n=39/50), respectively, while the response rate for monthly interviews ranged between 66% (n=33) and 94% (n=47). The mean weight loss at 1 year was 2.2 kg, and the reduction in mean calorie intake was 386 kcal/day. There were no changes in the mean calorie expenditure. During the IDIs, participants and peers reported intervention via WhatsApp and peer support as convenient, flexible and supportive. CONCLUSIONS: The quantitative and qualitative findings of the current pilot study support the scale-up of this work with minor modifications to the screening method as well as close monitoring and motivational interviewing to improve adherence in terms of physical activity. TRIAL REGISTRATION NUMBER: NCT05928338.

High prevalence of food insecurity in peri-urban communities in Karachi, Pakistan: The flood aftermath.

BACKGROUND: Food insecurity (FI) is at a steep risk, especially in low middle-income countries. FI is further compounded in areas that experience environmental and economic instability, thus a reassessment in such critical times is required for burden estimation and to propose targeted interventions. AIMS: The objectives of this study were to assess the prevalence of, and sociodemographic factors associated with FI, as well as the coping strategies utilized in response to FI in peri-urban communities in Karachi, Pakistan. METHODS: We conducted a cross-sectional survey from November-December 2022 on 400 households in four peri-urban communities in Karachi, Pakistan. The Household Food Insecurity Access Scale (HFIAS) and reduced Coping Strategies Index (rCSI) questionnaire were used to assess FI. A Poisson regression was used to assess associations between sociodemographic factors and FI. RESULTS: The overall prevalence of FI was found to be 60.2% (n = 241) of which 33.8% (n = 135) were severely food insecure. Age, women's and breadwinners' education, women's occupation, and parity were significantly associated with FI. Participants reported relying on less expensive foods (44%) and borrowing food or help from others (35%) as the most common coping strategies overall in the FI households. CONCLUSION: With more than half the households facing FI and adopting severe measures to cope in these communities, it is pivotal to design and test interventions that can withstand economic and climate catastrophes and help ensure a safety need for food security for the most vulnerable.

Pregnant Women's Experiences with Midwifery-Led Antenatal Care Services in Peri-Urban Communities in Karachi, Pakistan.

Purpose: To understand pregnant women's experience with midwifery-led antenatal care services using the Respectful Maternity Care charter in primary health centers in Karachi, Pakistan. Methods: This cross-sectional study was at Rehri Goth and Ibrahim Hyderi, two peri-urban communities in Karachi, Pakistan, where women receive antenatal care services. All pregnant women in their third trimester who consented during the study period were included. The participants were asked about access to care, antenatal care experience, person-centered approach, and general satisfaction with the facility using a pre-designed questionnaire. These themes were mapped onto the universal Respectful Maternity Care charter. Descriptive statistics were used to summarize the findings in each of these themes. Multivariable logistic regression techniques to determine the relationship between the dependent and independent variables. Results: There were 904 women who agreed to participate in this study during January to December 2021. Majority of the women (94%, n=854) were satisfied with the operating hours and cleanliness. More than 90% of the women reported positive experiences regarding privacy, respectful treatment by midwives, and non-discriminatory care. However, 40% (n=362) of the women reported not receiving adequate information and informed consent before a medical procedure, while 65% (n=587) reported poor counseling for birth preparedness. Maternal age, women's occupation, women's education, and parity were found to be significantly associated with respect provided, satisfaction with counseling and the consent process. Conclusion: This study reported satisfaction of pregnant women with the facility's ambiance, respect, and care; however, poor communication skills regarding consent and antenatal counseling were reported. The findings suggest the need for more efficient strategies, such as regular respectful maternity care and technical training to strengthen midwife-patient interactions and enhance overall satisfaction, thus improving maternal and newborn outcomes.

Health workers' experience of a digital health intervention implemented in peri-urban communities in Karachi, Pakistan.

Objective: Digital health interventions (DHIs) have the potential to improve access and quality of care in low-middle-income countries. The aim of this study was to assess the acceptability, usability and aesthetics of a DHI by frontline workers in peri-urban community settings in Karachi, Pakistan. Methods: A mixed-methods study was carried out in peri-urban field sites in Karachi, Pakistan, where maternal and childcare services are provided through front-line care providers using a DHI. These workers include community health workers, midwives, and physicians who were using the DHI for at least six months. For quantitative data, a questionnaire regarding the module design and interface, technical difficulty, and appropriate utilisation was assessed using a 5-point Likert scale. For qualitative data, focus group discussions (FGDs) based on experiences regarding operability, design, its effect on work efficiency and the provision of beneficial health services were conducted. Results: There were 93 respondents for the quantitative questionnaire who reported high satisfaction (>85%) with the DHI in many themes including content quality, aesthetics and ease of use. Participants were least satisfied with service quality (45% satisfaction only) due to issues related to data sync and network connections in these areas. During the FGDs, the workers stated that the DHI helped them with accessing previous data and providing quality health care services to the community. Conclusion: Although frontline workers reported a few technical difficulties while using the DHI, the majority reported that it was acceptable, had user-friendly features and was beneficial in their work processes.