1. family and parenting
2. motherhood
3. pregnancy

Volume 1:
Qualitative Formative Research Findings - Summary
Volume 2:
Qualitative Formative Research Findings DG Khan District, Punjab
Volume 3:
Qualitative Formative Research Findings Khanewal District, Punjab
Volume 4:
Qualitative Formative Research Findings Rawalpindi District, Punjab
Volume 5:
Qualitative Formative Research Findings Buner District, NWFP
Volume 6:
Qualitative Formative Research Findings Jafferabad District, Balochistan
Volume 7:
Qualitative Formative Research Findings Sukkur District, Sindh
Volume 8:
Qualitative Formative Research Findings Dadu District, Sindh
Volume 9:
Qualitative Formative Research Findings Study II
Volume-5
Qualitative Formative
Research Findings - Buner
July 2006
PAIMAN project is funded by the United States Agency for International Development
and implemented by JSI Research & Training Institute Inc.
in conjunction with Aga Khan University, PAVHNA, Contech International, Save the Children US,
Population Council, Johns Hopkins University/CCP, and Greenstar Social Marketing.
SUNRISE DIGITAL 051-2278515
Center for Communication Programs
The Pakistan Initiative for Mothers and Newborns (PAIMAN) is a five-year United States Agency for
International Development (USAID) funded project designed to reduce country's maternal and
neonatal mortality by making sure women have access to skilled birth attendants during childbirth
and through out the postpartum period. PAIMAN works at national, provincial and district levels to
strengthen the capacity of public and private health care providers and improve health care system
infrastructure. The PAIMAN Program is jointly implemented by John Snow Inc (JSI), the Johns
Hopkins Center for Communication programs (JHU/CCP), Agha Khan University, Contech
International, Greenstar Social Marketing, Population Council and Pakistan Voluntary Health and
Nutrition Association (PAVHNA) .
Copyright © 2006 by JHU/CCP. All rights reserved.
Published by:
PAIMAN
House 6, Street 5, F-8/3, Islamabad, Pakistan.
Author:
Dr. Arjumand Faisel
Arjumand and Associates
Editor:
Daniela Lewy
Cover Design, Layout & Printed: Sunrise Digital, Islamabad, Pakistan.
Inquiries should be directed to:
Fayyaz Ahmed Khan
Team Leader BCC
Johns Hopkins Bloomberg School of Public
Health
Center for Communication Programs
PAIMAN Office
House 6, Street 5
F-8/3, Islamabad, Pakistan
E-mail: [email protected]
Suruchi Sood, Ph.D.
Senior Program Evaluation Officer
Johns Hopkins Bloomberg School of Public
Health
Center for Communication Programs
111 Market Place
Suite # 310
Baltimore, MD 21202
E-mail: [email protected]
Disclaimer:
This study/report is made possible by the generous support of the American people through the United States Agency for
International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. and do not
necessarily reflect the views of USAID or the United States Government.
contents
5.1. District profile
6
5.2. Participants Characteristics
5.3. Current Maternal Health Seeking Behaviors and the Key Factors that
Facilitate or Hinder Health Seeking Practices
5.3.1 Recognition of and reaction to pregnancy
5.3.2 Health seeking behavior adopted at home
5.3.3 Perception of required health services in pregnancy, delivery and
postpartum
5.3.4 Availability of services to women and their utilization
5.3.5 Health seeking from skilled providers during current/last pregnancy,
last delivery and last postpartum
5.3.6 Knowledge about life threatening complications
5.3.7 Actions taken during obstetric emergency
5.3.8 Assistance of husbands, family members, health care providers and
community in emergency situations
5.3.9 Conclusions
7
5.4. Current Health Seeking Behavior for Newborns and the Key Factors
that Facilitate or Hinder these Health Seeking Practices
5.4.1 Perception of required health services for newborn
5.4.2 Availability of services for newborn and their utilization
5.4.3 Steps to ensure health of the newborn
5.4.4 Knowledge about life threatening complication in newborn
5.4.5 Actions taken for threat to life of newborn
5.4.6 Conclusions
5.5. Current Birth Preparedness and Complications Readiness Behaviors
and the Key Facilitating and Hindering Factors
5.5.1 Preparations made for birth by woman, husband and family
members
5.5.2 Hindrances in BPCR
5.5.3 Conclusions
5.6. Religious and Cultural Practices Surrounding Maternal and Neonatal
Health
5.6.1 Religious/Cultural ceremonies
5.6.2 Preferred and forbidden food items for breastfeeding mothers
5.6.3 Precautions taken during postpartum to ensure safety of mother
and newborn
5.6.4 Feeding of newborn
5.6.5 Bathing patterns
5.6.6 Presence and effects of Nazar (evil-eye)
Conclusions
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26
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27
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Qualitative Formative Research Findings - Buner
Qualitative Formative Research Findings - Buner
ACKNOWLEDGMENTS
Arjumand and Associates (Management Team)
Dr. Arjumand Faisel
Dr. Narjis Rizvi
Dr. Naveed-I-Rahat
Wasiq Mehmood Khan
Sabeena Kausar Satti
Dr. Fauzia Waqar
Johns Hopkins Bloomberg School of Public Health (Baltimore)
Dr. Suruchi Sood
Anne Palmer
Dr. Corinne Shefner-Rogers
Daniela Lewy
Margaret Edwards
Johns Hopkins Bloomberg School of Public Health (Pakistan)
Fayyaz Ahmed Khan
Dr. Zaeem Ul Haq
Shereen Rahmat Minhas
John Snow Inc.
Dr. Theo Lippiveld
Dr. Nabeela Ali
Dr. Tahir Nadeem
Dr. Nuzhat Rafique
Dr. Iftikhar Mallah
Dr. Syed Hassan Mehdi Zaidi
Local Government Health Department Staff
EDO Health,
District Coordinator LHW Program
LHWs
National Program for Family Planning and Primary Health Care
Dr. Haroon Jahangir Khan
A special thank you for all the individuals who graciously
participated in this formative research
Study 1: From Pregnancy to Newborn Care:
Health Seeking, Birth
Preparedness/Complication Readiness,
Religious and Cultural Practices
Report - Study 1 (Volume 5)
Findings: Buner, NWFP
In-depth Interviews (IDIs) with Married Women,
Husbands and Family Members
04
Qualitative Formative Research Findings - Buner
5. Findings District Buner (NWFP)
5.1 District Profile
Buner, a district of North Western Frontier Province (NWFP) is situated in the
northern part of the Pakistan. It is an agriculture area with almost no industry.
According to 1998 Census, the population of the district was 506,048 with 50%
males and 50% females and an annual growth rate of 3.86%. Population
density was 271 persons per square kilometre with 100% population being
1
designated as rural. For administrative purposes, the district has been divided
into 6 Tehsils i.e. Dagar, Gadezai, Chagherzai, Gagra, Chamla and Totlai.
The medical coverage provided by the Health Department in district Buner
comprises of 1 District Headquarters Hospital (DHQH), 3 Tehsil Headquarters
Hospital (THQHs), 2 Rural Health Centers (RHCs), 20 Basic Health Units
(BHUs) and 8 dispensaries.
Figure 1: Map of District Buner with Sampled Areas
Qualitative Formative Research Findings - Buner
5.2 Participants Characteristics
A total of 38 interviews were conducted with the distribution given in Table 5.1:
Table 5.1: Distribution of In-depth Interviews
Area
Number of Interviews
Currently Women with Husbands
Pregnant
Live Birth
Women
CP* LB*
Swari
Regga
Chamla
Korea
Total
3
2
3
3
11
3
3
3
3
12
1
0
1
1
3
1
1
1
1
4
Family
Members
Male Female
1
1
1
1
4
1
1
1
1
4
Note: CP= currently pregnant, LB= woman with live birth
One female interview of currently pregnant women was excluded from the
analysis, as she was an LHW. The interview of the husband of any of the 7
currently pregnant women identified in Regga could not be carried out as 5 of
them were out of station, 1 was a drug addict and was not in condition to give
the interview, and one refused.
The ages of participants were: women from 20 to 40 years with the mean of
28.55 years, husbands 27 to 47 years with mean of 32.4 years, and family
members 29 to 70 years with mean of 47.75 years. Their living children ranged
from 0 to 10; the number of sons ranged from 0 to 6, and the number of
daughters ranged from 0 to 5. The age of the youngest child of women
participants and husbands was from 1 month to 6 years and 2 months to 2
years, respectively.
The randomly sampled areas in the district were four (all rural) and their
locations are shown in the district map below:
1.
Korea (rural)
2.
Swari (rural)
3.
Regga (rural)
4.
Chamla (rural)
Swari is the most urbanized rural area as compared to other three areas.
Many women (16 out of 23) had no schooling, some (6) completed grades
ranging from 1 to 10, with 1 woman reported having completed 14th grade. In
contrast, many (5 out of 7) husbands interviewed had education from primary
to grade 10 level, while one had no schooling and the other had studied up to
14th grade. Several (5) of the family members had no schooling and 2 had
attended school up to the 10th grade, whereas only one held the postgraduate
degree.
The husbands were shopkeeper, government servant, did farming or owned
small businesses. Male family members were farmers, workshop mechanic,
teacher and butcher.
All participants, except 4 spoke Pushto language. Among the 4 non Pushto
participants, 3 spoke Hindko and 1 Urdu language.
Among the participants, three belonged to Sikh religion, one woman with live
birth, her sister-in-law and her husband.
5.3 Current Maternal Health Seeking Behaviors and the
Key Factors that Facilitates or Hinder Maternal Health
Seeking Practices.
Health seeking behaviors and practices of an individual or family is influenced
by several factors, such as the felt need, importance given to disease
1. Population Census 1998, Report
06
07
Qualitative Formative Research Findings - Buner
prevention and health promotion during different stages of life, whether the
condition can be shared with others or not, severity of symptoms if ill, access
to health services, behavior of and confidence in the staff, availability of
financial resources, etc. The behaviors recorded in the Buner districts, and the
factors that influence them are presented below.
5.3.1 Recognition of and reaction to pregnancy
In general, the recognition of pregnancy is early by women. Majority of women
presume that they are pregnant, if the menses are over due by few days to
four weeks, especially if they have one or more associated symptoms such as
nausea, vomiting, giddiness, lethargy, headache, backache, palpitation,
tiredness, pain in ankles, and feeling of heaviness during urination.
Almost two-third of women (15 out of 24) sought help from a skilled provider
when the menses were overdue or appearance of any symptom to get the
pregnancy confirmed. Several of them visited doctor/hospital and also got the
urine test done for confirmation.
Discussing the subject, a currently pregnant woman in Regga gave information
about recognition of pregnancy as follows: “When menses did not come, I went
to the hospital with my husband, the female doctor got the urine test done and
informed me that I am pregnant” (jab mahwari band ho gai to khawand kay
sath dagar haspatal gai, wahan lady doctor ko bataya tou peshaab ka test
karwaya, us kay baad doctor nay kaha kay tum hamla ho gai ho).
Qualitative Formative Research Findings - Buner
mein ne khud kisi aur ko nahi bataya).
Only one of the female participants reported informing the LHV and another
mentioned LHW for seeking advice for pregnancy care.
Participants reported varied emotions on learning about the current or last
pregnancy. Several women (13 out of 23), all husbands (7) and many of the
family members (6 out of 8) reported happiness; and they had 0 to 8 children
before the occurrence of the current/last pregnancy.
A husband in Regga with 8 living children said: “(I) felt happy as I knew that it
is a son” (Khushi hui kyunke pehlay se pata tha kay larka hay)
A woman with live birth in Swari said: “ I felt happy when I learnt about my
pregnancy, Why should I have been unhappy, it is a blessing of Allah” (Jab
mujhey apnay hamal ka maloom hua tou mein khush thi, khafa kyun hoti, ye
tou Allah ki dain hai)
However, some women (10 out of 23) and few family members (2 out of 8)
expressed unhappiness on learning about the current or last pregnancy and
they had 0-10 living children. None of the husbands expressed unhappiness.
The reasons for unhappiness mentioned by women were: youngest child is too
young, too many children, not healthy themselves, afraid of discomforts of
pregnancy, getting pregnant very soon after marriage. One male family
member quoted “poverty” as his reason for being unhappy.
Slightly over half of the women stated that they shared this news first with their
husbands, indicating that the level of spousal communication is moderate in
this district.
A currently pregnant woman with no living children in Korea said: “I was
unhappy as people talk around that it is not even a year since the wedding and
the baby is born” (Is wajah se khafa thi kay log batain kartay hain kay abhi
shadi ka aik saal bhi nahi hua aur phir baccha sath ho gya).
A 25 year old currently pregnant woman in Chamla, with four living children
said: “I told my husband as I talk about such (private) things with my husband
and cannot do it with any other (person) because I feel shy” (Apnay shohar ko
bataya, kay aisi batain tou mein shohar ko hi karti hun aur kisi se ye batain
nahi kar sakti, sharam aati hay)
Importantly, some of the women who expressed unhappiness also mentioned
the desire for abortion (4 out of 10) and two reported attempting abortion but
failed. In the third case, the husband forbade due to religious reason and the
fourth did not attempt anything because of her bad health.
Next in line in terms of information about pregnancy was shared with motherin-law, other female members of the house, mother and sister. A very
interesting pattern is seen here about sharing the news within one's family.
Some of the woman said that they informed only one woman in the house as
they feel shy to talk about it even with other woman, and very few did not even
share the news with any woman. Most participants mentioned that even within
a household the news about pregnancy is shared in a restricted manner.
A currently pregnant woman in Chamla with 10 living children said: “I ate
abortion causing medicines that costs Rs. 120, but the fetus did not abort”
(baccha zai karnay wali golian jo 120 rupay mein milti hai wo bhi khain likin
baccha zai nahi hua).
A currently pregnant woman in Korea, discussing the subject said: “I did not
tell anyone because I feel shy and it feels bad to talk about such matters.
Everybody learns about it themselves when it (pregnancy) becomes evident
from the body changes.” (Mein ne kisi ko nahi bataya, is liyae kay sharam aati
hay, bura lagta hay is tarah ki batain karna, jab jism se zahir ho jata hay tou
phir sab ko khud hi pata chal jata hay).
A currently pregnant woman in Korea said: “I did not go for sterilization, one
reason was that I did not have enough money, and the second reason was
that some people have said those who (women) gets sterilization done are
condemned (to the extent that even their funeral prayers are not accepted by
God)” (Bacchay band karnay ka ilaj mein ne nahi kya, aik wajah tou ye thi kay
meray pas itnay paise nahi thay, aur doosri wajah ye thi kay kuch logon ne
kaha tha kay bacchay band karnay ka jo ilaj karay us ka janaza nahi hota).
Another currently pregnant woman from Swari said “One day a death
happened in the family (and) all family members were going. My husband told
them that my wife is pregnant and she cannot go. That's how others learnt
about it, I did not tell anybody else” (aik din khandan mein mayat ho gait thi,
sab ghar walay ja rahay thay tou meray shohar nay un ko bata diya kay meri
biwi hamla hay, wo nahi ja sakti tou is tarah baqi ghar walon ko pata chal gya,
08
The interviews revealed that women who are willing to adopt family planning
are not doing so as they cannot afford it or have religious inhibitions.
From the above, it is clear that:

Recognition of pregnancy is mostly early and its clinical confirmation is
also sought by about two-third of the women.

Slightly more than half of the women shared the news of pregnancy first
09
Qualitative Formative Research Findings - Buner
with their husbands indicating that spousal communication is moderate.
The main reason for sharing the news with one's spouse is that they are
shy to share it with any other member of the house, including other
women

Some (10 out 0f 23) women reported unhappiness on learning about the
pregnancy, and some of them (4 out of 10) desired to have abortion
indicating unmet need for family planning. Two of the women reported
attempting unsafe abortion but failing.

Two-third of the women sought help from a skilled provider to confirm
pregnancy

There is a desire for family planning but there are limitations such as
inability to afford the services or religious inhibitions

Reactions to being pregnant do not appear to be related to previous
pregnancies and number of living children one already has.

Son preference is evident through the fact that despite having 8 living
children one of the husbands expressed happiness on his wife's current
pregnancy, as he was confident that she was carrying a male fetus.
5.3.2 Health-seeking behavior adopted at home
The participants reported behavioral changes by women and her family on
learning about the pregnancy of women. These are related to food intake,
daily routine, rest, etc.
Food intake: It is important to note that comments about food intake varied
among different groups of participants. Only some women (7 out of 23)
reported increased food intake during pregnancy, while many of the husbands
(5 out of 7) and several family members (5 out of 8) mentioned the same. It
was stated that this care was mainly initiated by husbands followed by family
members or self. Details are given in Table 5.2.
Qualitative Formative Research Findings - Buner
Rarely mentioned items were lassi, fish and rice. The reason commonly
mentioned for the increased intake of the preferred items was that they give
strength to the mother and overcome deficiency of blood (anemia) in her.
Apple, banana and orange were the most commonly taken fruits, while a few
participants mentioned grapes, guava, and pomegranate. The frequency of
intake mentioned by some women is about one fruit per day. The quantity of
increased intake of meat/chicken/liver was not specified. Spinach was most
commonly reported vegetable. Others mentioned radish, carrot and potato.
The frequency of increased intake of milk was reported by only 3 women and it
was about a cup per day.
A husband in Chamla reported increased food intake in the following words:
“(I) increased her diet when I learnt (about the pregnancy), infact doubled it,
because the fetus in the womb also needs it” (jab pata chala tou is ki khourak
mein izafa kya, balkay khorak dogna kya, kyunke pait mein palnay walay
bachay ko bhi khoraak ki zaroorat hoti hay)
A father-in-law in Regga said: “The meat is cooked everyday as a routine, but
since learnt about her pregnancy, (we) have been especially feeding her meat,
fish and chicken. By this the fetus will be healthy and also the mother” (Ghost
tou waise bhi ghar mein roz aata hay magar jab se is kay hamal ka pata chala
tou us ko khususan ghost machli aur murghi khilatay rahey, is tarah anay wala,
baccha mazboot aur tawana rahey ga, aurat bhi sehat mand rahey gi).
Some of the women (9 out of 23) reported decrease intake of food during
pregnancy, while none of the husbands and family members mentioned it. It is
noticeable that decrease intake was reported by more women (9) than those
reported increase intake (7). The reasons quoted were nausea, lack of desire
to have food, indigestion. Also, about one-fourth of women, husbands and
family members mentioned that there was no change in food intake. The
reason for not changing the diet was given by two family members, who
expressed that they could not bring any change due to poverty.
Table 5.2: Preferred Foods in Pregnancy by Number of Participants
Only some women and husbands and several family members did not mention
any forbidden food during pregnancy, while the remaining specified foods that
were forbidden to maintain health of the mother or fetus. Details are given in
Table 5.3.
Number of Participants Who Specified Different Preferred Foods
Table 5.3: Forbidden Foods in Pregnancy by Number of Participants
Food
Fruit
Milk
Meat
Vegetable
Chicken
Eggs
Roti 2
Lassi 3
Fish
Rice
Pickles
Dates
Pulses
Tea
1
2
3
4
5
6
7
8
9
10
11 12 13 14 15 16
17 18 19 20
Number of Participants Who Specified Different Forbidden Foods
Food
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Chilies
Pulses
Sweets
Spinach
Pickle
Yoghurt
Corn
Lemon
Oils
Potato
Beef
Lassi
Brinjal
Meat
Salt
Half cooked food
The most commonly reported food items of increased intake mentioned by all
groups were fruit and milk while few participants' mentioned meat, and
vegetables. Chicken, eggs and roti were mentioned by very few participants.
Milk
Very warm Roti
2. Roti: Jesus bread/flat bread made of wheat
3. Lassi: Yoghurt based drink
10
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Qualitative Formative Research Findings - Buner
The forbidden foods, predominantly mentioned were chilly and spicy foods that
are considered to be harmful for fetus and cause bleeding and miscarriage.
Very few mentioned some vegetables (brinjal, spinach, potato) and pulses as
having hot effects inside the body. Other forbidden items mentioned rarely
4
were salt, sweet dishes (halwa, etc.), hard foods (pulses and red beans), and
not well-cooked meat.
Qualitative Formative Research Findings - Buner
other is interesting. Although husbands and family members feel they
pay attention to the pregnant woman's health by increasing her intake of
food the fact that women themselves report otherwise has important
implications for program design.

Increase in intake consisted of fruits, meat, chicken, liver and vegetables
A currently pregnant woman in Regga explaining forbidden foods said: “Oil,
salt and sweets are forbidden as they cause high blood pressure” (Chiknai,
namak aur mithay se mana kya jata hay, is liyae kay is se blood pressure
zyada ho jata hay)

There does not seem to be agreement with regards to what are
considered good or bad foods for example, on the one hand the
increase intake of spinach was mentioned while on the other it was listed
as a forbidden food.
A husband in Swari described other reasons and said:” If the meat and chicken
is not cooked well then we call it difficult to digest food. It can affect the
digestion and cause abdominal pain, hence it should not be given” (gosht ya
mughi agar achi tarah se nahi pakaya jai tou us ko ham sakht khorak kehtay
hain, is se hazme par bojh par sakta hay aur pait mein dard ho sakta hay, is
liyae ye nahi deni chaiyae)

Forbidden foods were mostly chilly and spicy foods that are considered
to have “garam” effects and can cause miscarriage.

Some women were also able to decrease their routine work, especially
heavy work.

The extent to which women make their own decisions even when it
comes to relatively simple things like food intake is questionable. The
interviews with several males revealed that they decided how much their
wives should eat and what work they should or should not do.

In cases where food intake was increased or there were restrictions on
the type and amount of work a pregnant woman was allowed to carry out
appears to be related more with a concern for the health of the fetus and
not necessarily the woman.
Daily routine: Some women (10 out of 23), all husbands and several family
members reported decrease in daily work load. The reduction was in
strenuous work such as lifting of charpoy (cot), water buckets, sweeping
floors, basket of washed clothes, etc.
A husband in Korea describing this said: “Prohibited (her) from heavy work so
that the problem of miscarriage does not arise” (Bhari kam karnay se mana
kya takay phir hamal girnay ka masla na aai)
A father-in-law in Regga while mentioning the same point, said: “(she) should
not lift heavy weights and also not undertake work in which (she) has to bend,
as this type of works carries the risk of miscarriage” (zyada bojh uthana nahi
chahiyae aur wo kam jis mein jhukna parta hay, kay is qism kay kamo mein
hamal girnay ka andaisha hota hay).
Besides this, rest was also increased from few hours to no work at all. A
pregnant woman of 20 years said: “(I) do not do any work since (I) got
pregnant. Swept (the floor) once that resulted in backache. Since then I have
not done any work” (jab se hamla hui hon koi kam nahi karti, aik dafa jharo di
thi, us se kamar mein dard ho gya tha, us kay baad se koi kaam nahi kya).
Some women (9 out of 23) also reported no change in their daily work routine.
A currently pregnant woman from Regga said : “I work even after the
conception because there is no other person in the house, (and) I have to do
it”(hamal thairnay kay baad bhi kam karti hun kyunke ghar mein aur koi fard
nahi, mujhey hi karna parta hay).
It can be concluded that:

Both positive and negative changes in life style of pregnant women were
reported by all groups of participants.

More women (9 out of 23) reported decrease intake as compared to
those (7) who reported increase in food intake.

The difference in perceptions of increased food intake between the
women on the one hand and the husbands and family members on the
4. Halwa: A sweet dish made of semolina, clarified butter and nuts
12
5.3.3 Perceptions of required health services in
pregnancy, delivery, and postpartum
Pregnancy: Most of the participants (31 out of 38) believed that check up
should be done during normal pregnancy. Majority of them preferred the
doctor/hospital, while rarely participants suggested seeking health services
from LHV, LHW, dai, or dispenser. The various purposes identified for seeking
health services included: confirmation of the pregnancy, advice for pregnancy
care, check up of the status and position of the fetus, blood pressure of the
mother, prescriptions or tablets for “strength” and tetanus toxoid vaccinations.
A woman with live birth in Regga expressed: “ (One) should go to the hospital
during pregnancy, as the urine is tested and lady doctor Gulnaz is there (to do
the check up)” (Hamal kay doran haspatal jana chahiyae doctor kay pas
kyunke wahan paishab test hota hay aur wahan lady doctor Gulnaz bhi hay)
A husband in Chamla emphasizing the check up during pregnancy stated:
“(She) should go to the Dagar Hospital, (or) to Naheed (LHV), and it is must to
go to other doctor who is a TV surgeon (one who has ultrasound)” (Dagar
haspatal jai, Naheed (LHV) kay pas jana chahiyae aur doosri doctorni jokay TV
surgeon hay, is kay pas jana zaroori hay)
Rarely the frequency of visits for check up was mentioned and it was
suggested to be once in a month to every two months. A woman with live birth
in Regga expressed: “The pregnant woman goes for check up every 1 to 2
months” (Hamla har mah ya do mah baad check up kay liyae jati hay)
Few participants (9 out of 38) mentioned about the need for getting tetanus
toxoid (TT) injections during pregnancy, which reflects low felt need or
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Qualitative Formative Research Findings - Buner
acceptability. A father-in-law in Swari said: “Earlier, I was very much against it
5
(TT). Moulvi of the mosque told (us) that it is a plan of westerners for enforcing
family planning. But not now, my daughter (a LHW) says that it is necessary,
as this will (help to) give birth to a healthy baby” (Pehlay tou mein is kay bahut
khilaf tha, Masjid kay moulvi sahib ne bataya kay ye angraizon ki taraf se
bacchay band karnay ka mansooba hay. Likin ab nahi, meri beti (LHW) kehti
hay kay ye lazmi hota hay, teekay lagwa kar baccha sehatmand paida ho jai
ga).
Delivery: Many women (16 out of 23), husbands (5 out of 7) and family
members (6 out of 8) preferred doctor/hospitals for delivery, as the first choice.
They belonged to all the four areas of the study.
A woman with live birth in Korea favoring deliveries by doctor in hospital said:
“(one) should go to a doctor in hospital for birth to avail medicines easily, and if
operation is required, it should be done without delay” (Paidaish kay liyae
haspatal mein doctor kay pas jana chahiyae take wahan dawaiyan aasani se
milain aur agar operation ki zaroorat paray tou waqt par ho).
A currently pregnant woman from Regga also emphasizing deliveries by doctor
said: “(one) should go to a doctor, she has the facility to give stitches (perineal
sutures) and also has warm water” (Doctor kay pas jana chahiyae, wo tankay
lagain tou is ki sahulat bhi hay, garam pani bhi hota hay).
Only few women and one family member preferred dai as the first choice for
conducting the delivery. A woman with live birth in Korea while expressing faith
in the services provided by dai, said: “(For us) it is a must to call dai at the time
of birth. Nobody else has ever conducted deliveries. We consider it bad to go
outside home for deliveries” (Paidaish kay liyae tou lazmi dai ko hi bulatay
hain, kabhi kisi aur kay hath bacchay paida nahi huay, hamaray yahan kay log
bacchon ki paidaish kay liyae bahar jana bura mantay hain).
Only two women and also two husbands preferred LHV as the first choice for
conducting delivery.
Postpartum: Some women (9 out of 23) and husbands (3 out of 7) mentioned
that doctor/hospital or LHV should be seen during postpartum period, with
most of them preferring the doctor.
While some of the other women (9 out of 23) mentioned that doctor's/hospital
help should be sought if there is any need.
A woman with live birth in Chamla expressed this as: “A woman does not go
out of the house in postpartum, however, she goes to hospital if there is a
need” (Chillay mein aurat ghar se bahar nahi nikalti, likin agar zaroorat par jai
tou phir haspatal jati hay).
Participants rarely mentioned dai as the provider of choice during postpartum
period.
Inference drawn from above is that:

Encouragingly, most of the participants believed that there is need for
seeking skilled or trained health care for normal pregnancy, and majority
of them expressed need for check up by a doctor. There is little
information on the number of routine visits.
5. Moulvi: Imam of the mosque
14
Qualitative Formative Research Findings - Buner

The attitude towards TT vaccination is negative and there is little felt
need expressed for TT.

Many participants preferred a skilled provider for delivery, mostly female
doctor.

The preference for doctors was often expressed in terms of the
equipment that they had such as TV (ultrasound), ability to apply stitches
and even simple things like warm water.

Some participants believed that there is need for seeking health care in
normal postpartum.
5.3.4 Availability of services to women and their
utilization
In Pregnancy: The common health services available to women within
community for pregnancy care, delivery care and postpartum care are given in
Table 5.4:
Table 5.4: Available Health Services in the Sampled Areas for Maternal
Care
Chamla (rural)
· Dai
· LHW
· Private female
doctor
· Private LHV
· Private
dispenser
· Civil Hospital
Korea (rural)
· Dai
· LHW
· BHU (LHV)
Regga (rural)
· Dai
· LHW
· Moulvi
Swari (rural)
· Dai
· LHW
· Private
dispensers
· Private female
doctor
· Sultan General
Hospital(private)
· DHQH (Dagar)
Hospital
Hws were available in all areas, but only one woman in Chamla and one
husband in Regga reported utilizing their services for antenatal care (ANC),
indicating that they are not working very actively for ANC.
A currently pregnant woman from Regga said: “(We) have the facility of Husn
Ara (LHW) but she has never given us any medicine, nor came to our house.
(She) came to enlist me as a pregnant woman as per her duty, but never came
back” (Husn Ara LHW ki sahulat hay likin is ne hamy kabhi koi dawai nahi di,
kabhi hamaray ghar nahi aai, is naukri kay liyae naam likhnay aai thi, phir nahi
aai)” .
A brother-in-law in Chamla, commenting about LHWs remarked: “we do not
consider her a health care provider as she cannot do anything, she only has
advice” (Hum log us ko sahulat is liyae nahi samajhtay kay LHW baichari tou
kuch nahi kar sakti, us kay pas sirf mashwaray hotay hain).
Very few women reported utilizing the services of dai during pregnancy, and
they are called if there is a need. A currently pregnant woman in Swari said: “
We have two dais in our area, if needed, we call them” (Hamla aurton kay liyae
hamaray ilaqay mein dou dai hain, agar zaroorat paray tou unko bula laite
hain).
15
Qualitative Formative Research Findings - Buner
Qualitative Formative Research Findings - Buner
Male paramedics are utilized for treatment of minor ailments during pregnancy
and also TT vaccination.
Several participants praised doctor Gulnaz at Dagar Hospital for her
availability, skills and behavior.
The services of LHV in BHU at Korea for pregnancy care were reported by
almost all women participants of the area.
A woman with live birth in Swari said: “Lady doctor Gulnaz is at Dagar
Hospital, and (everybody) is available at the time of need. It has X-ray,
operation theatre, laboratory, and a medical store in front of the hospital.
People go there as their services are good and transport is transport is easily
available for going and returning back.(Dagar haspatal mein lady doctor
Gulnaz hay, ye log waqt par mil bhi jatay hain, yahan X-ray, operation theatre,
laboratory, aur haspatal kay samne medical store bhi hay. Log yahan jatay
hain kyunke yahan ka ilaj acha hay aura nay janay kay liyae gari asani se mil
jati hay)
Dr. Gulnaz posted at Dagar Hospital, Swari, who also runs her private clinic in
the area seems to be a very popular choice of participants for pregnancy
confirmation and care.
Civil Hospital in Chamla is popular among most participants of the area and
women are utilizing its services for ANC, vaccination and treatment.
Delivery:
Several women (13 out of 23), 1 husband and some family members (3 out of
8) mentioned that the services of dai are utilized for delivery. This indicates a
wide gap in their reported preferences and actual utilization.
A woman with live birth in Korea, while explaining this difference mentioned
24-hour availability of dai and cost of her services as the reasons: “Women go
to the LHV in BHU for check up during pregnancy, but the birth of the child
takes place at the hands of dai, as she is available all the time and charges
less” (Khwateen BHU mein LHV kay pas check up kay liyae jati hain, likin
baccahy ki paidaish dai kay hatoun hoti hay kyunke dai har waqt mil sakti hay
aur paise bhi kam leiti hay).
A woman with live birth from Regga gave another reason, i.e. close proximity
of dai for utilizing her services and said: “Doctor Naz Parwar (who is a dai)
lives close in our area (and) we go to her” (Hamaray ilaqay main doctor naz
parwar (dai) hay jo qarib hi hay, us kay pas jatay hain).
Male dispensers are called at home in two areas, Chamla and Swari, to give
injections and IV infusions to facilitate delivery if it is being conducted by family
members at home.
A woman with live birth in Swari said: “My husband does not allow me to go
out (for delivery) as he is a (religious) preacher. (We) call Babu (dispenser) at
home to give injections and IV infusions”(Kyunke meray shohar tablighi hain
bahar nahi janay daite, Babu (dispenser) ghar bula leytay hain, wo zichgi kay
doran ghar aa kar injection aur drip laga daite hain).
Only few women mentioned that they utilize skilled providers for delivery i.e.
LHV or doctor.
Postpartum: The health services available to women within their community
during postpartum are similar to those for pregnancy care, but almost none of
the women mentioned the utilization of any service unless there is some illness
or problem during this period.
6
7
One husband mentioned availing dum and Tawiz from a moulvi to prevent
drying up of the milk of woman.
Participants in all areas stated that services outside the community are
accessible to them. People from all four areas are mainly utilizing services in
Swari. These included DHQH (Dagar Hospital), Sultan General Hospital
(private), private clinic of a female doctor and LHV, male paramedics,
laboratory and blood bank, medical stores, and transport. Participants
mentioned that services in the facilities at Swari are good and they are availed
according to the need and affordability.
Some participants (12 out of 38) also mentioned utilizing services in other
cities like Mardan or Swat or Peshawar or Nowshera.
The specific reasons mentioned for utilizing the services outside community
are:

Insufficient facilities within community

Easy accessibility

Quality of care is good

All facilities are available (all types of providers, lab, X-ray, medical store,
transport)

Free services in some facilities
Very few participants (4 out of 38) mentioned that not all people utilize the
health services outside the community and the major reason mentioned was
poverty.
In brief:

Health services available to women within their community for pregnancy
care varied from dai to DHQH

Women are mainly utilizing services of skilled providers for pregnancy
care. This indicates that if available, services are utilized even in
conservative communities where women are shy to even share the news
of pregnancy with other females in the family

The role of LHWs and dai is very limited in pregnancy care

There is a distinct gap in preference and utilization for delivery services.
Though doctor is preferred but dai is being most commonly utilized

The services outside community located in Swari are being used due to
easy accessibility, popularity of the female doctor, and her availability.
The participants presented a fairly positive picture related to the
availability of services outside their community, both to the various types
of services available as well as the quality of care.

The practice of utilization of health services for normal postpartum is non
existent.
6. Dum: Verses from Holy Quran are read and then the breath air is blown over the
individual or water, which is then used for drinking
7. Tawiz: Amulet
16
17
Qualitative Formative Research Findings - Buner
5.3.5 Health seeking from skilled providers during
current/last pregnancy, last delivery and last postpartum
Participants were asked to report their personal experiences of seeking care
beyond the level of dai during pregnancy, delivery and postpartum.
Most women participants (18 out of 23) reported seeking antenatal care from a
female doctor/hospital or LHV during current or last pregnancy. Majority of
them visited doctor Gulnaz in Dagar Hospital or in her private clinic. Most of
the visits were for confirmation of pregnancy, check up and vaccination. Few
(5 out of 23) also sought care for some illness or problem during this period. All
husbands reported that their wives attended Dagar Hospital. Most family
members ( 7 out of 8) also provided similar statements. These visits ranged
from only one to fortnightly check ups.
A woman with live birth in Regga said: “I went to Dr. Gulnaz during first
pregnancy and for the last birth, she has a private clinic, the delivery is
conducted comfortably, she is a senior doctor” (Mein pehlay hamal kay doraan
aur maujooda bachay ki paidaish kay waqt doctor Gulnaz kay pass gai thi, us
ka private clinic hay, wahan baccha aram se paida ho jata hay, bari doctor hay
samajhti hay).
According to women participants, some (7 out of 23) deliveries were
conducted by skilled providers such as LHV, doctor or in hospital. Only one
woman from Swari availed this service. Some husbands and few family
members reported deliveries in hospital.
A woman with live birth in Regga said: “(We) do not go to dai, she is not
experienced like a doctor, (we) go to Dr. Gulnaz” (Dai ke pass naheen jatey
who doctor jitna tajruba naheen rakhtee, doctor Gulnaz ke pass jatey hen)
Qualitative Formative Research Findings - Buner
More than half of the women, husbands and family members stated that they
did not seek any service from health care providers during the period of
postpartum. Few women and husbands and only one family member
mentioned availing health care from doctor/ hospital but in case of
complication or illness. Seeking care from paramedics during this period was
rarely mentioned by participants.
In brief:

Most women are seeking ANC from providers beyond the dai. Majority of
these are going to a female doctor

Some deliveries were also conducted by skilled providers such as LHV or
doctor

No care is sought from skilled providers during normal postpartum
5.3.6 Knowledge about maternal life threatening
complications
Pregnancy: Most women (18 out of 23) mentioned 1 to 4 conditions that could
threaten the life of a pregnant woman, while 5 did not know any. Some
husbands (3) and family members (3) also did not know of any condition.
The conditions mentioned are given in Table 5.5.
Table 5.5: Knowledge of Life Threatening Conditions During Pregnancy
Among Different Groups of Participants
Total
Participants
(38)
0
2
Family
Members
(8)
1
1
3
3
1
1
1
1
1
1
1
0
3
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
6
4
1
1
1
1
1
1
1
1
Beating by husband
Palpitation/ Difficulty
in breathing
0
0
0
0
1
1
1
1
Don’t know/No response
5
3
3
11
Women
(23)
Husbands
(7)
Bleeding
Miscarriage/death of fetus
11
4
Malposition of fetus
High Blood Pressure
High Sugar
Labor pains before 8 months
Severe abdominal pain
Vomiting
Jaundice
Paralysis
Fits
Malaria
Conditions
Those who sought services from dai, preferred her care as:

People do not have money to pay other providers

Expenditures are far less as compared to other providers

Family members do not like delivery to be conducted outside the
home

She conducts deliveries at home which is logistically convenient

She is considered to be experienced and skilful

Going outside for deliveries are not perceived well in the
community
A sister-in-law of a woman with live birth in Korea expressed: “Women go to
hospital for check up (during pregnancy) but dais are called during deliveries,
because the people in the area do not allow women to go out and consider it
bad (practice). Secondly, poverty is widespread in this area and dai conducts
the deliveries in small amount and she is available, (one) does not have to go
outside the community” (Aurten haspatal jatee hen check up bhee karwatee
hen liken zichgi ke waqt dayon ko bulwaya jata hey kion ke yahan ke log
aurton ko bahar janey naheen detey, bura mantey hen. Dosrey yahan gurbat
ziada hey, dai kam pasoon men zichgi kar detee hey or ilakaye men mil bhee
jatee hey, kaheen or jana naheen parta)
12
7
As evident from the above table, the knowledge about life threatening
conditions in pregnancy is very limited, and bleeding was the most commonly
mentioned condition.
A currently pregnant woman from Chamla, while describing the amount of
blood loss that threatens the life said: “If (she) bleeds to the extent that it drips
down from the charpoy 8(khhon zyada aay jo charpoy se nichay nikal paray).
8. Charpoy: Cot
18
19
Qualitative Formative Research Findings - Buner
Delivery: It is important to note that 10 participants did not know of any life
threatening conditions during delivery. Others mentioned 1 to 4 conditions, and
the most common were bleeding and retained placenta.
Qualitative Formative Research Findings - Buner
Table 5.7: Knowledge of Life Threatening Conditions During Postpartum
Among Different Groups of Participants
Conditions
A woman with live birth in Swari said: “At the time of delivery, excessive
bleeding, transverse lie of fetus, retained placenta for more than half hour,
paralysis due to cold,
are dangerous for (maternal) life”(paidaish kay waqt khoon ka zyada aana,
bachay ka aara hona, placenta ka aadhay ghantay tak bahar na aana, thand ki
wajah se falij ho jana, zindagi kay liyae khatra hay)
The details are given in Table 5.6.
Table 5.6: Knowledge of Life Threatening Conditions During Delivery
Among Different Groups of Participants
Conditions
Women
(23)
Husbands
(7)
Family
Members
(8)
Total
Participants
(38)
2
0
0
Bleeding
Retained Placenta
High Blood Pressure
Mal Positioning
Uterus prolapse
Paralysis
Bursting of water bag
Premature Delivery
Prolong labor
High Sugar
Need for Blood
Overweight fetus
Overdue Delivery
Zakhm 9 in Uterus
Need for Operation
Excessive pain
Non availability of health
provider
9
6
4
2
2
2
2
0
1
1
0
1
1
1
0
0
0
1
1
0
1
0
0
0
1
0
0
1
0
0
0
1
0
1
0
0
0
1
0
0
0
0
0
0
0
1
1
12
7
4
3
2
2
2
2
1
1
1
1
1
1
1
1
1
Don’t Know/No Response
5
2
3
10
Postpartum: Again, bleeding was mentioned as the most common condition,
followed by paralysis and high blood pressure. However, the reason for
10
paralysis was mostly given to be thand.
A woman with live birth in Swari said: “In postpartum, a woman has danger of
getting paralysis if she goes out of her room in the winter months” (Chiley mein
agar aurat sardion mein kamray se bahar niklay tou usey falij ka khatra hota
hay).
The conditions mentioned by different groups of participants are given in Table
5.7.
9. Zakhm in uterus: an injury in uterus
10. Thand: effect of cold
20
Bleeding
Paralysis due to cold
High Blood Pressure
High Fever
If gets scared by being alone
TB
Pain
Prolapse uterus
Stress
Heavy work
Improper diet
Fits
Jaundice
Thand (Effects of cold)
Cold Cough
Don’t Know/No response
Women
(23)
Husbands
(7)
Family
Members
(8)
Total
Participants
(38)
10
4
4
3
1
0
0
0
0
1
1
1
1
0
0
11
5
5
3
2
1
1
1
1
0
0
1
1
0
1
6
0
0
0
0
1
1
0
0
0
0
4
0
0
0
0
0
0
0
0
1
0
4
1
1
1
1
1
1
1
1
1
1
14
It is also important to point out that husbands and male family have very
limited knowledge about maternal life threatening conditions during
postpartum. A brother-in-law in Chamla showed his ignorance in the following
words and said: “There is no condition that threatens life during
postpartum”(Chillay kay doran koi aise baat nahi jis se zindagi ko khatra ho)
It could be concluded that:

Knowledge of warning signs of obstetric complications is limited, and is
minimal among husbands and also male family members.

Though varied signs were mentioned by participants but the knowledge
of individual participants was very low.

Bleeding is the predominantly recognized sign for pregnancy, delivery
and postpartum. The amount of bleeding that can be considered
dangerous is not very well understood. It is considered as a danger sign
if there is blood visible through the clothes and bedding.

Paralysis appears to be a problem in this district, as it has been
mentioned both during delivery and postpartum, but the cause is mainly
considered to be thand and not high blood pressure.

Postpartum appears to be a neglected area. No participant reported the
need for skilled care during the postpartum, while fewer recalled danger
signs during this period
5.3.7 Actions taken during obstetric emergency
The trend for seeking emergency care during pregnancy, delivery and
postpartum is very similar, hence dealt together. Several women (15 out of
23) and family members (5 out of 8) and most husbands (6 out of 7) mentioned
seeking medical care from a skilled provider as the first choice during an
obstetric emergency. Most women mentioned that the woman should be taken
21
Qualitative Formative Research Findings - Buner
to the female doctor in Dagar Hospital, and if she cannot handle then to
Mardan or Peshawar. One woman each mentioned that a dai/LHV was
consulted first for obstetric complication. Another woman In Regga mentioned
that initially herbs11are given at home to treat emergencies: “We give a
medicine patarlak if the bleeding starts before delivery,
which
stops it.14In
12
13
postpartum, if the uterus gets infected then kuri, mamegh or khudungh is
given”(Paidaish kay waqt se pehlay khoon aae to aik dawaii (patarlak) deitay
hain jis se khoon ruk jata hay. Chillay mein agar aurat ki baccha dani mein
zakhm ho jai to kuri, mamegh ya khudungh deite hain).
However, it could not be inferred that what stage of the illness is considered
serious enough to take the woman to the doctor/hospital. The limited
knowledge of warning signs and discussions by participants suggest that the
decision is delayed.
In brief:

In emergency help is mainly sought from the female doctor in hospital

Although the doctor is perceived to be the first choice in an emergency
the reference to home remedies and consultation with dais is important to
keep in mind. Given the lack of knowledge about danger signs and the
low levels of communication at the household level, it is entirely possible
that care from a doctor is sought as a last resort when it might be too
late.
5.3.8 Assistance of husbands, family members, health
care providers and community in emergency situations.
Husband: Several women (15 out of 23) stated that the husband plays an
important role in emergency situations by arranging for money and transport or
he accompanies the woman to the health facility. Few mentioned arrangement
of blood. Rarely mentioned assistance was moral support, calling dai,
arrangement of medicines.
The assistance described by husbands and family members had similar
pattern. A husband in Chamla while describing assistance given by husbands
said: “Husband can take (her) to the doctor, arrange transport, provide moral
support, arrange money. Anything that is to be done will be done by the
husband” (shohar doctor kay pas le ja sakta hay, gari ka intizam kar sakta hay,
hosla day sakta hay, paison ka intizam kar sakta hay. Bus ye samjhain kay jo
bhi karma hay shohar ne karna hay).
Family Members: Women identified several modes of assistance that can be
provided by family members in obstetric emergency. Many (17 out of 23)
mentioned that family members can accompany to the health facility, some
said that they can arrange money, take care of the household chores or
arrange transportation. Few opined that they can take her to the doctor in the
absence of the husband or arrange blood. One woman mentioned that family
members do not provide any assistance.
Almost similar pattern of assistance was identified by husbands and family
members
11. Patarlak: a herb which is grinded and mixed with clarified butter and given about a
pinch with black tea
12. Kuri: herbal medicine prepared at home
13. Mamegh: herbal medicine prepared at home
14. Khudungh: herbal medicine prepared at home
22
Qualitative Formative Research Findings - Buner
Health Care Providers: Most women, husbands and family members
mentioned provision of better care by health care providers through good
medicines and treatment. However, husbands and family members mentioned
that it depends on the amount of fees paid to them. Women also rarely stated
that health care providers could give good guidance for the place to seek care
from. Two women mentioned that dai can accompany a woman in case of
complication.
Community: Many of the women participants (17 out of 23) stated that
members of the community can provide monetary assistance. Some said that
they can assist in arranging the transport and accompany to the facility. Few
women also mentioned that they can arrange blood or take care of household
chores. Rarely mentioned assistance were taking to the doctor or hospital,
providing moral support, praying for the safety of the mother
Arrangement of money was mentioned by most husbands and some of the
family members as the assistance from community members. Many husbands
and one the family members thought that community can assist in obstetric
emergency through arrangement of blood and/or accompany to the health
facility. Some husbands also mentioned arrangement of transport.
A husband in Swari while describing assistance from the community said:
“Villagers can go to the hospital with the patient, women can take charge of the
household chores, monetary assistance can be given (by them), (they) can
give blood if required. People of the area are like one body and they equally
share the sorrow and happiness” (gaon walay mareez kay sath haspatal ja
saktay hain, auratain ghar kay karobar sambhal sakti hain, mali imdad kar
saktay hain, khoon ki zaroorat aai to khoon dein gay kyunke ilaqay kay log aik
jism ki tarah hotay hain, aik doosray kay dukh dard mein barabar kay shareek
hotay hain)
Only one women participant said that no assistance is provided by the
community.
On specific questioning, 8 participants (5 women and 3 family members)
recalled cases of obstetric emergencies. Two participants mentioned that no
assistance was given by the community members. Others mentioned that
community members provided assistance in the form of arrangement of
transport, accompanying the patient, giving blood and/or money (up to Rs.
10,000).
A father-in-law in Korea said: “The fetus died in the womb of one of our
relative's wife, she had to be taken immediately to the hospital, all villagers
came, arranged transport, and they also gave three bottles of blood that was
required” (Hamaray rishtaydar ki biwi kay pait mein baccha mar gya tha, us ko
foran haspatal phonchana tha, sab gaon walay in kay sath aai, gari ka intizam
kya, aur teen bag khoon ki zaroorat thi wo bhi gaon kay logon ne fraham ki).
Briefly:

In emergency situations, husbands appear to play the key role in
arranging money and transport and accompanying her to the hospital.

Family members assist by arranging money, accompanying to the
hospital, or doing household chores.

Community members also assist by arranging money and transport,
23
Qualitative Formative Research Findings - Buner
accompanying the patient to hospital, giving blood and doing household
chores. It should be pointed out that among those who were aware of
actual obstetric emergencies in two out of eight cases community help
was not available.

The assistance of health care providers has been mentioned to be
provision of good care and advice, but participants also expressed
cynicism by reporting that the quality of care depended to some extent on
the payments made to them
5.3.9 Conclusions
The Table 5.8 below summarizes the findings reported under theme 5.3.
Table 5.8: Key Factors Influencing Maternal Health Seeking Behavior
Facilitating Factors
Hindering Factors
Recommendations
Link maternal health
with the family
planning program
MNH Program
should include a
strong nutrition
component focusing
on families to first
eat more of their
traditional foods and
then add some
higher cost foods
periodically
Focus on antenatal
check up, TT
vaccination and iron
supplements
Maternal health
needs to be
conceptualized in
terms of pregnancy,
delivery and
postpartum care
Build on the positive
associations of
seeking skilled care
during pregnancy to
extend it for delivery
and postpartum
care
Qualitative Formative Research Findings - Buner
Perception that
services are not
affordable
In a cultural context
where women have
little or no decision
making power male
involvement
becomes crucial.
However, the
traditional mindset
that pregnancy and
delivery are female
domains needs to be
tackled
Incorporate dais in
the program
effectively by
defining their
responsibilities and
educating the
community people
about their role
Improve the
knowledge about life
threatening obstetric
complications
The difference in
perceptions of
women and their
husbands/family
members with
regards to
pregnancy care is
eye opening. It is
important to
implement programs
that bridge the gap
between varying
perceptions
The fact that
individuals report
preference for skilled
care is a heartening
finding. This
indicates that the
barriers to accessing
skilled care are not
related to a lack of
knowledge but a
function of access
and cultural barriers.
Explore the
possibility of
harnessing
community support
for establishing
financial schemes
24
25
Qualitative Formative Research Findings - Buner
5.4 Current Health Seeking Behavior for Newborns and
the Key Factors that Facilitate or Hinder these Health
Seeking Practices
5.4.1 Perception of required health services for newborn
Not a single participant mentioned the need for check up of newborn by a
skilled provider, unless ill.
A currently pregnant woman in Chamla stated: “(one) should not go anywhere
if the newborn is not sick, but should take (the infant) to Government hospitals
if ill” (Theek ho bacha to kaheen naheen jana chayey, bemar ho jaye to
sarkaree haspatal ley kar jana chayey)”
Most of the participants stated a doctor/hospital should be visited for the
treatment of illness(es) of newborn. Some of these participants mentioned
availing the services of a child specialist in such cases.
A husband in Chamla emphasizing the need to consult a specialist for a
newborn in case of illness said: “As far as the infants are concerned, I think
child specialist should be consulted for treatment because there is a risk in
consulting a common doctor (physician)” (Jahan tak bachoon ka taaluk hey to
merey khayal men sirf children specialist sey ilaj karwana chayey kion kea am
doctor sey bachoon ka ilaj karwana ek risk hey)
Few thought that paramedics should be consulted for the treatment of the
newborn because they charge less and even provide their services on credit.
A woman with live birth in Swari stated: “We don't go to any one else except
babu (paramedic) our children get well with his treatment and we trust him”
(Hum babu ke ilawa kaheen naheen jatey kion ke un key ilaj sey humrey
bachey theek ho jatey hen or humen un par yaqen bhee hey).
It is alarming that only very few participants mentioned need for vaccination for
newborns.
Rarely participants mentioned that the child should not be taken out of the
house unless there is some extreme illness.
5.4.2 Availability of services for newborn and their
utilization
None of the participants pointed out non-availability of health services for
newborn in their area. The availability of at least a medical doctor and male
paramedics was mentioned in all areas, with addition of some other facilities
as given in Table 5.9:
Table 5.9: Available Health Services for Newborn in the Sampled areas
Chamla (rural)
Private male
paramedics
LHV
Male doctor
Civil Hospital
Korea (rural)
Private male
paramedics
Private male
doctor
BHU
Regga (rural)
Male
paramedics
Male doctor
Private clinic
Swari (rural)
Male paramedics
Male doctors
Female doctor
DHQH
(Dagar Hospital)
Laboratory
X-ray
Qualitative Formative Research Findings - Buner
None of the participants mentioned any services of LHWs for newborn care in
any of the four areas.
Almost all participants from all areas mentioned that services outside their
community are accessible to them. These included Dagar Hospital, Civil
Hospital Chamla, BHU Torwarsak and Cheena, private clinics of doctors and
paramedics and health facilities in adjoining districts of Mardan, Swat and
Peshawar.
Two major reasons were mentioned for seeking care from outside the
community:

Inadequate services in their community

The good quality of care being provided by facilities outside their
community.
A currently pregnant woman in Regga said: “We go to Dagar hospital (DHQH)
because there is facility for (laboratory) test. (It also) has incubator, x-ray and
machines for chest examination. We go for (availing) these services” (Dagar
haspatal men test karney kee sahulat hey, sheesha bhee hey, x ray bhee or
seeney kee kuch machiney bhee hen, hum log in sahulatun ke liye jatey hen
wahan).
A father-in-law in Chamla stated: “For newborn (health care) (we) can go to
Dagar hospital, besides, those who could afford visit Mardan, Peshawar or
Swat” (Nozaeda bachey ke liye Dagar Haspatal ja saktey hen, is ke ilawa jink
e pass paisa ho who Mardan, Peshawar or Swat jatey hen)
Very few participants mentioned that seeking health care from outside
community is expensive and sometimes difficult because of transport
problems. They said that such services are availed by only those who can
afford them. A woman with live birth in Chamla said: “If somebody has money
but could not get treatment in their own area, visit outside (the community)
facilities, otherwise these paramedics are to be consulted for treatment” (Agar
kise ke pass paisey hun or apney ilakey men ilaj na ho sakey to who bahar
chaley jatey hen warna inhee babun sey ilaj karatey hen).
Discussing personal experiences, some women and husbands reported that
they have sought health services for the newborn from either a doctor/hospital
or a paramedic for seeking treatment of an illness. The problems for which
health care was sought from the health providers for the newborn were fever,
diarrhea, pneumonia, malaria, vomiting, cough, abdominal pain and pain in the
chest.
5.4.3 Steps to ensure the health of the newborn
Most participants mentioned a few specific steps to ensure the health of the
newborn. Several women and some family members mentioned keeping the
infant warm or cold according to the season, as the main step. Few
participants in all the three groups also mentioned seeking treatment for illness
from a skilled health provider or hospital and keeping the infant clean. Rarely,
other measures mentioned were improving the diet of the mother, vaccination
of the newborn, TT vaccination of the mother during pregnancy, oil massage of
16
the newborn, protection from saya and evil-eye and giving ghutti.
A few husbands and family members were not aware of any measures that are
taken to ensure the health of the newborn.
16. Saya: effect of evil spirits
26
27
Qualitative Formative Research Findings - Buner
There was some evidence of gender bias. A woman with live birth in Korea
said: “If the newborn is a boy we do take some care, but girls are left on Allah
(to help), nothing is done (for them)” (Agar larka ho tou thora bahut khyal kar
leytay hain, larki ho to Allah kay asray par chor deytai hain, kuch nahi kartay)
5.4.4 Knowledge About Life Threatening Conditions in
Newborn
Many women participants did not mention any condition, while most husbands
and family members specified that they do not know about life threatening
conditions among newborn. Seven women, 1 husband and 2 family members
identified the conditions as given in Table 5.10:
Table 5.10: Knowledge About Life Threatening Complications in Newborn
Conditions
Jaundice
Cold/cough/Pneumonia/Thand
Diarrhea
Does not take feed
Does not cry
Fits
Not mentioned
Don’t know
Women
(23)
Husbands
(7)
Family
Members
(8)
Total
Participants
(38)
5
3
1
1
1
0
1
0
0
0
1
1
0
0
0
6
5
1
1
1
1
0
0
1
12
4
0
6
0
6
12
16
It appears from the above table that the knowledge of life threatening
conditions in newborns is extremely poor among women, husbands and family
members in all four areas of Buner. This situation is well reflected in the
statement of a currently pregnant woman with 5 living children, who said:
“There is no danger to the life of newborn, I don't know what could be
dangerous” (bacchay ki zindagi ko tou koi khatra nahi hota, mujhey nahi
maloom kay usey kya khatra ho sakta hay).
A husband in Chamla said: “I have no knowledge about it”(is ka mujhey koi
pata nahi)
A father-in-law in Swari asked the interviewer in response to his query and
said: “What could be dangerous to the life of newborn?” (nai paida honay
walay bacchay ko kya khatra ho sakta?)
However, it should be noted that in 10 out of 12 interviews of women with live
birth no mention was made about life threatening condition of newborn. All
these interviews were conducted by one interviewer and it appears that she
this question was inadvertently dropped during the discussion on this issue.
Hence a definitive conclusion is not possible.
5.4.5 Actions taken for threat to life of Newborn
As compared to mothers, newborns appear to be receiving somewhat less
medical care in case of an emergency (again, this could be due to the same
interviewer error as mentioned above). Several women, some husbands and
half of the family members mentioned that they prefer to take the newborn to a
28
Qualitative Formative Research Findings - Buner
doctor or hospital in life threatening situations.
A woman from Chamla mentioned that the infant is only taken to a provider if
the parents have enough money, otherwise no help is sought and the newborn
dies.
Only one woman participant from Regga recalled an emergency of newborn,
and the community provided money, arranged transport and accompanied the
family to the facility.
5.4.6 Conclusion
The perception of most of the participants about required health services for a
normal newborns is that health services should not be sought, unless the
infant is ill. Very few participants mentioned the need for acquiring vaccinations
to prevent the newborn from diseases. Also, the knowledge about the life
threatening conditions is very limited.
Table 5.11: Key Factors Facilitating or Hindering Newborn Health
Facilitating Factors
Protecting the
newborn from
severity of weather
conditions
Treatment from
skilled providers on
appearance of
symptoms
Accessible
services outside
community
Hindering Factors
Recommendations
Lack of knowledge
about the need for
check up after birth
Provide basic
information on
care necessary for
a neonate
immediately after
birth and also in
the first 40 days of
life.
Hardly any mention
of seeking
vaccinations
Very low
knowledge about
life threatening
conditions of
newborn in
husbands
Enhance the role
of LHWs in
neonatal care
Provide
information about
warning signs in
newborn
Gender related
issues need to be
considered when
developing
interventions
5.5 Current Birth Preparedness and Complications
Readiness Behaviors and the Key Facilitating or
Hindering Factors
5.5.1 Preparations made for birth by woman, husband
and family members
Spousal Communication: A very clear trend is seen regarding spousal
communication and discussions with other family members on birth
29
Qualitative Formative Research Findings - Buner
preparedness. About half (12 out of 23) of the women mentioned that they
discuss these issues only with their spouse. A woman with live birth in Regga
said: “(I) do not talk about such matters with mother-in-law or other family
members, (as I) feel shy”(Sas ya ghar kay logon se hum is tarah ki batain nahi
kartay, sharam aati hay).
Few women (6 out of 23) mentioned that they discuss it with other female
members of the household and in most of these cases husbands were out of
station.
The remaining few women (5 out of 23) stated that they do not discuss birth
preparations with anybody, and two reasons were given. One was that they
feel shy to discuss it and the other was that it is not considered good to have
these discussions. A currently pregnant woman in Regga said: “I feel shy and I
do not talk about it with anybody at home and it is not considered good to talk
about these matters” (Mujhey sharam aati hay, mein is baray mein ghar mein
kisi se koi baat nahi karti aur aisy batain karnay ko acha nahi samjha jata).
In order of descending frequency of responses, the reported discussions about
birth preparations are: place where delivery should take place, arrangement of
money, transportation arrangement, blood arrangement, where to go in case
of complication, who will accompany the woman, and antenatal care. A
currently pregnant woman from Regga describing the spousal communication
said: “Yes, I have discussed, I have asked him (husband) to arrange money,
transport and blood. This has (also) been discussed that the delivery will be
conducted by Dr. Gulnaz” (han meri batain hui hain, mein us se kehti hon kay
paisay gari aur khoon ka intizam karo, yeh baat hui hay kay baccha doctor
Gulnaz kay hath paida hoga)
A woman with live birth in Chamla, describing her discussions for birth
preparation said: “I used to talk to my mother-in-law about non availability of
money at home and what will we do (without it) if the delivery happens
(unexpectedly)” (Sas se batain karti thi kay ghar mein paise nahi hotay aur
agar bacchay ki paidaish ka waqt ho gya tou phir karain gay)
In contrast to women, all husbands and several family members (5 out of 8)
mentioned that there is discussion among husband and wife regarding birth
preparation and the issues mentioned are similar to those described by
women. A brother-in-law in Chamla said: “It is strictly forbidden in our family
and culture that (a) woman talks about such matters with anybody, except
husband” (Hamaray khandan aur culture mein ye cheez sakhti se mana hay
kay aurat shohar kay ilawa kisi aur kay sath is tarah ki cheezon par behas
karay).
As evident from the above sentences of the participants, some preparations for
birth and complication readiness are taking place in this district.
Slightly more than half of the women (12 out of 23), most of the husbands (6
out of 7) and many family members (6 out of 8) mentioned money
arrangements as the primary preparation. Distinctively, the amount was
mentioned by males only and it was up to Rs. 13,000. A father-in-law in Swari
said: “I always keep Rs. 5000 to Rs. 10,000 and this is our preparation. (We)
have car, Besides this we neither think or prepare and leave the rest to God”
(bus hamari tayari tou ye hoti hay kay mein ghar mein panch dus hazar rupay
hamesha rakhta hun, gari pas hay, is kay alawa na hum sochtay hain na
kartay hain, bus Allah par chor daite hain).
Qualitative Formative Research Findings - Buner
from Swari said: “(we) take the loan from somebody (in advance). (The money)
could be required anytime as my 10th month has begun” (Paisay kisy se qarz
lay kar rakhay hain, kisy bhi waqt zaroorat ho sakti hay kyunke mera daswan
mahina shoru hua hay)
Several participants (24 out of 38) stated that the decision about the place of
delivery is made in advance. Most of them mentioned that they decided about
the doctor/hospital even in case of an expected normal delivery.
A currently pregnant woman in Swari said: “My motherin-law has told me that
we will go to Dr. Gulnaz for delivery”(Meri sas ne kaha hay kay bacchay ki
paidaish kay liyae doctor Gulnaz kay pas jain gay).
For very few the choice is to deliver at home and the dai is informed some
days in advance or LHV is called at the time of delivery.
A woman with live birth in Swari describing this said: “No preparations were
made, only dai was informed before hand and she was called for conducting
the delivery. Males do not allow us to go out”(Koi tyari nahi ki thi, sirf dai ko
pehlay se bata dya tha aur usey ko bulaya zichgi kay liyae, hamaray mard
bahar janay nahi deiti).
The decision is also taken in advance that in case the dai cannot handle, then
the woman will be taken to the hospital.
In case of anticipated complications, the provider/place is also discussed in
advance. A woman with live birth while explaining her reason for the
preference of doctor stated: “During pregnancy (we) decided that (I) will go to
Dr. Gulnaz for delivery, because I lost two babies at the hands of dai before
the birth of the twins”(Hamal kay doran socha tha kay lady doctor Gulnaz kay
pas jana hay kyunke jurwan bacchon se pehlay dai kay hath do bacchay zai
ho gai thay)
Few participants (8 out of 38) mentioned that arrangements for transport are
made in advance. The person with the vehicle in the community is identified
and the possibility of using the vehicle is discussed.
Very few participants (6 out of 38) mentioned prior discussions about
arrangement of blood. These arrangements included identification of donors
such as close relatives, husbands and friends.
A husband in Korea said: “(I) arranged blood, contacted friends and relatives
on phones and inquired about (their) blood groups, and prepared them for
giving blood”(Blood ka intizam kya, jo yaar dost aur rishtaydar hain un ke sath
telephone par rabta kya, blood group maloom kya, aur un ko blood kay liyae
arrange kya)
While others mentioned that they plan to purchase blood at the time of need. A
woman with live birth in Swari said: “(When) Dr. Gulnaz asked to arrange for
blood (at the time of delivery), we thought that we will purchase it (at that time)”
(Doctor Gulnaz ne khoon kay intizam kay liyae kaha to soch tha kai paison se
khareed lain gay).
Very few (5 out of 38) mentioned about antenatal care as a preparation for
birth.
Very few participants (4 women and 1 male family member) mentioned about
TT vaccination as the preparation for birth.
As part of preparation, monetary arrangements are made through savings,
contributions from close relatives and/or loans. A currently pregnant woman
30
31
Qualitative Formative Research Findings - Buner
Qualitative Formative Research Findings - Buner
A currently pregnant woman from Korea said: “I go to hospital for TT
vaccination during pregnancy so that I and the (expected) baby remains
healthy” (Mein hamal kay doran hifazati tikon kay liyae haspatal jati hon takay
meri aur meray bacchay ki sehat achi rahay. Hum tou gharib log hain aur tou
koi tyari nahi kartay).

Few participants (7 out of 38) reported that necessary clothes and beddings
are made for the expected infant. Only one participant, a husband, mentioned
that these are made for the mother also.
5.5.2 Hindrances in BPCR
Acquisition of desi ghee and chicken for feeding after delivery was mentioned
by very few participants (4 out of 38), and all of them were women.
Only one woman mentioned abstinence from sexual intercourse as a measure
to stay healthy in the later months of pregnancy.
Rarely participants (3 out of 38) mentioned that no preparations are made for
birth. One husband mentioned that they have enough money and transport,
hence there is no need for any preparation. One woman said that they are too
poor to make preparation, while the other woman from Chamla described a
totally different reason and said: “We don't discuss these matters beforehand
that what should be done at the time (of delivery). It is not good that family
members discuss that what will be done at the time (of delivery)” (Hum log ye
batain pehlay se nahi kartay kay us waqt kya karma chahiyae, yahan bura
samjha jata hay, ye achi baat nahi hoti kay aurat hamla ho aur ghar walay ye
batain karain kay us waqt kya karna hay).
About half of women (12 out of 23) mentioned that service providers helped
them in preparation for birth or complication readiness by providing good care
in pregnancy and advices. These included guidance for diet and rest,
supplements like iron, TT vaccination, prior information for operation. Most of
these providers were skilled providers, either doctor or LHV. Only two
mentioned about the visit of LHWs to their home and the guidance provided by
them. The remaining half of the women expressed that service providers do
not provide any help.
One husband mentioned that a service provider did not charge for treatment.
While some of the family members stated that only advice is given by the
doctor or LHV. The remaining relatives and husbands expressed that the
providers have given no support in BPCR.
It can be concluded that

Discussions about BPCR between wife and husband are of moderate
level and limited with other family members

BPCR is fairly low and is very variable among participants

Apart from the usual problems with making arrangements most notably
poverty, there are in this case some normative factors that hinder BPCR
namely the belief that is it's not appropriate to discuss these types of
things.

Different actions are taken by few to several participants include:
collection of money, decision for place of delivery, arrangement of
transport and blood, preparation of clothes for the infant, and some
improvements in diet.

The help from skilled service providers is mostly limited to antenatal care.
The difference in perceptions about spousal communication is
interesting, while all husbands reported spousal communication. Only
half of the women reported the same. In the context of a male dominated
environment one has to wonder about the level and quality of the
communication that is going on.
All women, family members and husbands pointed out hindrances in BPCR,
both for mother and newborn. All women and family members and almost all
husbands mentioned money as the major hindering factor in undertaking any
BPCR practices. However, only some of them gave examples of desired
actions in case they did have the money. These actions included arrangement
of transport, delivery by doctor or in hospital, purchasing medicine, providing
good diet to the mother, clothing for the newborn and treatment from
appropriate place in case of obstetric emergency and newborn complications.
A woman with live birth in Regga said: “Nothing could be done without money
as doctor gives treatment on payment of fees, medicines are purchased with
money, items needed for the newborn are acquired with money, and if any
complications or problem occurs then too money is required” (Agar paisey na
hoon to kuch bhee naheen kia ja sakta kion ke doctor paisey sey ilaj kartee
hey, dawaee paisey sey atee hey, bachey ke liye cheezen paisey sey atee hen
or agar koi pecheedgi ya masla ho to is ke liye bhee paisey zaroori hen).
Another currently pregnant woman in Chamla remarked: “No preparation can
be done if there is poverty and no money. Without money no transport is
available to carry the mother or newborn, and if the doctor is not close by one
cannot reach them” (Gurbat ho paisa na ho to koi tiyari naheen ho saktee,
paisey ke bager zicha bacha ko lejaney ke liye koi garee naheen miltee, agar
doctor nazdeeq na ho to wahan tak paisey ke bager naheen puhanch patee).
A husband in Swari said: “(Lack of) money is the hurdle in the preparation.
Those who do not have money can neither prepare nor do anything during
difficult times either in pregnancy or afterwards” (Tiyarion men rukawat to
paisa hey, jink e pass paisa naheen wo hamal ke doran ho ya is ke bad ho na
koi tiyari kar saktey hen na mushkilat ke waqt kuch kar saktey hen).
Very few women and only one relative mentioned permission of husband or
elders like father-in-law or mother-in-law to take the woman or newborn
outside the home, as a major hurdle at the time of delivery and dealing with the
maternal or newborn emergency. A woman with live birth in Swari said: “If the
husband does not allow to go outside home and insist that the delivery should
take place at home, whatever may happen, then the pregnant woman just
relies on the help of God” (Agar khawand ghar sey bahar janey kee ijazat na
dey or kahey ke jo bhee ho bacha ghar men paida hona chayey to phir zicha
Allah ke asrey par paree rehtee hey).
While very few women said that even discussing the issue of pregnancy or
delivery is not considered appropriate in the house, hence it is a major
hindrance in preparations.
Very few participants mentioned non-availability of the service provider or any
close by health facility as a significant hindrance. A woman with live birth in
Korea stating this hindrance said: “There is hindrance (in preparations for birth)
if hospital or doctor is not nearby” (Haspatal or doctor kareeb na hoon to
rukawat hey).
Very few women referred to non-cooperative attitude of husbands and family
32
33
Qualitative Formative Research Findings - Buner
members as a hurdle in preparations.
Table 5.12: Conclusions About BPCR and Recommendations
Very few women and family members mentioned non-availability of transport
as a hindering factor in BPCR.
Two of the women participants, whose husbands were away, said that their
absence from the house is also a hurdle in preparing for the birth or seeking
care during obstetric emergency. A currently pregnant woman in Chamla said:
“If the husband is not at home (and) is out of country, then it is a hindrance, as
preparations cannot be made” (Rukawat ye hey ke mard ghar par na ho, mulk
sey bahar ho to bhee log tiyari naheen kar saktey).
Rarely, participants indicated lack of knowledge about what to prepare,
arrangement of blood in case it is needed and absence of a male at the time of
delivery as limitations in preparation.
5.5.3 Conclusions for BPCR:
The conclusions with recommendations are presented in Table 5.12
Facilitating Factors
Hindering Factors
Recommendations
Some discussions
among husband and
wife about birth
preparation.
Discussions of
BPCR among family
members considered
taboo
Collection of money
for delivery
Not enough money
Well informed the families
about the needs in pregnancy,
delivery and postpartum and
newborn; the dangers
involved during these periods;
and specifying the problems
that need treatment
Decision making for
place of delivery and
provider
Efforts to make
arrangement for
transport
Support from family
members
Availability of
transport with some
participants
ANC from skilled
provider
Very limited skilled
female staff in rural
areas
Prior arrangements
for blood by few
Restriction by
husband in seeking
care from outside
home
Introduction at home level of
specific topics that merit
discussion at the spousal level
Consider schemes related to
making transport available at
community level
Introduce innovative
messages and materials that
address the real and
perceived issues related to the
lack of money as a hindrance
to BPCR
Advocacy at the policy level
regarding provider staffing at
the local level
Shared (Male & family)
responsibility for maternal and
neonatal health outcomes can
be a key message
Train health providers to take
a preventive approach and
clearly explain desired
behaviors, expected problems
and treatment that is
understandable to families
34
Qualitative Formative Research Findings - Buner
5.6 Religious and Cultural Practices Surrounding
Maternal and Neonatal Health
5.6.1 Religious/cultural ceremonies
Religious/cultural ceremonies and taboos during pregnancy: Almost all of
the female participants mentioned that no cultural ceremonies are performed
during pregnancy.
17
Many women stated that a religious ceremony of “Khatum” is held when a woman
gets pregnant, in which relatives and neighbors are invited for reading of the Holy
18
Quran or certain of its Surah. After this reading, a collective prayer session is
conducted for safe pregnancy and delivery and sweet meat is distributed among
the participants. A currently pregnant woman in Swari describing this event said:
“When a woman gets pregnant, we invite (other) women to the house for reading
of the Holy Quran“Khatum”, either prepare sweet meats or bring (from outside)
and distribute it among the women and neighbors. After “Khatum” (we) pray for
facilitation in pregnancy and delivery” (Jab aurat hamla ho to hum aurton ko ghar
bula kar, Quran ka khatum kartey hen, halwa pakatey hen ya mithai latey hen, ye
cheezen khatum karney waloon ko khilatey hen or mohaley men bhee detey hen,
khatum ke bad duwa kartey hen ke hamal or paidaish men sab kuch khariat sey
ho).
Almost half of the women said that various Surah of the Holy Quran are recited
during the period of pregnancy. These included Surah Yasin, Surah Marium,
Surah Yousuf, Surah Rahman, Surah Muzzammil and Surah Alum nashrakh.
These Surah are recited for facilitation in delivery and safety of mother and the
infant. Some of the women said that they say Nafil prayer during this period.
Rarely mentioned were reciting the 99 names of Almighty, vowing to fast, say
19
20
Nafil prayers and offer Sadqa.
One participant, a Sikh in Korea, mentioned
21
reading of “Garanth Sahab” during this period.
Almost all of the husband and family members stated that no cultural ceremonies
are performed during pregnancy. Many of these pointed out that Surah from the
Holy Quran are recited. These included Surah Yasin, Surah Muzzammil and
Surah Rahman. Sikh participants mentioned reading of “Garanth Sahab” during
pregnancy for easy delivery and to avoid any complication. Rarely mentioned
22
23
were actions like visiting Pir or Faqir for seeking their blessings for safety of the
mother and the infant and distribution of alms among the needy or contributing to
the Mosque expenses.
17. Khatum: An occasion where a group of men or women gather to read different Chapters
of Holy Quran and complete the reading of the entire Holy Quran in one sitting
18. Surah from Quran: chapters from Quran
19. Nafil Prayers: Namaz offered at will and not linked to the five daily Namaz which are
mandatory
20. Sadqa: a religious act in which cash or slaughtered animal is distributed among needy to
protect from or ward off the bad effects
21. Garanth Sahab: A Holy Book of Sikh religion
22. Pir: Saint who have several hundred followers
23. Faqir: A person who is perceived to have given up all worldly things in pursuit of God
35
Qualitative Formative Research Findings - Buner
Several taboos were mentioned by the participants during the discussions
which included persons and occasions which pregnant women should strictly
avoid. While some women said that pregnant women should avoid going outside
the house at all. Very few women mentioned different persons that should be
avoided. These included women in postpartum, women who had still births and
people wearing Tawiz. Almost half of the women mentioned occasions that a
pregnant woman should not attend, and these were funerals and weddings. The
reason for applying all these inhibitions is that they have bad effect on fetus and
could lead to its death while going outside of the house is thought bad and
shameful.
A currently pregnant woman in Regga said: “(Pregnant women) are forbidden to
attend funeral because (it is believed that) the fetus will be dead in her womb even
if the shadow of the dead is cast on her” (Mayat men janey sey mana kartey hen
ke agar mayat kee charpaee ka saya is aurat par par gaya to is ka bacha pet men
mar jata hey).
Another currently pregnant woman in Korea stated: “Pregnant woman is not
allowed to go outside of the house because it is not perceived good. It is not taken
as good if such a woman visits outside” (Hamla aurat ko ghar sey bahar janey
naheen detey kion kea cha naheen lagta. Asee aurat ghar sey bahar jaye is ko
bura samjha jata hey)
Many husbands also mentioned occasions, which included funerals and wedding
ceremonies while some said that a pregnant woman should stay at home. It was
believed that attending such ceremonies could be harmful to the fetus and going
out of the house is considered against the traditions. Few husbands thought that
visiting places like graveyard or hilly areas could prove harmful to the woman who
is pregnant. A husband in Swari said: “(Pregnant woman) cannot visit a grave or
24
go close to the dead because in that case she will come under “saya” and this
could affect the fetus (negatively)” (Maqbarey men bilkul naheen jatee hey or gum
yanee murdey ke pass bhee naheen ja saktee kion ke aisa karney sey us par saya
par jata hey or phir aney wala bacha zerey asar ata hey).
Half of the family members also mentioned about not attending funeral by a
pregnant woman whereas some of them considered it bad for a woman to get out
of the house during pregnancy. Reasons for such inhibitions were similar to those
given by husbands. A brother-in-law in Chamla said: “Women are strictly not
allowed to go out of the house during pregnancy, especially for weddings, other
happy or sad occasions, as it does not look good and people gossip (about the
pregnant women)” (Hamal kay doran aurton ka ghar se bahar nikalna khas kar
ghami khushi shadi kay mawaqay par bilkul jana mana hay kyunkay acha nahi
lagta aur log batain banatay hain).
Qualitative Formative Research Findings - Buner
Around the time of delivery: None of the participants mentioned any cultural
practice around the time of delivery. Though very few women and only one
relative reported that Nafil prayer is said around this time for the safety of woman
and infant during delivery. Only one woman mentioned offering Sadqa at this
time.
In postpartum: Many women, few husbands and half of the family members
stated that a woman in postpartum should not go outside of the house (for about
40 days as mentioned by some) because it is believed that she could come under
25
the influence of evil spirits orJinn, she could get scared, going out is a “sin”, she
could get evil eye, and even fall sick. Some places, occasions and persons were
also identified by the participants that should not be visited, attended or met by a
woman during the postpartum period. These were similar to those mentioned for
pregnancy and almost all indicated having bad effects on the newborn.
A husband in Chamla said: “A woman cannot go out of the house during
postpartum as her body and mind, both, are weak during this period. People say
that she might get frightened and there is danger of jinn (overpowering her)”
(Chiley ke doran to aurat ghar sey bahar kaheen bhee naheen ja saktee us waqt is
ka badan or zehan dunon kamzoor hotey hen, is liye log kehtey hen ke who dar
jaye gee or jin bhoot ka khatra hota hey).
Rarely women and few husbands said that there is no such prohibition during
postpartum period.
26
Only two women specifically mentioned that they celebrate Aqiqa. Many women,
several husbands and most of the family members mentioned that they distribute
sweets such as sweet rice, halwa, peanuts etc, serve lunch to the relatives and
neighbors, friends, distribute alms among the poor, distribute clothes among
relatives on the birth of the infant within the first fortnight. A few of family members
and husbands mentioned additional activities such as beating drum, firing shots
in the air and singing songs, which is done only on the birth of a male child. Few of
the husbands and family members mentioned that relatives bring clothes and
gifts for the newborn at this occasion.
The fact that some report that pregnant women should not be allowed to go out of
the house at all has programmatic implications.
Many of the participants mentioned that celebrations are more for the male
newborn. A husband in Korea said: “If the newborn is a girl then nothing is done,
but there are different traditions for boys. Drumming and singing is arranged,
some fire (bullets) in the air, some send food to mosque, incoming guests are fed
and also given sweets and peanuts, and those who visit to congratulate also bring
clothes and gifts for the newborn” (Jab bacha paida ho jaye to agar larkee hey to
kuch bhee naheen kartey jahan tak larkey ka taaluk hey to is kee paidaish ke
moqey par mukhtalif riwaj hen, dhol or ganay bajanay ka bandobast kartey hen
koi hawaee firing karta hey koi masjid ko roti chawal bhejtey hen jo mehman ghar
men atey hen un ko roti chawal khilatey hen, mithai or mong phalli detye hen or
jatey waqt mong phalli sath ley jatey hen, jo log mubaraki kliye atey hen who
nozaida ke liye suit or chotey tuhfey bhee ley atey hen).
24. Saya: effect of evil spirits
25. Jinn: a spirit able to appear in human and animal forms and to posses humans
26. Aqiqa: a christening ceremony
Very few participants did not mention any of these beliefs.
36
37
Qualitative Formative Research Findings - Buner
In summary, while there are almost no cultural practices, Khatum appear to be
highly prevalent. Women are restricted to meet certain people, visit places and
attend some occasions some of which has important program connotations.
Apart from avoiding weddings and funerals there is also the belief that pregnant
women should not go out of the house at all. This has implications for the kinds of
information she can access, without it being filtered through others.
5.6.2 Preferred and forbidden food items for breastfeeding
mothers
Chicken (mentioned by 20 out of 38 participants) and meat (mentioned by 16 out
of 38) are the predominantly preferred foods for mothers. This was followed by
vegetables (brinjal, spinach, potato, pumpkin, tomatoes) fruits (apple, banana,
orange, grapes guava) and milk, desi ghee,27pulses, halwa, fish, liver, dry fruits.
Those mentioned by one participant were juice, soup, roti and yoghurt. The stated
reasons were that these foods increase the milk of the mother (apple, milk, juice,
chicken, meat, desi ghee, yoghurt, dry fruits), increase blood in the mother (liver
and apple), prevent jaundice in newborn (kaddo/tinday).28
Table 5.13: Preferred Foods and Number of Participants Who Mentioned it
Number of Participants Who Specified Different Preferred Foods
Food
Chicken
Meat
Vegetables
Fruit
Milk
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Desi ghee
Pulses
Qualitative Formative Research Findings - Buner
Table 5.14: Forbidden Foods and Number of Participants Who Mentioned it
Number of Participants Who Specified Different Forbidden Foods
Foods
Vegetables
Spices/Spices
1
2
3
4
5
6
7
8
9
Pulses
Rice
Lassi
Yoghurt
Corn
Ghee
5.6.3 Precautions taken during postpartum to ensure
safety of mother and newborn
Participants identified several precautions that are taken to ensure safety/health
of the mother and newborn. These are given in Table 5.15 and 5.16.
Table 5.15: Precautions During Postpartum to Ensure Safety of Mother
Precautions during
postpartum for safety
of mother
Family
members
(8)
Women
(12)
Husbands
(8)
Total
Participants
40
Do not go out for 40 days
14
2
2
18
Protect from cold
Should not work at all
14
8
1
3
3
2
18
13
Avoid heavy work/lifting
weights
7
4
2
13
Take good diet
7
1
4
12
Protect from hot weather
4
0
2
6
No water but only green/
black tea for 7 days
2
0
0
2
Halwa
Should not be left alone
1
0
0
1
Fish
Liver
Dry fruit
Juice
Soup
Should not go out in the
evening
0
1
0
1
No bath for 40 days
1
0
0
1
Keep a knife with mother
1
0
0
1
Roti
Yoghurt
Among forbidden foods, vegetables (potato, radish, spinach), pulses and
chili/spicy foods topped the list and were mentioned by all groups of participants.
Other foods mentioned were lassi, corn, rice, yoghurt, and ghee. Rarely
29
mentioned were meat, fish, sour items like lemon, garam food, chilled water. Nine
out of 38 participants did not mention any forbidden food.
Vegetables, pulses, spicy foods are considered to give colicky pain or diarrhea in
30
the newborn who is being breastfed. Sour and cold foods are believed to give
cold, flu, pneumonia to the newborn. Some foods are believed to dry up the milk of
the mother (potato, lemon, chilies, and yoghurt).
Table 5.16: Precautions During Postpartum to Ensure Safety of Newborn
Precautions during
postpartum for safety
of newborn
Protect from cold
Do not take outside home
for 40 days
Women
(12)
17
15
Husbands
(8)
Family
members
(8)
1
0
6
0
24
15
7
Total
Participants
40
Protect from hot weather
4
0
3
Should not be left alone
1
0
0
1
Keep a knife with mother
1
0
0
1
Breastfeeding
Mother to avoid cold foods
1
0
0
1
0
Vaccination
0
0
1
1
Expose to sun to protect
from jaundice
1
0
0
1
1
1
27. Desi ghee: clarified butter
28. Kaddo/Tinday: pumpkin
29. Garam foods: foods believed to have hot effects inside the body
30. Cold foods: those foods that are believed to have cold effects on the body
38
39
Qualitative Formative Research Findings - Buner
Reasons were given for different precautions.


Mother and newborn should be protected from cold weather, to avoid illness
The mother and newborn is restricted from going outside of the house to
31
avoid from the effects of jinn, saya (evil spirits), nazar; getting scared;
developing paralysis; getting effects of cold.

Mother and newborn should never be left alone during postpartum period, as
they both could get scared.

Mother should not indulge in heavy household work like washing clothes,
lifting weight etc. because this could cause bleeding and also lead to thand
(effects of cold).

Mother should place a knife beside her to keep the jinn away

Mother should be given good diet during the postpartum period to keep the
newborn healthy

Mother should not take bath for 40 days as she could get pains and the
newborn could fall sick

Mother should not drink water for seven days but only green tea as she could
get the effects of cold and her abdomen can swell.
Qualitative Formative Research Findings - Buner
5.6.4 Feeding of newborn
Several of the participants (25 out of 38) mentioned Ghutti as the first item of the
intake while few suggested breast milk (7 out of 38). Other items mentioned were
green tea (4), honey (2) and water (1).
Ghutti is given for several reasons:






It is believed that mothers milk does not come immediately (colostrums is
not considered mothers milk) hence ghutti is given as a replacement,
which could be up to 3 days
Cleans the stomach of the newborn and avoid colics
Keeps the newborn warm
Infant sleeps well
Gives strength and keeps the newborn healthy
32
The person who gives the ghutti, transfers his/her personality traits to the
newborn.
33
A woman with live birth in Korea said: “My mother-in-law tell s me not to go out as
(I) will get the effects of evil-eye. If a boy is born and some outsider comes, she
tells them
that the newborn is a girl” (meri sas tou kehti hay kay bahar na niklo, nazar lag jai
gi. Agar larka paida hua ho aur ghar mein bahar se koi aae tou keh deti hay kay
larki paida hui hay)
A mother-in-law in Regga said: “In postpartum, the woman is restricted from lifting
weight, doing household chores, wetting body or washing hands and feet with
cold water, going out of the house, and newborn is kept warm”(Chillay mein ma ko
wazan uthanay se mana kartay hain, ghar kay kam nahi karnay daite, thanday
pani se jism ko gila karnay ya hath paon dhonay se mana kartay hain, bacchay ko
garam rakhtay hain, aur chillay mein ma ko bahar nahi janay deitay).
As evident from above, two key measures that could affect the health of the
mother are not to do heavy work and good diet, and these have been mentioned
by only less than one-third participants. Hence, it could be inferred that not much
is being done to maintain or promote the health of the mother during postpartum.
For newborn, only one significant step is being taken and that is protection from
severity of weather.
Ghutti is mostly prepared at home and is mainly composed of herbs (ajwain, alam,
mamber, hanja, rajja, sona patta, saparkey, potay, and landlais) in desi ghee or
green tea. 6 out of 38 participants mentioned buying prepared ghutti from the
market.
A husband in Regga said: “Ghutti is given before milk, it is a herb called raja that is
mixed in black tea. It is given to avoid illness in the newborn as the mother's milk is
given after three days”(doodh se pehlay ghutti daite hain, ye aik jari booti hay jis
ka naam raja hay, is ko baghair doodh ki chai mein milaya jata hay. Ye is liyae
daite hain kay baccha beemar na hojai kyunke ma ka doodh tou teen din baad dya
jata hay)
Discussing the first feed of mother's milk, some women (10 out of 24), very few
husbands (1 out of 7) and few family members (2 out of 8) mentioned that it should
be given within the first hour of birth. Some women (7) and husbands (2) and very
few family members (1) mentioned timings that fell within 1-6 hours. Few women
(6 out of 23) and family members (2 out of 8) and several husbands (4 out of 7)
stated that the first feed of mother milk should be given sometime between
second to fourth day. The main reason given for delayed initiation of
breastfeeding is that milk flows from the breast after 2-3 days.
Different items were mentioned as alternative for mother's milk, which are given in
the first 2-3 days. These include ghutti or black/green tea. It is interesting to note
that mother's milk is not replaced by cow or goat milk. A woman with live birth in
34
Korea expressing this view said: “Ajwain, saunf are boiled in black tea, then
strained, and then given to the newborn as the mother's milk comes after three
days”(qahwa mein ajwain, saunf ubal kar, chan kar, putli mein bhigo kar bacchay
ko daite hain kyunke zichha ka doodh teen din baad utarta hay).
Once initiated, the feeding of breast milk has been mentioned to be frequent by
several of the participants (25 out of 38). They stated that the newborn should be
31. Nazar: evil-eye
40
32. Ghutti: mixture given as a ritual first food to newborn and later to soothe the infants
33. Ajwain, alam, mamber, hanja, rajja, sona patta, saparkey, potay, and landlais: different herbs
34. Saunf: anis seed
41
Qualitative Formative Research Findings - Buner
fed on demand or after every 2-3 hours. This was higher among husbands then
women.
With the above evidence, it becomes apparent that misconceptions pertaining to
initiation of breast feeding and feeding of colostrums are important intervention
areas.
5.6.5 Bathing patterns
Many women (16 out of 23), some husbands (2 out of 7) and half of family
members were in favor of giving bath to the newborn immediately within first hour
after birth. Few women (5 out of 23) felt that this should be done between 2 to 24
hours after delivery. Other gave the timing of first bath to be from second to 20th
day, which included 1 woman, many husbands (5 out of 7) and few family
members (2 out of 8). This reflects that husbands are not very closely involved in
the delivery process; hence they are not aware when the baby is being given first
bath, which is soon after delivery in many cases.
In the following days, the frequency of bathing for newborn varied substantially
from daily to the 40th day among all the three groups. However, the commonly
suggested frequency for summer is daily or every 2-3 days.
Many participants (27 out of 38) were of the opinion that the mother should take
her first bath between 35 to 40 days. Nine mentioned it between 13 to 25 days.
Only one woman stated that it should be on the third day and she was Urdu
speaking, indicating the difference in practice by a different ethnic group. A Sikh
husband said that it should be taken when the woman feels fit. Hence, the first
bath is delayed and the commonly mentioned reason was that it is a tradition.
A husband from Regga said: “The woman takes bath 40 days after delivery (and)
does not wash face and hands for 20 days” (Baccah paida honay kay baad aurat
40 din baad nahati hay, bees din tak munh hath bhi nahi dhoti).
5.6.6 Presence and effects of Nazar (evil-eye)
Most participants (18 out of 23 women, 6 out of 7 husbands and 7 out of 8 family
members) believed that nazar exists.
Pregnant women: Many husbands (5 out of 7) expressed that nazar has bad
effects and it could cause illness in the expectant mother or lead to death of the
fetus. The affects mentioned by 18 women were some kind of illness or
complication, which included lethargy, headache, fever, heavy eyes, abdominal
pain, body ache, irritable, pain in bladder, bleeding, difficult delivery. Among
family members, all except one believed in the bad effects of nazar on a pregnant
woman, with which she could fall sick, bleed, have miscarriage or even die.
Women in postpartum: Many women (16 out of 23) believed in the effect of
nazar during postpartum. They mentioned different symptoms, which include
headache, fever, body ache, backache, cough. Some husbands (3 out of 7) and
several family members (5 out of 8) stated that women could get illnesses such as
vomiting, headache, body ache, stomachache, cough, fever. One husband from
42
Qualitative Formative Research Findings - Buner
Swari mentioned that a woman in postpartum cannot get the effects of nazar
during postpartum: “It is strange for a woman to get nazar during postpartum as
she does not take bath for 40 days and stinks, has uncombed hairs and is in
horrible state. What could an evil-eye do to her?” (Chillay kay doran aurat ko
nazar lagna ajeeb hay kyunke wo challis din tak nahati nahi hay, us kay badan se
badbo aati hay, bal bikhray hotay hain, bura hal hota hay, us ko nazar kya keh
sakta hay?).
Newborn: All, except 2 husbands, 1 family member and 5 women believed that
the newborn could be affected by evil-eye. The women mentioned that the
newborn becomes ill. Other mentioned effects were: cries a lot, stops taking milk,
becomes irritable, develops fever, colic, cough, vomiting, diarrhea, constipation,
starts drying up. Interestingly one husband expressed that it does not affect the
female infant and only affect the male newborn as they are beautiful
Measures to protect mother and newborn from Nazar : The measures
mentioned to protect mother and newborn from nazar are:
 Say mashallah 35
 Tie a piece of black cloth on arm
 Giving smoke of nazar panrah
 Wear Tawiz
36
Measures to overcome Nazar in mothers and newborn: Some specific
measures to overcome the effects of nazar were mentioned by all groups of
participants:
37

Dum from buzurg

Treat the affected with smoke of red chilies, alum, mustard seeds, and herbs
38
39
like harmal, nazar panra, sipleni

Rotate alum, chilies, harmal over the head of the affected and burn in fire

Burn a piece of black cloth in fire
Conclusion:
Some cultural beliefs and practices have positive effects on health, others have
negative effects, while some have neither. Summary of these are given in Table
5.17.
Table 5.17: Summary of Positive and Negative Cultural Practices
Positive Practices
Negative Practices
Recommendations
Surah of the Holy
Quran is recited during
pregnancy and delivery
for gaining Allah's
blessings. Hence give
psychological comfort
and strength
Not feeding colostrums
considering it to be bad
for the baby and giving
replacement feeds like
ghutti, tea
The importance of
giving newborn
colostrums should be
stressed.
Milk is given to
breastfeeding mothers
and effort is made to
give good diet mother
during pregnancy and
postpartum
Mother should take her
first bath after between
35-40 days. Lack of
hygienic practices could
factor into both maternal
and neonatal falling ill
Optimal and appropriate
bathing patterns need to
be promoted and
established
35. Mashallah: Islamic version of touch wood
36. Nazar panra: a leaf
37. Buzurg: elderly pious man
38. Harmal: turmeric
39. Sipleni: a leaf
43
Mother should take her
first bath after between
Qualitative
Research Findings - Buner
35-40
days. LackFormative
of
hygienic practices could
factor into both maternal
and neonatal falling ill
Breastfeeding the infant,
early initiation and
frequent feeding
Significantly preferential
treatment for male child
Might consider
addressing preference for
male children as an over
arching social norm
Protecting mother and
newborn from the
severity of weather and
thand
Restricting the mother
and newborn from going
outside of the house
during postpartum
Work on highlighting that
measures to overcome
nazar should
simultaneously be
carried out with medical
interventions
Restricting mother from
undertaking heavy work
Some symptoms of
medical problems are
related to Nazar. This
could lead to delayed
medical intervention.
Regular bathing of
newborn
44