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In qualitative research, there is a growing interest in understanding the use of timelines in combination with other qualitative methods. In this paper, we will address how the creation of timelines facilitated and informed the process of semi-structured interviews. We used an interpretive descriptive qualitative study to understand the perceptions and experiences of developing sexuality among female adolescents of Pakistani descent, and timelines were used as a part of the semi-structured interview process. Timelines were created in a participatory way in which girls were asked to recount significant events related to their sexuality. We found that the methodological combinations within qualitative research such as semi-structured interviews and timelines have the potential to advance knowledge regarding the experience of immigrant female adolescents’ sexuality. Using the timeline strategy to collect data helped in building rapport with the participants, allowed the participants to become active partners and navigate the process, and helped them to think about future resolutions through reflection.

Background Pakistan’s maternal mortality rate remains persistently high at 186/100,000 live births. The country’s government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the “24/7 BHU” initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab? Methods The project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4–5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, “change ideas” are selected for testing in one district and 2–3 BHUs through carefully documented pilots using the PDSA (plan–do–study–act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project. Discussion This theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities.

Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives’ experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1–19), attended 2.9 births (range 0–10) and provided care to 1.6 postnatal patients (range 0–7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan’s minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients’ inability to pay was the critical factor in the midwife practices’ low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government’s responsibility to provide safe childbirth services onto providers who can least afford to offer such care.

A key objective of Pakistan’s family planning program has been to increase awareness of the benefits of a small family. Despite five decades of effort, family size ideals of four children persist. ...

The sexual health needs of female immigrant adolescents in Canada have been largely unmet and have increased in magnitude over the last few years. Evidence suggests that immigrant adolescents lack sexual and reproductive health knowledge and use fewer sexual health-related services and sex education resources than do non-immigrant youth. In Pakistani immigrant adolescents, this difference appears to be associated with socio-cultural and religious practices. This paper aims to describe how first-or-second generation Pakistani-descent female adolescents, living in Canada, describe their perspectives on developing sexuality and well-being. In addition, this paper explicates female adolescents’ perceptions of their needs to support their sexuality while going through the adolescence stage. Using a qualitative interpretive descriptive design, individual interviews were conducted in combination with drawing timelines. A purposive sample of 21 female adolescents who were first- or second-generation Pakistani-descent was obtained. A thematic analysis approach was used for data analysis. Findings suggest that immigrant female adolescents encounter mental health concerns as a result of confusing messages they received from their parents related to sexuality. Also, discrimination, exclusion from sex education classes, and lack of knowledge on sexual health can result in social exclusion, avoidance of health care, and poor mental health outcomes such as depression and anxiety. These participants related experiences are potentially contributed by the lack of communication with parents about sexuality and lack of health care providers who can understand and speak to their needs and realities as immigrant individuals. Female adolescents expressed their need to break the silence around the topic of sexuality, to have a non-judgemental and blame-free attitude from adults, and for open, honest, and stigma-free conversations. This study provides preliminary qualitative evidence of the interplay between experiences of developing sexuality and overall well-being, particularly psychological wellbeing in female adolescent immigrants. It is crucial to involve, listen to, and incorporate adolescent girls’ voices when planning and implementing interventions to support healthy sexuality among immigrant adolescents.

During puberty and emerging sexuality, adolescents experience important physical, mental, and social transformations. In the process of dealing with these changes, adolescents can become potentially vulnerable to mental health problems.The aim was to identify and synthesize published research evidence on sexuality-related mental health stressors among adolescent girls and boys, identify gaps (if any) in current knowledge, and contribute to knowledge about the experiences of emerging sexuality and health among adolescents, to further inform research, practice, and policy initiatives in sexual health.A scoping literature review of peer-reviewed articles published between 1990 and 2018. MEDLINE, CINAHL, EMBASE, PsycINFO, Global health, ERIC, and Sociological Abstracts databases were searched for research studies that reported experiences of sexuality related mental health issues and symptomatology of adolescents. We targeted studies conducted with adolescent populations between ages 11-24 years living in LMICs.Data from 12 published research papers, including 8 qualitative studies, 3 quantitative studies, and 1 mixed method study, were systematically analyzed. Four major themes and 4 sub themes were identified regarding sexual health and mental health of adolescents: 1) Relationship of sexuality and mental health; 2) Social and cultural influences; 3) Challenges in seeking sexuality information and services among adolescents; and 4) Educational needs among adolescents related to sexuality; and 4) Educational needs among adolescents related to sexuality. Lack of social support, Unmet needs for accessible adolescent friendly sexual health services, counseling, and age-appropriate information may be associated with several mental health stressors and symptoms, such as sadness, depressive and anxiety symptomatology, regret, fear, embarrassment, low self-esteem, guilt, shame, and anger. Therefore, tackling sexuality-related stressors could play an important role in addressing the overall wellbeing of young people. Future studies need to generate a deeper understanding of the concept of sexual health and its relation to mental health in diverse contexts. Health care professionals need to be aware of sexuality-related experiences of adolescent girls and boys by offering effective youth-friendly sexual and reproductive health education to support overall mental health and improve the experiences of emerging sexuality in adolescents.

Public health scholars describe “culture of quality” in terms of desired values, attitudes, and practices, but this literature rarely includes explicitly stated theories of culture formation. In this article, we apply Fredrik Barth’s transactional model to demonstrate how taking a theory-centered approach can help to identify what would be necessary to foster “cultures of quality” outlined in the public health literature. We draw on data from a study of the Republic of Malawi’s Performance and Quality Improvement for Reproductive Health initiative. These data were generated in 2017–2018 through a 6-month organizational ethnography in three facilities selected to represent a range of districts with differing social and economic contexts. Our analysis revealed facility-level organizational cultures in which staff valued providing care, but responded to structural constraints by normalizing divergence from quality-of-care protocols. These findings indicate that sustaining a quality-oriented organizational culture requires addressing underlying conditions that generate routine experiences and practices.

As the population of Pakistan has increased beyond 200 million, it is evident that the country's family planning program has been unable to sufficiently expand contraceptive use. To understand the obstacles, researchers have tended to focus on service delivery failures, ‘cultural’ barriers and varying political support. However, a small body of literature documents citizen's suspicions of an ulterior motive underlying Pakistan's family planning program. Often dismissed as unfounded conspiracies, a gap in our knowledge is the role these beliefs might be playing in the failure of the program. Using a critical ethnographic approach, we conduced 242 observations of daily life, 109 informal and 197 in-depth interviews with 41 women and 35 men living in a village in Khyber Pakhtunkhwa. Data were collected between September 2013 and April 2015 and analysed using latent content analysis. Our respondents viewed Western support for family planning as confirmation of their suspicions of the program's hidden agenda. Western military intervention in the region complicated their beliefs about the potential altruistic nature of foreign support for the family planning program. Awareness of rampant corruption among Pakistani government officials had fractured their trust in the state while contributing to the notion that the government was complicit with foreign interference. These considerations coupled with the fact that the priorities of Pakistani Family Planning program did not align with the reality of their lives contributed to the skepticism of family planning. For our respondents, resisting family planning and its ideology was a means to resist the perceived violence inflicted by the West and the complicity of the Pakistani government. These findings signal how geopolitics influence the use of family planning services. By demonstrating the importance of embedding perceptions of family planning programs in their local and global contexts, these findings suggest potential areas for future research in the field.

The sixth most populous country, Pakistan's modern contraceptive use rate is just 25%. Of the multiple reasons for avoiding contraceptives, women cite side effects as a significant deterrent to contraceptive uptake. Efforts to understand these side effects are limited by overreliance on the biomedical framework, which typically dismisses some of women's negative experiences and explanatory models as misperceptions. Drawing on 13 months of ethnographic data from a village in Khyber Pakhtunkhwa, Pakistan, our study sought to provide an emic description of contraceptive side effects. Respondents' described what we call "spiritual" and "somatic" side effects. While the latter included experiences such as irregular bleeding and leg pain, spiritual side effects had more severe implications ranging from job loss, birth defects, to child death. In a context of a firm belief that family planning was a sin, contraceptives were believed to negatively impact spiritual well-being and invite God's wrath. Our data suggest these perceptions and experiences played a crucial role in contraceptive decision-making. The spiritual and somatic experiences of contraceptive use described by respondents also demonstrate the importance of broadening dominant biomedical approaches to holistically understand contraceptive side effects and usage.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan – Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient–provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

Objective To explore the preference for female obstetrician/gynaecologists among immigrant women, and providers' understandings of these preferences, to identify challenges and potential solutions. Methods Five databases (Medline, Embase, CINAHL, Global Health, and Scopus) were searched using combinations of search terms related to immigrant, refugee, or Muslim women and obstetrics or gynaecological provider gender preference. Study Selection Peer reviewed, English-language articles were included if they discussed either patient or provider perspectives of women's preference for female obstetrics or gynaecological care provider among immigrant women in Western and non-western settings. After screening, 54 met inclusion criteria and were reviewed. Data Extraction Studies were divided first into those specifically focusing on gender of provider, and those in which it was one variable addressed. Each category was then divided into those describing immigrant women, and those conducted in a non-Western settings. The research question, study population, methods, results, and reasons given for preferences in each article were then examined and recorded. Conclusion Preference for female obstetricians/gynaecologists was demonstrated. Although many will accept a male provider, psychological stress, delays, or avoidance in seeking care may result. Providers' views were captured in only eight articles, with conflicting perspectives on responding to preferences and the health system impact.

To investigate obstetricians' perspectives of the importance, effect, and challenges of providing intrapartum care to immigrant women who request a female obstetrician.A focused ethnography was conducted at a large teaching hospital, which serves a high proportion of immigrant clientele (predominantly North or East African, Middle Eastern, and South Asian) in Edmonton, Alberta, Canada. Data collection comprised single, semistructured interviews with a purposive sample of 20 obstetric health care providers (10 resident and 10 staff obstetricians). Interviews were audio-recorded and transcribed verbatim. Data were managed with Quirkos and analyzed using thematic analysis.A total of 13 female and seven male physicians were interviewed. Physicians recognized the validity of immigrant women's preference and requests for female health care providers and expressed sympathy for them. However, they were also resistant and expressed several concerns about accommodating these requests, including fear of perpetuating and exacerbating gender inequalities in medicine, the extent to which patient decision-making was coercion-free, the ability of the health system to meet the demands, and implications for training and quality of care.Although physicians were sympathetic to immigrant women's requests for female obstetricians, they placed greater value on maintaining gender equity both within the medical profession and in wider society and resisted accommodating gender-of-health-care-provider requests. Our qualitative study suggests a need for greater research to inform policy that meets the professional and personal values of both physicians and patients.

Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.

Introduction Despite the growing attention to the relationship between menstruation and girls schooling, there remain many challenges to addressing the issue. Current interventions, which mostly focus on developing WASH infrastructure and sanitary hygiene management products, while necessary, may not be sufficient. This paper aimed to identify the root causes of poorly maintained WASH infrastructure, and understand the deeply embedded socio-cultural values around menstrual hygiene management that need to be addressed in order to provide truly supportive school environments for menstruating girls. Methods Qualitative data were collected in rural and urban sites in three provinces in Pakistan using participatory activities with 312 girls aged 16–19 years, observations of 7 School WASH facilities, 42 key informant interviews and a document review. Results Three key themes emerged from our data: (1) a poorly maintained, girls-unfriendly School WASH infrastructure was a result of gender-insensitive design, a cultural devaluation of toilet cleaners and inadequate governing practices; (2) the design of WASH facilities did not align with traditionally-determined modes of disposal of rag-pads, the most common used absorbents; (3) traditional menstrual management practices situate girls in an ‘alternate space’ characterised by withdrawal from many daily routines. These three socio-culturally determined practices interacted in a complex manner, often leading to interrupted class engagement and attendance. Conclusions To be truly effective, current menstrual hygiene management strategies need to address the root causes of poor WASH infrastructure and ensure facility design is sensitive to the gendered and deeply embedded local socio-cultural values and beliefs around menstrual hygiene management.

Pakistan, with a population of over 207 million, is the sixth most populous country in the world. Yet, only 25% of eligible couples' report using a modern contraceptive method. A large body of literature indicates the existence of a widely-held perception among Pakistanis that family planning use is a sin, which is then often cited as evidence that Islamic beliefs impede contraceptive use (see Agha, 2010; Ali and Ushijima, 2005; Azmat, 2011; Zafar et al., 2003). We argue that this body of literature, which has relied primarily on quantitative measures and survey methodology, is highly reductive. Missing from this discourse is a nuanced analysis of how individuals engage with their Islamic beliefs to make fertility decisions. Drawing on 13 months of ethnographic data, our findings demonstrate that despite most of our respondents overwhelmingly believing that family planning use was a sin, many had, at some stage, tried to control their fertility. Our findings evidenced that respondents' beliefs surrounding the morality of fertility control was informed by multiple moral registers beyond Islam. For our respondents, moral action was informed by interpretations of Islamic teachings, economic insecurity, socioeconomic inequities, community/public discourse, and geopolitics. We argue there is a need to complicate our understanding of how Islam shapes reproductive strategies in Pakistan, and its relative importance in contraceptive decisions.

Purpose Issues related to program context are important components of population health interventions and particularly among complex, adaptive initiatives in schools. Health Promoting Schools (HPS) is a global approach to support early development of healthy behaviors among children and youth. The purpose of this study was to explicate the practical and contextual processes that influenced implementation of HPS in schools in Nova Scotia (Canada). Methods Using a case-study approach, data was collected using interviews ( n = 14) with principals, teachers and parents, observations collected during school visits and document review in five diverse schools. Results Case study schools reported a variety of HPS practices and three key themes emerged that provided context to the processes that facilitated their implementation. The results suggest that although school characteristics (theme 1), like staff allocation, physical location and resources, are important, these barriers can be mitigated by building organizational capacity (theme 2) and establishing a supportive school community culture (theme 3). Conclusions The study provided insight to the variability in implementation by describing how contextual barriers were experienced and mitigated by schools. Establishing a broad system to support HPS, with collaboration across health and education sectors, could help to progress adoption, implementation and sustainability of HPS.

Objective This study sought to gain an understanding of the importance and effect of provider gender for immigrant women accessing obstetrical care. Methods A focused ethnography was conducted using purposive sampling of 38 immigrant women from one hospital in Edmonton, Alberta. Data collection consisted of semistructured interviews conducted antenatally (n = 38); an attempt was made to conduct interviews postpartum (n = 21), and intrapartum observations were made (n = 17). Interviews were audio-recorded and transcribed verbatim. Data were managed using qualitative data analysis software and analyzed through thematic analysis. Results Study participants came from varied educational and ethnic backgrounds (predominately North/East African, Middle Eastern, and South Asian), but most were Muslim (n = 30) and married (n = 36), with a mean age of 27.7. All of the women stated that they preferred a female provider, which they explained in terms of the high value they placed on modesty, often as part of the Muslim faith. The women deemed provider competency and having safe childbirth more important, however, and said that they would accept intrapartum care from a male provider. A small minority of the women reported experiencing psychological stress as a consequence of having received care from a male provider. Conclusion As a whole, our study population accepted care from male providers, yet for some women this compromise came at a price, and a small minority of women perceived it as profoundly detrimental. There is a need to identify those women for whom gender of provider is a substantial barrier, so that optimal support can be provided.

Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May 2010–February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan.

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

Despite rising uptake of maternal healthcare in Pakistan, inequities persist. To-date, attempts to explain and address these differentials have focused predominantly on increasing awareness, geographic and financial accessibility. However, in a context where 70% of healthcare is private sector provided, it becomes pertinent to consider the value associated with this good. This study examined patterns of maternal healthcare use across socioeconomic groups within a rural community, and the meanings and values attached to this behaviour, to provide new insight into the causes of persistent inequity. A 10-month qualitative study was conducted in rural Punjab, Pakistan in 2010/11. Data were generated using 94 in-depth interviews, 11 focus group discussions and 134 observational sessions. Twenty-one pregnant women were followed longitudinally as case studies. The village was comprised of distinct social groups organised within a caste-based hierarchy. Complex patterns of maternal healthcare use were found, linked not only to material resources but also to the apparent social status associated with particular consumption patterns. The highest social group primarily used free public sector services; their social position ensuring receipt of acceptable care. The richer members of the middle social group used a local private midwife and actively constructed this behaviour as a symbol of wealth and status. Poorer members of this group felt pressure to use the afore-mentioned midwife despite the associated financial burden. The lowest social group lacked financial resources to use private sector services and opted instead to avoid use altogether and, in cases of complications, use public services. Han, Nunes, and Dreze's (2010) model of status consumption offers insight into these unexpected usage patterns. Privatization of healthcare within highly hierarchical societies may be susceptible to status consumption, resulting in unforeseen patterns of use and persistent inequities. To-date these influences have not been widely recognised, but they deserve greater scrutiny by researchers and policy-makers given the persistence of the private sector.

A safe, consistent blood supply in Pakistan is critical in combating maternal deaths due to haemorrhage. The dominant form of blood donation in Pakistan is a directed-replacement system. Complex sociocultural values influence from whom a recipient can receive blood. This focused ethnography aimed to investigate if, in this patriarchal society, the gender of the recipient influences who will donate blood. Data were collected from the district of Rawalpindi/Islamabad, Jhelum and Layyah in 2009 and 2012. Findings revealed that gendered notions of blood and blood donation construct reproductive blood loss as less serious than other types of blood loss. Husbands almost universally removed themselves from the process of blood procurement for their wives in the midst of a maternal health emergency. This was due to a combination of gender norms and beliefs about the power of blood, akin to the power of breast milk, to connect husbands and wives in a donor–recipient relationship that would lead to the negation of ...

The Pakistan Lady Health Worker (LHW) program provides door-step reproductive health services in a context where patriarchal norms of seclusion constrain women's access to health care facilities. The program has not achieved optimal functioning, particularly in relation to raising levels of contraceptive use. One reason may be that the LHWs face the same mobility constraints that necessitated their appointment. Past research has documented the influence of gendered norms and extended family (biradari) relationships on rural women's mobility patterns. This study explores whether and how these socio-cultural factors also impact LHWs' home-visit rates. A mixed-method study was conducted across 21 villages in one district of Punjab in 2009-2010. Social mapping exercises with 21 LHWs were used to identify and survey 803 women of reproductive age. The survey data and maps were linked to visually delineate the LHWs' visitation patterns. In-depth interviews were conducted with 21 LHWs and 27 community members. Members of a LHW's biradari had two times higher odds of reporting a visit by their LHW and were twice as likely to be satisfied with their supply of contraceptives. Qualitative data showed that LHWs mobility led to a loss of status of women performing this role. Movement into space occupied by unrelated males was particularly shameful. Caste-based village hierarchies further discouraged visits beyond biradari boundaries. In response to these normative proscriptions, LHWs adopted strategies to reduce the amount of home visiting undertaken and to avoid visits to non-biradari homes. The findings suggest that LHW performance is constrained by both gender and biradari/caste-based hierarchies. Further, since LHWs tended to be poor and low caste, and at the same time preferentially visited co-members of their extended family who are likely to share similar socioeconomic circumstances, the program may be differentially providing health care services to poorer households, albeit through an unintended route.

This study documents the long-term gendered impact of the 2005 Pakistan earthquake on women and men who were rendered paraplegic as a result of spinal cord injuries sustained during the disaster. Coping mechanisms are also mapped. The findings show that three years after the disaster, paraplegic women are socially, emotionally, and financially isolated. The small stipend they receive is a significant source of income, but it has also led to marital distrust, violence, and abuse. In contrast, men receive full social and emotional support. Their key concern is that the government is not providing them with opportunities to be economically productive. Contemporary discourse and post-disaster policies, while acknowledging the importance of incorporating a gender perspective in the immediate post-disaster period, have failed to acknowledge and address the longer-term gendered impact of disasters, in terms of the different types of impact and strategies adopted by women and men.

Contemporary public policy, supported by international arbitrators of blood policy such as the World Health Organization and the International Federation of the Red Cross, asserts that the safest blood is that donated by voluntary, non-remunerated donors from low-risk groups of the population. These policies promote anonymous donation and discourage kin-based or replacement donation. However, there is reason to question whether these policies, based largely on Western research and beliefs, are the most appropriate for ensuring an adequate safe blood supply in many other parts of the world. This research explored the various and complex meanings embedded in blood using empirical ethnographic data from Pakistan, with the intent of informing development of a national blood policy in that country. Using a focused ethnographic approach, data were collected in 26 in-depth interviews, 6 focus group discussions, 12 key informant interviews and 25 hours of observations in blood banks and maternity and surgical wards. The key finding was that notions of caste-based purity of blood, together with the belief that donors and recipients are symbolically knitted in a kin relationship, place a preference on kin-blood. The anonymity inherent in current systems of blood extraction, storage and use as embedded in contemporary policy discourse and practice was problematic as it blurred distinctions that were important within this society. The article highlights the importance—to ensuring a safe blood supply—of basing blood procurement policies on local, context-specific belief systems rather than relying on uniform, one-size-fits-all global policies. Drawing on our empirical findings and the literature, it is argued that the practice of kin-donated blood remains a feasible alternative to the global ideal of voluntary, anonymous donations. There is a need to focus on developing context-sensitive strategies for promoting blood safety, and critically revisit the assumptions underlying contemporary global blood procurement policies.

Recent research and policy discourse commonly view the limited autonomy of women in developing countries as a key barrier to improvements in their reproductive health. Rarely, however, is the notion of women's autonomy interrogated for its conceptual adequacy or usefulness for understanding the determinants of women's reproductive health, effective policy formulation or program design. Using ethnographic data from 2001, including social mapping exercises, observation of daily life, interviews, case studies and focus group discussions, this paper draws attention to the incongruities between the concept of women's autonomy and the gendered social, cultural, economic and political realities of women's lives in rural Punjab, Pakistan. These inadequacies include: the concept's undue emphasis on women's independent, autonomous action; a lack of attention to men and masculinities; a disregard for the multi-sited constitution of gender relations and gender inequality; an erroneous assumption that uptake of reproductive health services is an indicator of autonomy; and a failure to explore the interplay of other axes of disadvantage such as caste, class or socio-economic position. This paper calls for alternative, more nuanced, theoretical approaches for conceptualizing gender inequalities in order to enhance our understanding of women's reproductive wellbeing in Pakistan. The extent to which our arguments may be relevant to the wider South Asian context, and women's lives in other parts of the world, is also discussed.

The First Nations and Inuit Health Branch, Health Canada, commissioned a review of the current evidence on efforts to promote mental health in Aboriginal young people in Canada. A systematic review of the literature reveals that peer-reviewed ‘evidence-based’ evaluations of mental health promotion interventions with Canadian Aboriginal young people are virtually non-existent. The few published studies on mainstream young people, with their focus on those at risk, addressing individual-level factors within Western positivist conceptualizations of reality, have limited applicability to a colonized people with constructions of health that place emphasis on wholeness, connection, balance and harmony. This paper reviews several inter-related forces shaping mental health promotion discourse and programming as they pertain to Aboriginal young people in Canada today. They include colonization and neo-colonial relations, Aboriginal world views, meanings of health and selfdetermination, the conceptual and methodolo...

Background: Canada is among the top immigrant-receiving nations in the world. Immigrant populations may face structural and individual barriers in the access to and navigation of healthcare services in a new country. The aims of the study were to (1) generate new understanding of the processes that perpetuate immigrant disadvantages in maternity healthcare, and (2) devise potential interventions that might improve maternity experiences and outcomes for immigrant women in Canada. Methods: The study utilized a qualitative research approach that focused on ethnographic research design and data analysis contextualized within theories of organizational behaviour and critical realism. Data were collected over 2.5 years using focus groups and in-depth semistructured interviews with immigrant women (n = 34), healthcare providers (n = 29), and social service providers (n = 23) in a Canadian province. Purposive samples of each subgroup were generated, and recruitment and data collection – including interpretation and verification of translations – were facilitated through the hiring of community researchers and collaborations with key informants. Results: The findings indicate that (a) communication difficulties, (b) lack of information, (c) lack of social support (isolation), (d) cultural beliefs, e) inadequate healthcare services, and (f) cost of medicine/services represent potential barriers to the access to and navigation of maternity services by immigrant women in Canada. Having successfully accessed and navigated services, immigrant women often face additional challenges that influence their level of satisfaction and quality of care, such as lack of understanding of the informed consent process, lack of regard by professionals for confidential patient information, short consultation times, short hospital stays, perceived discrimination/stereotyping, and culture shock. Conclusions: Although health service organizations and policies strive for universality and equality in service provision, personal and organizational barriers can limit care access, adequacy, and acceptability for immigrant women. A holistic healthcare approach must include health informational packages available in different languages/media. Health care professionals who care for diverse populations must be provided with training in cultural competence, and monitoring and evaluation programs to ameliorate personal and systemic discrimination.

An integrated analysis of detailed ethnography and large-scale survey data is presented to explore the gendered influences on women's uptake of antenatal care (ANC) services in Punjab, Pakistan. Pregnancy and its associated decisions were shown to be normatively the older women's domain, with pregnant women and their husbands being distanced from the decision-making process. Women who successfully claimed ANC did so not by overtly challenging the dominant construction of young femininity, but rather by using existing gendered structures and channels of communication to influence authority figures. The quality of a woman's inter-personal ties, particularly with her mother-in-law and husband, were found to be important in accessing resources, including ANC. Gendered influences were moderated by social class. Family finances were an important determinant of ANC use, as was women's education. Wealthier, higher status women also found it easier to circumvent gendered proscriptions against their mobility while pregnant. As well as illuminating the ways in which the sociocultural construction of gender acts to constrain women's access to ANC, the empirical findings are used to highlight significant inadequacies in the 'autonomy paradigm' that has dominated much of the research into women's reproductive health in South Asia.

ObjectiveTo examine how availability of misoprostol has impacted women's abortion-seeking behaviour in Pakistan.DesignFocused ethnography.SettingA facility providing reproductive health services, including induced abortions in Chakwal, a small town in Northern Punjab, Pakistan.PopulationWomen who came to the clinic seeking an abortion or who had had one in the last 6 months (n=23) and all healthcare providers working in the facility (n=14).MethodsSemi-structured interviews (n=37), a focus group discussion (n=1) and participant observation (n=41). Latent content analysis was conducted drawing on principles of constant comparison to generate key themes in reported experiences.ResultsAll the respondents had sought an abortion to limit their fertility. Although some reported contraceptive use, improper use, undesirable side effects and restrictions on use had led to the unwanted pregnancy. All the women specifically requested misoprostol within days of their pregnancy, suggesting that they not only had knowledge of misoprostol as a backup in case of contraceptive failure, but may have pre-planned its use of in place of using contraception. Women reconciled their decision to undergo an abortion by describing it as a mistake, miscarriage or menstrual cycle issue.ConclusionsMisoprostol's availability, ease of use and effectiveness have increased the role of abortion in fertility control.

An integrated analysis of large-scale survey data and detailed ethnography is presented to examine the patterns of women's mobility and their relationships with contraceptive and antenatal care use in Pakistan. Findings confirm that women's mobility is circumscribed but also illustrate the complex and contested nature of female movement. No direct relationship between a woman's unaccompanied mobility and her use of either contraception or antenatal care is found. In contrast, accompanied mobility does appear to play a role in the uptake of antenatal care, and is found to reflect the strength of a woman's social resources. Class and gender hierarchies interact to pattern women's experience. Poor women's higher unaccompanied mobility was associated with a loss of prestige and susceptibility to sexual violence. Among richer women, such movement did not constitute a legitimate target for male exploitation, nor did it lead to a loss of status on the part of their families. The findings caution against the use of western notions of 'freedom of movement' and associated quantitative indicators. At the same time, the wider impact of mobility restrictions on women's reproductive health is acknowledged and policy implications are identified.

The results of this study and other re cent work suggest the need for greater attention in future studies to the husband-wife relation ship intra-household distribution and control of resources as well as inter-household linkages. (authors)

Objective\ud To understand why skilled birth attendance—an acknowledged strategy for reducing maternal deaths—has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.\ud \ud Design\ud Implementation research was conducted using an institutional ethnographic approach.\ud \ud Setting and population\ud National programme and local community levels in Pakistan.\ud \ud Methods\ud Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.\ud \ud Main outcomes\ud Alignment of programme theory with real-world practice.\ud \ud Results\ud Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public–private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography.\ud \ud Conclusions\ud Greater attention to programme theory and the ‘real-world’ setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

Background To address it's persistently high maternal mortality rate of 276/100,000 live births, the government of Pakistan created a new cadre of community based midwives (CMW). One expectation is that CMWs will improve access to maternal health services for underserved women. Recent research shows the CMWs have largely failed to establish midwifery practices, because CMW's lack of skills, both clinical and entrepreneurial and funds necessary to develop their practice infrastructure and logistics. Communities also lack trust in their competence to conduct safe births. To address these issues, the Saving Mothers and Newborn (SMNC) intervention will implement three key elements to support the CMWs to establish their private practices: (1) upgrade CMW clinical skills (2) provide business-skills training and small loans (3) generate demand for CMW services using cellular phone SMS technology and existing women’s support groups. Methods/Design This 3-year project aims to investigate whether CMWs enrolled in this initiative are providing the essential maternal and newborn health care to women and children living in districts of Quetta, and Gwadar in a financially self-sustaining manner. Specifically the research will use quasi-experimental impact assessment to document whether the SMNC initiative is having an impact on CMW services uptake, financial analysis to assess if the initiative enabled CMWs to develop financially self-sustainable practices and observation methods to assess the quality of care the CMWs are providing. Discussion A key element of the SMNC initiative - the provision of business skills training and loans to establish private practices - is an innovative initiative in Pakistan and little is known about its effectiveness. This research will provide emperic evidence of the effectiveness of the intervention as well as contribute to the body of evidence around potential solutions to improve sustainable coverage of high impact Maternal, Neonatal and Child Health interventions in vulnerable populations living in remote rural areas.

The study sought to determine the direct and indirect costs of hospitalization incurred by the provider and consumer in a public funded tertiary care hospital in Islamabad, Pakistan. The cost per hospital bed per day in both medical and mixed specialty wards was determined in terms of infrastructure, manpower, diagnostic investigations, drugs and utilities, and the cost to the hospitalized individual in terms of transport, food, drugs, investigations, and indirect costs such as time and material requirements of relatives or friends resulting from and associated with the hospitalization. The average daily cost per occupied bed to the institution amounted to Rs. 777 (US $ 18.95) per day. The average cost borne by the patient was Rs. 1,071 (US $ 26.10) per day or 58 percent of the total daily cost of a (medical) bed. A disproportionate share of this expense was under specific subheadings, namely purchase of medicines, laboratory services, transportation and food. Study findings confirm that in contrast to stated national policy, stationary health care is not only not free but that the consumer may end up directly paying more than the state for the services she/he receives.

1—concerns have arisen that this focus has often been diluted in eff orts to translate the Millennium Development Goals (MDGs) into actions. 2 Nowhere is this more apparent than in relation to MDG 5. Analyses of national survey data and local programme assessments show that policy directives and interventions often fail to reach the poorest women within local populations. In Pakistan, for example, a ten-district intervention aimed at upgrading health facilities while simultaneously increasing demand through behavioural change resulted in a rise in institutional deliveries in the highest wealth quintile (from 62% to 74%), but no change in the poorest (remaining at roughly 18%). 3 Meanwhile, a crossnational analysis 4 identifi ed large inequalities between wealth groups in access to skilled birth attendance 5 and antenatal care uptake in many countries. Thus, despite repeated assertions that reducing inequity is a top priority, international organisations, donor agencies, and country-level policy makers continue to fail to address the obstacles to care faced by the poorest women. Furthermore, despite reductions in maternal mortality in several countries, comprehensive reviews 6,7