Knowledge about nutrition.

Men described nutrition as ‘good and hygienic food’ and identified fish, meat, chicken, fruits, vegetables, yogurt-based drinks, and butter as sources of good nutrition. They expressed that impurities in food and drinking water can pose a health hazard. The majority claimed not to know much about anemia but felt able to tell from the physical appearance of a woman who appeared weak that it was likely due to ‘blood deficiency’. However, women lacked awareness about health maintenance and the need to seek medical assistance when necessary.

They stated that the diets of pregnant women should include fruits such as apples, bananas, and pomegranates, and vegetables including spinach, cauliflower, okra, eggplant, and ridge gourd. Processed fruit juices were not encouraged. Unlike urban women, women from rural areas had a good intake of fish since their husbands’ primary occupation was fishing.

“We belong to the Sindhi culture so we mostly eat fish instead of vegetables and meat” (FGD-F-01)”.

Most women were not aware of anemia and described it as ‘deficiency of blood in the body’ or ‘weakness’. Some described it as a condition that requires medical treatment including blood transfusion as per the advice of a healthcare provider.

“Blood is synthesized from food and water and when we eat 10 grams of food then body forms 1 drop of blood”(FGD-F-02).

According to healthcare providers, some women considered anemia/blood deficiency to be a physiological process and not a disease.

"Women think that blood deficiency is a normal process, which occurs during delivery and the older women (in the community) tell them that it is not a disease or a health problem"(KII-HCP-02).

Knowledge about signs, symptoms, and burden of anemia.

Healthcare providers reported that most community women had obvious signs and symptoms of anemia such as fatigue, pallor, leg cramps, and edema. They carried out physical examinations to look for signs of anemia followed by a blood hemoglobin test to determine its severity and start necessary treatment. They believed most hemoglobin levels to be lower than 8 gm/dl due to frequent pregnancies.

“For every 100 women we assess, almost 60 to 80 are anemic and if I measure it on a scale of 10, then 8 out of 10 women are anemic” (KII-HCP-02).

They highlighted that 99% of pregnant women in the area were anemic and that anemia was more common in women than men. In addition, the vast majority of these women presented to clinics with Hb levels of 3 to 4 gm/dl during their pregnancy and low hemoglobin was the most common reason for specialist referrals. Some women reported not having enough energy for their daily activities as well as feeling short of breath, experiencing shivering, pallor, and gastric burning due to anemia. Some talked about how they could identify anemia by looking at the nail beds and eyes, which develop pitting and pallor respectively. According to them, anemia could have an adverse effect on their vision and also cause tachycardia.

"We generally get the idea of blood deficiency from the hands and eyes of women as they become pale. Women feel weak and are unable to perform daily activities. Upon checkup, doctors ask for some blood tests and inform us that they are anemic" (FGD-M-01).

“Due to blood deficiency, our blood pressure also goes down, and we cannot perform any work” (FGD-F-02).

Causes of anemia.

Doctors in KIIs and males in FGDs reported that intake of chewable tobacco [Gutka/Mawa/Chura in the local language] was a major cause of anemia among pregnant women. They noted that women in the district were addicted to chewable tobacco (gutka), which damages the mucosal membrane and prevents iron absorption. Gutka also reduced their appetite, preventing them from consuming a nutritious diet, consequently making them weak and anemic.

Some women also reported leading far more stressful lives than their male counterparts who were sometimes away from home for days on end, leaving them solely responsible for the care of their children. However, we did not find health care providers and males who reported stress as a cause of anemia among WRA.

“Our husbands come home like guests but we have to stay at home with our children all the time. These stressors make us weaker” (FGD-F-05).

Besides, men reported that early marriages were very common in rural areas resulting in multiple pregnancies at a young age predisposing young females to anemia. Furthermore, the doctors stated that most males residing in rural areas did not consider anemia to be a serious health issue.

Additionally, consumption of fuller’s earth [multani mud in the local language] was also considered to be an indirect cause of anemia as it decreased the consumption of a nutritious diet. Women in the FGDs identified strenuous fieldwork performed by pregnant women as a potential cause of anemia. However, strenuous work was not identified as a cause of anemia by men or health care providers. Other factors that TBAs and healthcare providers enumerated were illiteracy, lack of knowledge about the causes of anemia, and limited antenatal follow-ups. Working barefoot in the fields was also identified as a causative factor as it could provide a favorable route for worms to penetrate the skin of the feet and enter the body.

Women with short inter-pregnancy intervals who did not consume a balanced diet were more likely to be anemic. Similarly, those who were engaged in strenuous field-work were left with little time to focus on their diet. Healthcare providers noted that breastfeeding mothers who did not consume a nutritious diet were at a significantly greater risk of developing anemia.

"We are addicted; we will not eat meat but we will buy gutka even though gutka is more expensive than medicines" (FGD-F-05).

"In the villages, women have a lot of workloads; they work barefoot in the fields all day, I think that is the reason why they get blood deficiency. The heat that enters the body from their feet has an adverse effect on their eyes and causes their blood to dry as well " (KII-HCP (TBA)-06)

“Women who stay at home are healthier and their blood levels normal” (FGD-F-03).

"In the present time, a major cause of anemia is frequent pregnancies; each female has almost 9 to 10 children" (KII-HCP-01).

"God knows how many children a woman produces because usually, they do not tell us how many children are alive. I have received a patient who has 23 gravidae with six to seven miscarriages. Is this not the reason for becoming anemic?" (KII-HCP-02).

"Here in rural areas, early marriages are very common and this is our biggest mistake. We just fix their marriages once they reach puberty. We don’t think if they are mature enough to take up the responsibility or not. In urban areas, people send their girls to school so that they gain awareness but here we don’t do that " (FGD-M-02).

Consequences of anemia for pregnant women.

Women expressed that anemia caused them to experience vertigo and weakness. Additionally, some women believed that anemia may cause pregnancy complications including seizures, headache, dehydration, life-threatening bleeding, necessitating a Cesarean delivery. Healthcare providers highlighted the strong association between a hemoglobin level of less than 5gm/dL and postpartum hemorrhage.

“If she is anemic and has blood deficiency then she will not be able to deliver the child through a normal delivery and will have to undergo a major surgery, which can cause death” (FGD-F- 02).

Consequences of anemia for children.

Concerning child development, the consensus among women was that anemia resulted in stunted growth and inability to gain adequate weight. Besides causing miscarriage and stillbirth, anemia during pregnancy could also be a potential cause of premature birth, low birth weight, congenital anomalies, and malnutrition in the offspring. Males in the FGDs and healthcare providers voiced their concerns about growth retardation and emphasized that women should have a nutritious diet to avoid long-term complications in the offspring.

“With the inadequate transfer of nutrients from the mother to the developing baby, the child will become ill" (FGD-M-03).

"The child may die in the mother’s womb due to blood deficiency in the woman” (FGD-F-05).

Current dietary practices of pregnant women.

According to most couples, while pregnant women in urban settings were encouraged to consume protein-rich foods including fish, meat, and pulses, those in the rural areas had a diet similar to that of non-pregnant women because of financial constraints. On inquiring about the number of meals per day, women from rural areas mentioned that they only consumed food when hungry.

They highlighted that tobacco makes up 80% of the pregnant woman’s diet and was considered a regular grocery item. The consumption of fuller’s earth by pregnant women was another major cause of anemia within this subset.

Healthcare providers noted that most pregnant women believed that tobacco consumption was associated with energy and strength. The participants further explained that unfortunately these behaviors and habits got passed on to their children as well. When a young boy asked his parents for gutka, they would take pride in the fact that their sons were old enough to do so.

They also reported that despite having easy access to vegetables grown on their farms, most women preferred selling them in the market to make money rather than consuming it themselves.

"Eating gutka is very common in women. Every mother eats gutka herself as well as feeds it to the baby that is still in her lap" (KII-HCP-01).

"In villages, children who do not even have a complete set of teeth have been eating gutka" (KII-HCP-02).

Recommended dietary practices to alleviate anemia.

Women in the FGDs mentioned that vegetables such as spinach, eggplant, bottle gourd, and okra and fruits such as apples, bananas, and pomegranates are essential to alleviate anemia.

Healthcare providers recommended that pregnant mothers eat with other family members rather than eating leftovers at the end as well as increase the intake of available resources such as cucumbers and dates. They proposed consuming a bowl of spinach a day to meet the daily iron requirements, stating that it has the same nutrition value as injectable iron.

“1 ampule of Jectofer (iron injection) is equal to 1 bowl of Spinach and if you take that instead, it will save the doctor’s fee, transportation expense, and also be more beneficial because it’s natural food”(KII-HCP-03).

"In winters, family members give dates and oil to their cattle but don’t give it to the women" (KII-HCP-02).

Barriers in adopting healthy food practices.

On inquiring about barriers encountered in adopting healthy dietary habits, men stated that the poor quality food available in the markets could be a potential reason for women developing anemia during pregnancy. The use of tap water instead of purified drinkable water was another cause. One TBA highlighted that medication was not always used to treat anemia among pregnant women because of limited financial resources.

They also noted that over the years, people in the community preferred selling milk and eggs instead of consuming it themselves. They used the money to purchase unhealthy foods such as gutka for their family members.

"People coming from cities collect all the fresh items from villagers and give them a schedule for the next delivery’” (KII-HCP (TBA)-02).

Knowledge of IFA supplements.

Men and women in the FGDs mentioned that doctors and TBAs advised them to take ‘small yellow tablets’ (folic acid), ‘black tablets’ (ferrous sulfate), ‘syrups’ (syngobion), and ‘red or brown capsules’ for anemia. The healthcare providers mentioned that they provided iron and folic acid supplements from the government hospital medication supply to the women, but not all women used the supplements.

“We have invested too much time and money to visit your clinic not to get these tiny and useless tablets” (KII-HCP-02).

Reasons for non-compliance to iron supplements.

TBAs reported that limited financial resources, lack of awareness, and illiteracy are the major reasons for non-compliance to iron and folic acid supplements during pregnancy. The health care providers also mentioned that women residing in the city areas also do not consume their medications regularly. They purchase the medications or supplements from the store or government health care facility but do not consume the supplements regularly. Furthermore, the TBAs expressed that pregnant women do not visit healthcare facilities unless there is a real need for blood transfusion. They warned the husbands to take better care of their wives who were anemic because if not controlled, it might have serious health complications, necessitate transfusion, or even cause death. Unfortunately, however, the response that they usually received was that they still did not perceive anemia as something serious and would visit the clinic for a transfusion if need be. The doctors mentioned that the lady health workers (LHWs) provided iron and folic acid supplements to the women at their doorstep but did not follow up to ensure compliance. In addition, doctors in public hospitals did not have enough time to counsel women.

“Even educated people of urban areas are not smart; they buy iron during pregnancies but don’t take those medications” (KII-HCP-01).

"Even if a couple has lost 8 children in the past, it is not an issue for them as they believe they can produce another one. God forbid if, during the ninth pregnancy the woman loses her life, her husband would not worry about it because he would consider it God’s will" (KII-HCP (TBA)-01).

Insufficient facilities, resources, and support of staff.

The study participants reported that medicines were often unavailable at hospitals and nearby stores. Similarly, the hospitals charged heavily for most laboratory tests which they could not afford. When blood products were required for transfusion during delivery, it was usually very difficult to arrange them because of a dearth of blood banks in the district. The paramedical staff also demanded money as their commission (under-the-table payment), which put an additional burden on the family.

The healthcare providers noticed how most women who visited the clinics for their antenatal visits only underwent an ultrasound and were sent back without any prenatal counseling. If these doctors were to perform a thorough screening for anemia and provide adequate treatment as well as nutritional counseling, they could potentially prevent women from becoming anemic.

Healthcare providers expressed concerns about the risk of infection in women who came to the clinic for blood transfusions because of a lack of sterilization techniques employed by these centers. They were also at risk of acquiring blood-borne infections from the transfused blood products such as hepatitis B and HIV because of limited screening facilities. Transfusion without screening in a non-emergency setting is imprudent and could also be life-threatening.

They stated that many healthcare providers were not trained to interpret investigation findings such as a complete blood count of the patients. It is impossible for them to then diagnose and treat anemia.

"When we visit hospitals for C-sections, the woman may sometimes die due to bleeding because we cannot afford blood transfusion. She can only get blood if her family can afford to pay the cost of the blood products otherwise most people living here cannot afford it and so the women lose their lives" (FGD-M-02).

"Nowadays, doctors assess around 300 to 400 patients per day in their clinics, which is fine, but at least they should take out the time to guide and counsel them properly" (KII-HCP-01).

Most of the blood banks in the district are not registered and provide unscreened blood to patients; we are not even sure if we are provided with human blood” (KII-HCP-01).

Lack of government-led programs to alleviate anemia.

The lack of government support for the health sector means that public hospitals oftentimes fail to provide adequate facilities and quality care to families who can not afford treatment in private hospitals. Emergency room admissions also incur a massive fee, that most people from rural settings can not afford. The study participants highlighted that the government’s efforts to improve healthcare facilities have mostly targeted urban hospitals while the rural population continues to stay neglected. Most of the study participants also highlighted that the government needs to take immediate action to ban the use of gutka and other non-nutritious food items that are less expensive and accessible to the men and women in the communities. Healthcare providers expressed the failure of the government to invest in anemia- specific programs and recommended that they undertake counseling sessions to sensitize the population about adequate dietary intake and family planning. Indeed, the government has arranged training sessions to address other obstetrical problems in the past but unfortunately, anemia during pregnancy is not one of them. Therefore, it should take the responsibility to actively train doctors as well as educate the population with the help of awareness sessions and other campaigns.

“Government should ban the use of gutka and other harmful items that cause blood deficiency so that people can save money to buy healthy things" (FGD-F-01).

Weak social networks.

Women complained about a lack of social support from their community leaders who were power and money-oriented and would only reach out to them when they needed their support to win elections. Once that was done, there was nobody to pay heed to their health concerns and if they required medical assistance, they would have to arrange transport and manage the logistics themselves. These comments of women about the lack of prioritization to facilitating healthcare resonate with their comments on field-work and the absence of men in theme 2.

“You are the only one asking us about our health and interviewing us regarding this; no one else is working on health problems” (FGD-F-05).

"Community leaders do not even bother even if a woman dies in the village. They simply just forget about the deceased woman and move on with life" (FGD-F-02).

Financial barriers/constraints.

Both men and women highlighted the need for better employment opportunities to be provided by the government. This would ensure financial security and enable them to improve the quality of their lives. Equally important was the need for healthcare providers to provide medicines free of cost.

One of the women from the cohort expressed that she had been anemic for the past six months and upon consulting the doctor, was advised a drip costing 2000 rupees ($12). Unfortunately, this was out of her reach. The healthcare providers noted that most patients approaching them were too poor to afford fruits or iron-rich food.

“Wealthy families can afford blood transfusion for the treatment of blood deficiency among women but poor people cannot afford it” (KII-HCP-06).

"When doctors refer us to the hospitals, we have to take a loan from others to get treatment" (FGD-F-05).

Spacing between pregnancies.

Most study participants did not believe in family planning (FP) or birth spacing and thought it was normal to get pregnant every year. They also avoided contraceptives (especially the injectable forms) which were perceived to be associated with complications such as bleeding, weight gain, and dizziness. However, a handful of participants did admit that birth spacing was beneficial for the health of both the mother and the child.

Doctors reported that people in the district had several myths regarding FP. It also seemed to go against their religious and cultural beliefs. Thus religion was identified as the main barrier to use FP methods; however, women themselves did not directly state religion as a barrier to use FP. For instance, health care providers mentioned that post-partum FP was considered ‘sinful’ by most mothers. Healthcare providers thought that modern methods of FP would be fruitless unless awareness about their usage was created amongst the masses and their myths and misconceptions were addressed. Indirectly, health care providers considered lack of awareness as a cause behind disbeliefs towards pregnancy spacing. Cultural beliefs make it essential to counsel women in the absence of their husbands who typically express disapproval over FP methods. However, we did not find religion or resistance from men as reasons regarding disbeliefs towards pregnancy spacing.

They recommended the use of FP methods especially if the couple did not have the financial means to provide basic needs such as food, shelter, and education to their children, and also suggested permanent contraception such as tubal ligation and vasectomy when the family was complete.

“The woman who is getting pregnant is perceived to be better than the woman who is doing family planning” (FGD-F-05).

"As soon as her first child starts walking, the woman will try for another baby" (FGD-F-05).

"God will be unhappy if you discuss family planning with me and His unhappiness will result in the death of my child" (KII-HCP-02)

Health seeking behavior during pregnancy.

The poor health-seeking behavior of the women in the community meant that they sought medical treatment only when severely anemic and were often not compliant with treatment. Pregnant women visited the clinics during the 2^nd trimester with Hb levels of 6 to 7 gm/dL when they would be prescribed parenteral iron until delivery.

Additionally, most women were also not compliant with antenatal visits, investigations, and follow up visits after delivery—only 40% returned for post-partum follow-ups. The women, on the other hand, blamed this on the doctors who did not give them quality time during their visits. This controversy between the community and health care providers could be either true or it might be natural human behavior to blame others for their mistakes. However, we could not explore the reasons for this controversy and it might be possible that health care providers might have their limitations such as work overload or flow of patients given the higher population in the district. On the other hand, community people might not visit the health care providers on time due to lack of resources as highlighted by men, women, and TBAs.

“During antennal care, women only want to get their ultrasound done to determine the sex of the baby rather than being concerned about the health of their child" (HCP, KII- 01).

Furthermore, the men stated that if someone got sick, it took them up to three days to visit the doctor and start treatment. The doctors in private clinics also charged a higher fee than the ones in government facilities and so they avoided visiting them.

"When we go to a government hospital, doctors tell us that they also practice in "Doctors Street" in the evening and so I should come to visit them in their private clinic where they would perform some tests and start treatment” (FGD-M-Chatochand).

Who to contact?

Women in the FGDs mentioned seeking pregnancy care from the local TBAs and doctors who also provided medicines. Complicated pregnancies were referred to the public and private facilities for pregnancy care and childbirth. They often self-treated themselves using home-based remedies or visited homeopathic doctors or spiritual healers.

"We go according to our affordability, sometimes we don’t go to the hospital we just deliver the baby at home" (FGD-F-05).