CULTURAL BELIEFS AND PRACTICES REGARDING MATERNAL HEALTH: A CASE STUDY OF RURAL AREAS OF PUNJAB

People are strongly influenced by practices and beliefs whether they are based on custom or tradition, and these beliefs are difficult to change just by requesting scientific evidence. Traditional beliefs are more focused on pregnancy and childbirth than other aspects of life, making women more susceptible to them. This research study mainly focused on cultural beliefs which are contributing in determining the reproductive life of women in Pakistan particularly of rural areas. This research used a hybrid technique for data processing and interpretation. This approach mixed both qualitative and quantitative methods, and required researchers to seek and explain reality in its natural setting. Field data collection was carried out in Punjab's area; Jampur which is the tehsil headquarters in District Rajanpur, Punjab, Pakistan. Married women having at least one child were selected through purposive sampling. It was concluded that women in Jampur preferred to follow indigenous food habits, advised by their elders, during pregnancy. Women depend on their husbands or mother-in-law regarding maternal healthcare decisions. According to health professionals, the maternal health depends on the education and social status of families. The ordinary Pakistani woman will continue to endure a high risk of maternal death and would leave behind stories of misery, prejudice, and vulnerability if social and cultural practises are not addressed in broad integrated policies aiming at improving maternal health in the area. Findings of this study will be helpful for the health service providers to arise with worthwhile mechanisms to make their services women-friendly and accessible to the youth. Likewise, this study will also contribute to an in-depth understanding of the processes underlying social identities in shaping women's reproductive health-seeking behaviors. The study will be helpful for organizations that are working for maternal health and population welfare such as National Institute of Population Studies (NIPS) and also for policy-making bodies, including national health policymakers and Pakistan population policymakers.


INTRODUCTION
Cultural and social norms play a significant role in governing social structures as well as shaping the behavior of people that's why they are inseparable from daily interactions (Ministry of Health [MoH], 2019).It is a worldwide phenomenon that health concerning dynamics that govern human behavior are rooted in different perspectives (Omer et al., 2021) comprised on physical, social, cultural, economic and religious contexts (Shaikh & Hatcher, 2004).For instance, women's mobility restricted by culture even in emergency obstetric condition may lead them to a risk (Omer et al., 2021), and studying women's beliefs is very important in this regard.
Beliefs regarding maternal health depend on religious and cultural norms, for example the restriction of Purdah (veil).This restriction can result in the prevention of getting health care facilities from outside the houses for pregnant women and their children.As said by Jejeebhoy (2001) that there are some factors that affect women reproductive health status, such as gender-based role of mothers in child bearing according to traditional and cultural beliefs, that can result in less empowerment of women regarding taking decisions about child spacing, fertility and aspects of family planning.This study did not attempt to make any value judgments on practices based on such beliefs.It is also concerned with influence of these beliefs on reproductive health, their identification and their influence on respondents' behaviour.
This study has mainly attempted to assess the beliefs and practices of women's reproductive health services in Tehsil Jampur of district Rajanpur, a largly ignored rural area of Punjab.Furthermore, the study of women's reproductive health is pivotal for community development.According to the Government of Pakistan (2017), women of reproductive age, that is from 15 to 49 years, is 28.5 million.It is approximately 48% of the total population of Pakistan.Women's health assurance is a matter of global concern since women perpetuate mankind by reproducing population and then nurturing it.If effective reproductive health services would not be offered within affordable costs and socio-cultural norms, then a large number of young reproductive adolescents will face childbearing and pregnancy problems.
In South Asia like Pakistan women depend more on their elders regarding reproductive health issues.Women in Pakistan do not prefer doctors, midwives or nurses to seek care, rather they prefer decisions of in-laws or husbands (Hodzic, 2002;Anon, 2006).In Pakistan, the system of health care comprises of informal and formal sectors.The local uncertified health care providers, like spiritual healer, Hakims (practitioners that use home remedies or Greek medicines), and TBAs are included in informal sector.While in Formal sectors, both public health facilities and private health facilities are included.As far as public health system is concerned in Pakistan, it is recognized under the Federal Government and Provincial Health Ministries.Informal health care system is supported by a large number of people because of affordable treatment and its availability within the local community and more of it is associated with traditional and cultural beliefs (Sheikh et al., 2016).
The question arises over here is that, if women of rural areas in Pakistan prefer informal sector or private sector to get information regarding reproductive health care, do they have no awareness of their reproductive rights as the government has issued for them?According to the Reproductive Healthcare and Rights Act 2013 by national policy of Pakistan, women have a right to reproductive health care information.Women should be provided with reproductive healthcare information, which provides awareness regarding the mental and physical health and wellbeing of individuals and families.According to the Act women have the right to ensure that reproductive life decisions are made with informed consent and right to get public awareness on the prevalence and impact of morbidity and mortality and availability of medical facility to prevent this suffering.after relating all the aspects related to the reproductive health and women (Saeed & Malik, 2017).
The theoretical and conceptual issues discussed relating to healthcare services utilization include a review of Andersen's health behavior model (1995), the structure and agency theory (Giddens, 1984;Germov, 2014).There is a standing debate over the extent to which human behaviors are determined by social structure (Germov, 2014;Raffiee & Mirzaee, 2014).The structure may be described as the recurring patterns of social interaction through which people are related to each other (Germov, 2014).In contrast, agency is defined as the ability of people, either as individuals or groups to influence their own lives in society.
This research mainly focused on factors based on cultural beliefs which are contributing to determining the reproductive life of women in Pakistan.This research study specifically focused on the rural areas of Pakistan because rural women in Pakistan are facing the same problems as those women in other developing nations (Zahan, 2014).This research is concerned about the cultural or religious beliefs that are the reason behind preventing women from getting modern reproductive health care practices.To the best of our knowledge, no systematic research on reproductive health care of the rural women has yet been done in Tehsil Jampur of Rajanpur District, Pakistan.Although Punjab has a better progress level as compared to other provinces, however, Southern Punjab has disparities because of the overriding effect of existing social and environmental factors (Cesare et al., 2015).Research also focused on the influence of socio-cultural factors on RH (Mahmood et al., 2000;Asghar, 2010;Akhtar, 2014;Munir & Mohyuddin, 2015;Ahmed & Hyder, 2016).But these studies do not mainly focus on rural areas and Rajanpur is not studied yet in respect to cultural influence on RH.Reproductive health of a woman is one of the basic targets of socioeconomic development of Pakistan.Hence, it is significant to carry out research on the maternal and reproductive health issues with respect to the cultural factors because cultural factors determine the living patterns of individuals.This study is, therefore, focused on exploring cultural beliefs and practices of women regarding Maternal Health in the rural areas of Southern Punjab, Pakistan.

REVIEW OF LITERATURE
It is evident from literature that cultural beliefs and practices of women may affect their maternal health.For example, following purdah is considered essential in both cultural as well as religious context and restricted to travel outside without men and it is considered dishonor for family if a woman goes outside alone even in any emergency case (Omer et at., 2021).Culture of relying on TBA is a common and frequent practice rooted in socio-cultural context in poor regions of Pakistan (Agus et al., 2012;Gogoi, 2021).Provision of guidance on nutrition during pregnancy and lactation, counselling women throughout the pregnancy till childbirth, guiding about natural family planning strategies, and providing psychological support to them.Another cultural and customary practice is visiting spiritual healers and believing on positive results of performing spiritual rituals.People have blind faith in spiritual healers and follow their advices on all matters either relate to daily life or associated with health maintenance.That very often works as a hindrance for acquiring maternal health in rural areas ( Omer et al., 2021).For this reason, it is considered a social issue for women of rural and urban slum areas (Mcnojia, et al., 2020).The level of trust and dependency on healers is so intense that people prefer advices of these healers over physicians (Hassan et al.,2020).
Although, motherhood is a positive and fulfilling aspect of life but for many women motherhood is associated with illness and suffering that result in poor well-being and even mortality of those women (Chepkorir, 2014).Maternal mortality rate (MMR) is considered to be high if it is greater or equal to 300/100,000 live births and extremely high if it is greater or equal to 1000 deaths per 100,000 live births.In many developing countries, such as Bangladesh, women are considered to be responsible for any mishap related to reproductive health (Zahan, 2014).It means there is a lack of women reproductive health knowledge for the people.Shaikh and Hatcher (2004) found that women's access to health services is actually limited by constrictions on their independence for making decisions within her husband's house.Cultural norms tend a woman to follow her husband or mother-in-law as it is considered as, respecting behavior" that may result in overestimated influence of family members especially in case of teens (Upadhyay et al., 2014) as they are assumed to be less aware, inexperienced and immature and need more guidance and supervision than the adult.Pakistan is a patriarchal society where strong hierarchal system is embedded in complex family structure.Such complex structure prefers joint family system in which family plays a significant role in decision making.Majority of rural women take permission, usually from a male family member, before accessing any health care service (Dar, 2013).Sarfraz et al. (2015) documented that fathers are considered as responsible for making any decision or took advice from elder women regarding maternal care services when there are any financial hurdles.Singh et al. (2012); Mumtaz and Salway (2007) mentioned that, this happens because in rural areas of Pakistan elder women are considered to be wise and can better take any decision regarding maternal care aspects for the family well-being so a pregnant woman is supposed to follow them and not voice her opinion.
According to UNICEF (2012) there may be an influence of traditional and cultural practices on the beliefs related to reproductive health during pregnancy, early care of the newborns and the process of birthing.In poorer geographic regions, rural areas and religiously influenced areas, these beliefs are more prevalent (Siddiqi et al., 2007).In some areas cultural beliefs prevent young pregnant women from showing their pregnant bodies, so they cannot access to reproductive health services (Hira et al., 1990).
Consequently, these women are less likely to get RH care services from nurse, midwives or doctors.It is so, because they rely more on the decisions of their in-law and husbands (Chowdhury et al., 2007).A study from Dudgeon and Inhorn (2004) found that women are more likely to depend on their husbands' decisions regarding RH, that influence their health indirectly or directly and negatively or positively.In rural areas of Pakistan, women are more likely to depend on their mother-in-law's decisions regarding their reproductive health matters.Such as where the delivery will be take place, whether women will seek traditional RH services or of modern health providers (Piet-Pelon et al., 1999).
In rural areas of Pakistan, women have strong beliefs in traditional healers as well as spiritual healers.This results in low rate of the use of professional modern RH services among rural women (Gadit, 2003).The expected traditional gender-based role of a woman regarding child bearing activities are mainly constructed by cultural beliefs and that results in the lack of empowerment regarding RH decisions and poor health status of women (Sathar et al., 1988).Veil also known as Purdah prevent women from seeking reproductive health care services from outside their houses in Pakistan.Such beliefs that are based on religious and cultural norms regarding reproductive health are the main causes of poorer RH status of women (Rashid et al., 2001).
Traditional beliefs and practices are usually transfered from generation to generation from mothers to daughters or from mothers-in-law to the daughters-in-law respectively (Lundberg & Thu, 2011) in order to follow familial pressure or tradition given by the elders (Choudhury et al. 2012).A study conducted in rural Sindh reveals that antenatal care (ANC) is perceived to be taken at the time of any sever conditions so they visit doctor when they suffer from vertigo, high blood pressure, excessive bleeding, seizures and weakness because these dangerous symptoms show complication of pregnancy (Qureshi et al., 2016).The study reveals that people perceive emergencies at the time of child birth and in that case women access health facilities.
Many studies studied taboos related to food that are practiced during pregnancy (Withers et al., 2018) in this regard.Generally, "hot" foods are restricted and pregnant women avoid it.Such as, Pakistanis considered some foods abortifacient and hot like maize, beans, nuts, and sugar (Ali et al., 2004) so pregnant female are advised to avoid it.Alternatively, "cold" foods including curds, oranges, and buttermilk were avoided during pregnancy as they were considered to be harmful for the fetus (Withers et al., 2018).Others found that only during lactation "cold" foods were restricted (Agus et al., 2012;Ali et al., 2004).Women living in Indonesia believed that their breast milk smells and taste bad if they eat fish (Agus et al., 2012).Growth of the baby is associated with food restrictions (Ali et al., 2004).In order to promote excessive fetal growth, mostly prenatal vitamins were avoided (Culhane-Pera et al., 2015).
In many area, people had strong belief on traditional practitioners.Women in Pakistan favored to use holy water and amulets that are provided by religious/spiritual leader rather than seeking formal healthcare services (Syed et al., 2008).A massage related to prenatal period given by a traditional/spiritual healer, was also considered as a common practice (Agus et al., 2012).Mumtaz & Salway (2007) conducted a study in rural Punjab, a province of Pakistan, and found that people perceived pregnancy as predestined to childbirth that is why it should not be interfered with otherwise medical interventions can create complications and can be harmful for the pregnant lady and her baby.Another study (Ndidi & Osermen, 2010) found that cultural perceptions of care work as barrier; as ANC perceived to be reserved for the women having health problem or any reproductive complication instead of prevention from complication or then general well-being.
Women living in South Asian countries and belonging to the lower caste traditionally have given birth in a cowshed or the place like a special hut that was especially constructed for the process of delivery (Vallely et al., 2015).It was so because this time was seen as a time of impurity, where it is avoided to contact anything with a bodily fluids of a pregnant woman (Choudhury et al., 2012).

MATERIALS AND METHODS
This research used a hybrid technique approach, [qualitative and quantitative] for data processing and data interpretation.Field data collection was carried out in Punjab's area; Jampur which is the tehsil headquarters in district Rajanpur, Punjab, Pakistan.The reason behind selecting Jampur is its backwardness with respect to education and lack of awareness regarding reproductive health.The other main reason is that people blame women in case of infertility regardless it's from men.
To engage the participants for analysis, purposive sampling was used.The planned selection of participants provides a basis for the collection of rich information related to the subject area of the study (Patton, 1990) and maximum diversity among the participants of the study (Kielmann et al., 2011).Age and educational achievement levels of young people were used as sampling criteria in both rural and urban areas as a sampling strategy for data collection.Through interviews, uneducated, less skilled and educated females aged 15-49 with at least one infant were selected on the sampling criterion.
In order to get data from the individuals of the community through first hand data gathering, the researcher used to observe community by living with the people in the same community.Key informant is a key person and a native of the research study area.Interview guide is used to gather data by face to face talk.It is also used for observing the talking expressions of the respondents.Through 42 interviews, ideas and opinions, behavioral traits and body language were observed.In 5 focus group discussion, 7 to 8 people were involved in discussion at a time and on one point.Field notes were basically used to capture the main information and activities on the research area so that it can be memorized.All tools were used to get rich and high-quality data.

RESULTS AND DISCUSSION
The results deal with the norms, perceptions, attitudes and practices related to maternal health.The discussion is based on the data which address the cultural belief system that affects the maternal health during and after pregnancy along with how these beliefs have a strong influence on the maternal health system.

a. Food Habits
The most important aspect of belief system was how a mother used to take care of her food habits.Healthy lifestyle and maternal nutrition greatly influence the health of both the mother and the neonate (Fernández-Gómez, et al., 2020) that is why after conceiving baby the health care of a mother not remained just an outline matter but turned into an important task in the families.According to the findings, the diet had a vital role in maternal health since distant past that is also mentioned by Ali et al. (2004).As the need for nutrients increases during pregnancy as compared to other stages of life so nutritional requirements also increase (Das, et al., 2017;Nana & Zema, 2018) throughout pregnancy.Lack of nutritional intake may result in suffering of the mother as well as for the baby that may continue for a short term or a long-term (Shin et al., 2015) A family always wanted healthy children.This was also in mother's mind that it would increase her value if she gave birth to a healthy baby.In the families, care was taken to ensure the baby was born in normal delivery, besides this miscarriage and abortion could be avoided.Further proper and adequate nutritional food patterns may be helpful in prevention of diseases during pregnancy (Shin et al., 2015;Hu, et al., 2019).So, families especially mothers took different precautionary measures to avoid those fears.If the baby was lost due to mother's carelessness, she had to face different negative responses.
When talking about the women of Jam Pur community about food of pregnant mothers, they divided it into two major portions.The concept of hot and cold food was found regarding maternal health.It was called locally, hard and soft food.
"A 43-years old mother told the researcher, ''the soft food means having cooling effect.The mother should be protected from this, in the start of pregnancy.On the other hand, the hard food having warm effect creates heat in the body, especially heats up the stomach".Soft or cold food was usually given to women in the pre natal period because, in the first three months of pregnancy, the child had to develop.So, it was considered that such type of food would be useful for mother, in addition it also reduces the fear of abortion or miscarriage.On the other hand, hard or warm food was given to mothers during the natal and post natal period; it might heal up the pain and weakness that evolved as the result of delivery.Warm food was used to provide the immediate relief.While collecting the data, it was observed that belief about the warm and cold food existed among all the people whether educated or uneducated, living in towns or countryside.Such type of beliefs about food taboos were also observed in other regions too (Ali et al., 2004;Withers et al., 2018).However, it could be said that few people believed more and some less.The fact was that the medical concept prevailed yet.
A clear list of warm and cold food came up, after the findings and information from the interviews and group discussion.It was also clarified how it could be affect the mother and child health?Overall, the details obtained from educated and uneducated respondents belonging to rural and urban areas were as follows:

Cold or Soft Food
Excursive intake of fresh fruit juices, Lessi butter, milk, yoghurt, water and (tandoor ki roti) were the components of food which should be used by mothers, at least during the first three months of pregnancy.After the fourth month the child had fully developed which reduced the tension.Now then mother could use all types of food with essential care.

Warm or Hard Food
It is believed that intake of vermicelli, boiled or cooked in the milk or (Atay ka halwa) cooked in desi ghee might be speed up the process of delivery.Such type of food contains abundant amount of oil.Other than that cumin and ghee bread, meat, dal Mong and dal Masur, Tori,( Ridge gourd) pumpkin and turnips were also served to mothers, considering those as a warm food.It was observed that cumin and desi ghee were mostly used in all types of food."Kehwa" was generally used that was locally called ("Kahrah).The community had belief that cumin reduced the post-delivery pain.

Prohibited Food
The specific food could have put both the mother and the baby at risk.It could be harmful form mother's digestive system and it could also affect the baby in prenatal period.Moreover, if the mother ate that food, the stomach of the baby who was drinking her milk could get upset.The list of food was as follow: Pulses, Spinach, beef, eggplant, cabbage, Okra and Potatoes the food stuff mentioned above was not allowed to eat, during the nine months of pregnancy, locally.Vegetables like eggplant, cabbage and okra are regarded as flatulent that might disturb the digestive system of mother.These vegetables could cause gas or constipation so they should not be included in diet.It was prohibited to drink water immediate after one week of delivery.The local belief was that excessive use of oil opened up the uterus and the baby was born easily.It is believed that in the postnatal period, the mother should be given warm food immediately after the birth of baby.Whether it was winter season or summer, chicken or mutton soup was served.There was an overall opinion that came up through FGD and interviews that boiled egg, Kehwa, tea, red chilies and Dal Masoor could not be eaten in prenatal period but were allowed in postnatal.Potatoes could not cause ventose effect, if were eaten in baked form instead of curry.The time was set how to use those cold and warm foods during prenatal and postnatal periods.That was cold or soft food should be eaten, at least, in the first three months and warm or hard food could be used during forty days after delivery.
An opinion emerged that economic conditions were not the same for everyone so the intake of food was according to their status.A consensus was about mother's complaint of vomiting in the early three months of pregnancy.In that particular situation she used to choose her diet according to her own wish which could vary.When this phase had ended, she could eat the routine diet.The aggregate opinion related to post-delivery diet was the mentioned food used by the rich and the poor almost eleven days, then it was continued according to their social status.The staple food in Pakistan was wheat bread.This concept was found that tandoor, bread was easily digested while the bread cooked in pan was hard to digest.
Generally, the woman began to complain of smell of protein diet such as eggs and meat belief system did not allow to eat meat and on the other hand, they also did not like to eat vegetables and the result was nothing but weakness.
"A 37 years old mother who used to work in an NGO told the researcher, "During the first three months of pregnancy, I used to vomit a lot.The eggs and meat smelled very bad.Rather, my heart wanted to eat Multani mud.My husband and other family members got angry that you eat mud all the time.It will affect the baby negatively.Now I am mother of three sons and thank God they were born healthy though all three times, I suffered the same conditions."Regarding food, it was observed that women used to eat selected food during pregnancy which caused anemia in them.It directly affects the health of pregnant women (maternal health), along with their expected babies.A lady working in local media channel, so had a better awareness level regarding health issue, told that, "My husband got married twice.He has another wife besides me so he rarely comes to me.Like all other women, the early days of pregnancy were difficult for me.Health remained so poor for many days but I had to do all chores, sending kids to school cooking, going to office etc.But in spite of all these responsibilities, I never neglected my health." The role of a traditional birth attendant (TBA) is very important in the life of a rural mother.Every effort was made to ensure that the baby was born at home through normal delivery and be healthy.When the researcher talked to a lady doctor of BHU about maternal health, the diet of rural women was also discussed.She said that those women especially old ladies had a belief, having a baby was very difficult process.Thus the healthier the mother, the easier it would be for the baby to be born.
There was common perception in the community that, the mother should reduce her food intake during pregnancy to deliver normally.So, to avoid painful delivery in case of highly increased baby weight or big size of healthier baby head and fear of delivering at health center (Gardner et al., 2019) in addition of C-section (Asim et al., 2020) people follow food restrictions to control baby's weight and size.It was observed that women should not eat high-protein diet such as eggs, meat etc.A cultural notion had also been found that whatever food a mother eats, benefits her child instead of her.Because of this thinking, mother often ate less food.b.Family's Role While discussing the birth of children and decision making a participant told that it was not considered appropriate for men and women to talk about pregnancy.Family planning was also not being taken as good so they had more children.
"A 44 years old rural woman took things in stride by saying that, "Our husbands (Juwan) treat us like animals for morning to evening.We get tired of working all day long.Rather, pregnancy is the time of rest for us.Food is also good in this time.Milk or bread with great amount sometimes, we also buy fruits.Therefore, in our life these nine months is a time of relief.That's why we prefer to have more children".While researching, the women were asked about the age at the time of marriage.The responses were strange 62% of them answered that they were married in teen age.The next question was how long after their first child was born?60% of them were conceived during first year after marriage.It was so, because they were dependent on their families for such decisions.

c. Illness and Healing
The most important code which came to know after food habits, was illness.It was perceived through interviews of different mothers and focus group discussion that two types healthcare system existed there.First, they used to adopt allopathic treatment to cure the diseases related to maternal health and had firm beliefs in that.Secondly, the other type of medication was traditional, including home remedies, herbal medicines and self-medication.Both kinds of treatments went simultaneously that was clear through mothers' conversation in FGD that both methods were significant in their own place.There was no clear view of either.A 36 years old mother, who lived in the slum area of the city, said: "Today's diseases are intricate.So, we have to use allopathic medicines.Because of this tension a person does not easily recover.On the other hand, we have a tried and tested methods of treatment from elders.Indigenous medicines have cool effect and are not detrimental.The simple home remedies told by our grandmothers also bring relief.In short, we adopt both methods."There were two codes used to refer to types of illness that a mother suffered from during nine months of pregnancy were also had two parts.The first one, clinical illness included biological problems such as abortions, STDs, venial infections, extra bleeding, blood pressure etc.The second one, non-clinical illness were considered as common ailments.For example: Tension, Anemia, Malnutrition deficiency of iron and vitamin etc.They are taken as not a big deal and used to cure it without going to the doctor.In Jampur, those mothers, who had biological problems, used herbal medicines or home remedies, besides visit by the doctor.
Another point was highlighted after several interviews, most of the women had a strong belief that both types of diseases were caused by magic supernatural and demons.They were sure that relatives, ever sometimes real sisters used to do sorcery, just because of jealousy.In their opinion, the main reason behind not conceiving and repeated loss of children was only the supernatural element.And its best cure was recitation of the Holy Quran, bringing a talisman from Pir Sahib and in addition to holy verses ‫درود(‬ ‫.)دم‬These safety measures were common in practice.A 25 years old young rural mother told "We work hard in the fields all day long.The dry bread we get is eaten with milk and butter.I got married at the age of sixteen.I had two abortions.Now, I have four children.I breastfeed my youngest child.I have to take care of my kids and protect the animals while working in the fields.I had two checkups at a government hospital during pregnancy.They gave me energy pills which did not help so I preferred indigenous medication.Everyone eats simple diet such as bread, milk spinach etc. God is sovereign." The question was asked to them, what was the cause of the death of their children?Seventy percent of them answered that it was illness.According to them, the main reason behind this illness was the presence of anemia or malnutrition in their mother.It might cause wither miscarriage (locally called Athra), means prevention from conceiving, or abortion in case of conceiving the baby.The mother used to call it weak health.20% told that their children died because of mishandling and TBA was responsible for that.People could not go to towns due to poverty.Besides this, they needed the help of men to get to the city town who could not accompany them due to cultural compulsions and different assignations.10% claimed that the actual reason behind abortion was carelessness.Sometimes, women did not know in the first two or three months that they were pregnant.As a result, babies were lost due to overwork/ labor work.

d. Role of Health Professionals
During the discussion with lady doctor of a private hospital, it came into light that three major illnesses related to maternal health were found in that particular area; Hyper tension, Anemia, and Blood Pressure.The main reason standing behind these illnesses were actually the problems such as iron deficiency, imbalance diet and lack of clean drinking water, she explained further: "Local men used their women as a useful tool.Women of rural and tribal areas have to bear too much local of work.I divide those people into three groups who come to me for medical checkups; upper, middle, and lower class." According to the doctor, "upper and middle classes have awareness to some extent.They come for checkup twice or trice during pregnancy.On the other hand, the people of lower class are mostly illiterate and unaware.They have less information about their health.They are more in number and have firm belief in TBAs.These people come once and a half and ask us to inject the drip.They avoid the intake of tablets.They prefer drips for immediate relief.In this way, checkup cost increases.Most people are poor so they rarely go to the doctor to avoid the loss of daily income.Expenditures are high as compared to low income.That's why men do not support women.It's the big obstacle in the way of their health seeking.But the people belong to high income families consult me and another doctor out of city.These people are very few." It seems that poverty with the combination of social stature of residents impose a mixture of constraints on women access to health services (Mumtaz et al., 2011).That is why human capital and demographic conditions are considered as a key to dissimilar behavior and patterns among different economic classes (Agha, 2015).Moreover, the lady doctor described that the people here are strictly bound by rituals and have greats impact of TBAs on them.They are against the Ultra sounds and C section.According to them the rays of ultra sound are harmful for babies and C-section are done by doctors to make money, despite no scientific evidence supports their beleifs.

CONCLUSIONS AND IMPLICATIONS
In Pakistan, the extended family system was regarded as a symbol of collective, well-being and blessing.In Pakistani culture, in marriages the consent of the boy or girl was not as important as it is in the hands of Parents, uncles, aunts and brothers.It was also evident in the study area that the implications of decisions were made by older women and men regarding maternal health.The status of the eldest in the family had more importance, so to obey and accept his advice and respect his decision.As for as maternal health was concerned, a healthy lifestyle and maternal nutrition greatly influence the health of both mother and neonate.After conceiving a baby, the health care of a mother has not remained just an outline matter but turned into an important task in the families.
The diet had a vital role in maternal health.The need for nutrients increases during pregnancy as compared to other stages of life so women need higher nutritional requirements throughout the pregnancy.Lack of nutritional intake may result in the suffering of the mother as well as for the baby that may consist on short-term or long-term as well.Soft or cold food was usually given to women in the prenatal period.It is believed that in the postnatal period, the mother should be given warm food immediately after birth of baby.There exists a strong factor of religious and spiritual beliefs and practices related to mother and child.The women in the area, if did not get pregnant, was considered to be unlucky.They used clinical and traditional services, they strongly believed in spiritual and religious practices, according to their own religious beliefs.
In Pakistan, cultural customs, religious beliefs, and women's lack of autonomy, have a significant impact on maternal health.In the area chosen, the maternal mortality status is quite concerning.It will be difficult to reduce the number of fatalities among pregnant women unless sociocultural norms that limit women's access to maternity care are addressed.Even if the government of Pakistan makes attempts to offer medical coverage to rural women, societal behaviours and cultural beliefs have a significant impact on which women survive.Even with allopathy, women in Jampur prefer using traditional techniques during the complete pregnancy.Due to the time factor and resource constraints, study was limited to maternal health.Further, special population women with Infertility, Abortion, STIs and Family Planning and women with disabilities who constitute an important segment of the population were not covered in this study to discover the challenges they faced during pregnancy and childbirth.Geographically, this case study was focused on one Tehsil due to limited time and resources.In the future, it would be expand at the district or province Level.

RECOMMENDATIONS
• The low economic and social standing of rural households must be addressed if maternal health is to be improved.In order to raise the status of women in their society via economic empowerment and education must be a top priority.The ordinary Pakistani woman will continue to endure a high risk of maternal death and would leave behind stories of misery, prejudice, and vulnerability if social and cultural practises are not addressed in broad integrated policies aiming at improving maternal health in the area.• The study also recommends to the WHO, NGOs, the Punjab Health Department and their international and local partners to redesign the health promotion programs to strengthen both facility-based and community-based health promotion maternal health programs.• At community level, the efforts should be made to educate community members including men and adolescents on maternal complications to help them recognize problems and make timely decisions towards health-seeking.

•
To improve the poor clinical attendance observed in the study, people should be educated about the risk involved in the dualism of care and the need for timely and regular clinical attendance.• Interventions should be strategically directed to home care and facility-based care rather than only concentrating on facility-based clients and service providers.Author's Contribution: Mr. Altaf Ghani: Complete writing, Data analysis, Methodology, and references verification.Dr. Zamri bin Hj Hassan: Supervision, Conceptualization.Dr. Dolly Paul Carlo : Analysis investigation, and proofreading.