City Research Online

How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan

Ahmad, R. ORCID: 0000-0002-4294-7142, Zhu, N. J., Lebcir, R. M. & Atun, R. A. (2019). How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan. BMJ Global Health, 4(2), article number e001242. doi: 10.1136/bmjgh-2018-001242


Background: Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities.

Methods and findings: A system dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse and switch antenatal care services in four provider sectors: public, private, traditional and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different subgroups by geographical locations and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within trimester 2, but for rural women within trimester 1. Antenatal care access delayed to trimester 3 had no protective impact on neonatal mortality.

Conclusions: System dynamics modelling enables capturing the complexity of health-seeking behaviours and impact on outcomes, informing intervention design, implementation of targeted policies and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts and strong social network influences.

Publication Type: Article
Additional Information: © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Subjects: R Medicine > RG Gynecology and obstetrics
Z Bibliography. Library Science. Information Resources > Z665 Library Science. Information Science
Departments: School of Health & Psychological Sciences > Healthcare Services Research & Management
SWORD Depositor:
[thumbnail of Ahmad et al 2019 BMJ Global Health e001242.full.pdf]
Text - Published Version
Available under License Creative Commons Attribution Non-commercial.

Download (3MB) | Preview


Add to AnyAdd to TwitterAdd to FacebookAdd to LinkedinAdd to PinterestAdd to Email


Downloads per month over past year

View more statistics

Actions (login required)

Admin Login Admin Login