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How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan
  1. Raheelah Ahmad1,2,
  2. Nina Jiayue Zhu1,
  3. Reda Mohamed Lebcir3,
  4. Rifat Atun4
  1. 1NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
  2. 2Institute of Business Administration, Karachi, Karachi, Pakistan
  3. 3University of Hertfordshire Business School, Hatfield, UK
  4. 4School of Public Health, Harvard University, Boston, Massachusetts, USA
  1. Correspondence to Dr Rifat Atun; ratun{at}


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.

  • antenatal care
  • heath seeking behaviour
  • system dynamics
  • neonatal mortality

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  • RA and NJZ contributed equally.

  • Handling editor Dr Sanni Yaya

  • Contributors RaA, RiA and NJZ conceived the study. RaA, RiA and NJZ composed the first draft of the manuscript. RML contributed through high-level expert input on the technical modelling process. All contributed to the model development. NJZ and RML parameterised the model. NJZ ran the validation tests. All contributed to assessment of the validation results. All contributed to revision and finalisation of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.

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