Zubia Mumtaz

Background: Obstetric ultrasound is an essential tool for assessing fetal growth and wellbeing. While evidence-based recommendations advise one routine scan before 24 weeks of gestation, research suggests its use in low-and middle-income countries often extends beyond medical necessity. This study examined how ultrasound technology has become integrated into antenatal practices in rural Pakistan and how cultural, economic, and institutional factors shape its use. Methods: Drawing on data from two qualitative and one mixed-method studies conducted across six rural districts of Punjab, we used a pragmatic mixed-methods approach integrating latent content analysis of interviews, focus group discussions and observations with quantitative survey data. Results: Ultrasound use is common, with nearly 80 percent of women reported having at least one ultrasound and many undergoing three to six scans. For some participants, ultrasound had become synonymous with antenatal care, overtaking basic tests such as blood and urine analysis. The technology was widely perceived as both diagnostic and therapeutic, with some women believing it could cure health problems. Providers, particularly in the private sector, promoted frequent scans to meet patient expectations and financial targets, while women’s demand was driven by reassurance, perceived modernity, and son preference. This dynamic created a self-reinforcing supply–demand cycle in which clinical need played a secondary role. Conclusions: In rural Pakistan, obstetric ultrasound has evolved into a central socio-technical feature of pregnancy care that extends far beyond its clinical purpose. These findings highlight the interplay of technology, culture, and market forces in shaping maternal health behaviors and underscore the need for context-sensitive policy responses that align ultrasound use with evidence-based care while engaging with the social realities that sustain its widespread adoption.

The incongruity between South Asia’s economic growth and extreme poverty has led to a growing interest in social protection and subsequent implementation of anti-poverty initiatives. However, many programs have consistently fallen short of their full potential in reaching the poor. We reviewed the literature to understand the factors behind this failure. A search of EconLit, Global Health Database, MEDLINE and SocINDEX, supplemented by an external search, yielded 42 papers evaluating 23 programs. Inclusion criteria included social and political determinants of program outcomes. Articles were assessed for quality using the GRADE and GRADE CERQual criteria and analyzed using Thomas & Harding’s thematic synthesis approach. We identified five themes: (1) structurally flawed program theories overlook the complexities of poverty and are rooted in simplistic cause-and-effect approaches; (2) elite capture through appropriation of benefits, powerful positioning in program implementation, and gatekeeping through relationships of patronage; (3) insufficient targeting strategies to reach the poorest; (4) neglect of gendered restrictions, hidden costs, lack of legal documentation, and physical and social exclusion; (5) active self-exclusion from social protection to maintain dignity, a perception that programs are substandard, and a lack of resources required. The review highlights the well-documented disconnect between South Asian social protection program designs and the ground realities of their ‘ideal’ beneficiaries. This stems from a dominance of Western-led poverty discourse that disregards the influence of caste, the challenge of effective engagement with a group whose identity remains unclear, and fast-paced funding calls that do not lend themselves to meaningful identification and collaboration with the invisible poor. We suggest this disconnect is intentional and reflects a broader power dynamic rooted in geopolitical interests and national priorities. Study limitations reflect the shortcomings of the existing literature, which largely uses quantitative research methods that fail to capture the multidimensional experiences of the poor.

The incongruity between South Asia’s economic growth and extreme poverty has led to a growing interest in social protection and the subsequent implementation of anti-poverty programs. These work to promote inclusive growth and ensure that the poor do not get left behind. However, many programs have systematically failed to achieve their full potential in reaching the poorest of the poor. We reviewed the literature to understand the determinants behind this inequity in South Asia. A search of four databases, EconLit, Global Health Database, MEDLINE, SocINDEX, supplemented by citation tracking and an external search, yielded 42 papers evaluating 23 social protection programs. All articles were assessed for quality using the GRADE and GRADE CERQual criteria. Data were analyzed using Thomas & Harding’s thematic synthesis approach to generate new higher-order interpretations. Our analysis identified five themes underscoring program processes that stop resources from reaching the poor. These include: (1) structurally flawed program theories that overlook the complexities of poverty and are instead rooted in simplistic cause-and-effect approaches overestimating the poor’s gain from participation; (2) elite capture of program resources through the direct appropriation of benefits, their powerful positioning in program implementation, and their ability to dictate the poor’s accessibility through relationships of patronage and withholding of information; (3) insufficient targeting strategies to reach the poorest and a subsequent redirection of resources toward the rich; (4) program designs that overlook gender-based restrictions, hidden costs, the poor’s lack of legal documentation, and their physical and social exclusion; (5) some of the poorest households actively choosing self-exclusion from social protection due to a desire to maintain dignity, a lack of capital, and a perception of programs as substandard. The review highlights the disconnect between social protection program designs and the ground realities of their ‘ideal’ beneficiaries: the poorest of the poor. We propose the persistence of this well-documented disconnect may stem from three sources. First, there is an unclear understanding of who the poor are in South Asia, with definitions overlooking the historical influence of the caste system. Western perceptions of poverty continue to dominate the discourse. The second challenge is effective engagement and co-production of knowledge with the poor. Lastly, despite encouragement of international collaboration, fast-paced funding calls do not allocate sufficient time to build relationships with the poor primary stakeholders. We suggest the possibility that maintenance of this disconnect is intentional, reflecting a broader power dynamic in which the global and local elite dictate the lives of the poor based on geopolitical interests and national priorities.

Background: Obstetric ultrasound imaging is a relatively new, but rapidly expanding, technology in low‐ and middle‐income countries (LMICs). Given that new technologies modify practices, the influence of ultrasound on pregnancy management in LMICs is not comprehensively understood.Objectives: To map how ultrasound technology may be modulating the culture of pregnancy management in LMICs.Search Strategy: A search of five databases up to November 18, 2022.Selection Criteria: Original, peer‐reviewed articles from LMICs, published in English from 2000 to 2022.Data Collection and Analysis: All articles were assessed for quality using the GRADE approach. Data were analyzed thematically to generate new interpretive constructs and explanations.Results: Forty articles involving 113 000 respondents suggests that obstetric ultrasound is becoming the preferred method of pregnancy surveillance, replacing clinically important components of prenatal care. Mothers overestimate ultrasound as an all‐powerful diagnostic and “therapeutic” tool that can deliver the perfect baby. For‐profit providers are driving medically unnecessary scans while the poor do not receive the recommended scans.Conclusion: Ultrasound technology has modified the culture of pregnancy management in LMICs in unintended and possibly harmful ways. Private health services are pushing the detrimental trends. Limitations include generalizability of qualitative studies and insufficient attention to inequities.

In Canada, the demands of female immigrant adolescents in terms of sexual health are largely unmet and have grown significantly in recent years. According to studies, racialized immigrant adolescents are less likely than non-immigrant adolescents to be knowledgeable about sexual and reproductive health and to use resources for sex education and related services. This difference seems to be related to socio-cultural and religious practices in Pakistani immigrant adolescents. This paper intends to explain the viewpoints of female adolescents of first- or second-generation Pakistani descent who reside in Canada with regard to their development of sexuality and psychological well-being. Moreover, this paper also describes how female adolescents perceive the necessity to support their sexuality as they go through the adolescent stage. Individual interviews and timelines were created using qualitative interpretative descriptive design. We included 21 female adolescents of first- or second-generation Pakistani ethnicity using a purposive sample. Data analysis was performed using a thematic analysis. The findings indicate that immigrant adolescent girls received conflicting messages about sexuality from their parents which impacted their psychological well-being. Additionally, survey participants noted that prejudice, exclusion from sex education classes, and a lack of sexual health information contributed to social isolation, health care avoidance, and poor mental health outcomes like melancholy and anxiety among adolescent girls. The absence of sexuality-related communication with parents and the scarcity of medical professionals who can relate to and address the needs and realities of immigrants may have an impact on the participants’ experiences. Female immigrant girls also spoke up on the need for open, honest, and stigma-free conversations as well as for the need to end the taboo around the subject of sexuality. This study used principles from both intersectionality and postmodern feminist theories to increase our understanding of the interplay between the experiences of developing sexuality and overall well-being in female immigrant adolescents of Pakistani descent. It is crucial to involve, listen to, and incorporate female adolescents’ voices when planning and implementing interventions to support healthy sexuality among immigrant adolescents.

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.

BackgroundPakistan’s maternal mortality rate remains persistently high at 186/100,000 live births. The country’s government-run first-level health care facilities, the Basic Health Units (BHU), are an important source of maternity care for rural women. However, BHUs only operate on working days from 8.00 am to 2.00 pm. Recognizing 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 Basic Health Unit (BHU) initiative be successfully implemented at scale to provide high quality, round-the-clock skilled maternity care in rural Punjab? MethodsThe project consists of two overlapping work packages (WP). WP1 includes three modules generating data at directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicate programme theory 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 understanding and identify 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 improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project. DiscussionThis theory driven implementation research project will co-produce significant 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 LMICs that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalised communities.

Background: 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. Aim: The aim is to identify and synthesize published research evidence on sexuality-related mental health stressors among adolescent girls and boys, identify gaps (if any) in the current knowledge, and contribute to the knowledge about the experiences of emerging sexuality and health among adolescents, to further inform research, practice, and policy initiatives in sexual health. Design: A scoping literature review of peer-reviewed articles published between 1990 and 2021. 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 10–19 years living in LMICs. Results: 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 four sub-themes were identified regarding the sexual 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. Conclusions: 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 well-being 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. Implications for Practice: 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.

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.