Gender roles and their influence on life prospects for women in urban Karachi, Pak0istan: a qualitative study

Tazeen S Ali, Gunilla Krantz and Ingrid Mogren contributed equally to this work

Background

Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women's and men's life prospects.

Objective

The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men's and women's life circumstances.

Design

Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

Findings

Two major themes emerged during analysis: ‘Reiteration of gender roles’ and ‘Agents of change’. The first theme included perceptions of traditional gender roles and how these preserve women's subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

Conclusions

This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment.

• gender roles
• gender inequality
• women's health
• intimate partner violence
• focus group discussions
• Pakistan

Gender inequality is a global phenomenon, also deeply rooted in many Asian societies, resulting in discrimination of women and girls and inextricably linked to gender-based violence 1 2 with subsequent serious mental and physical health effects 3 4 5 .

When women and girls are expected to assume a position as subordinate to men, their general health, including reproductive health, is negatively affected at all stages of the life cycle 2. Heise gave examples of how gender discrimination may affect a woman's life at different points in the life cycle, starting with pre-natal sex selection. Young girls may experience differential access to food and medical care during childhood and later dating violence or economically coerced sex during adolescence eventually followed by intimate partner violence, marital rape and dowry abuse at marital age 6. Furthermore, women who are raised to bear tolerant attitudes to traditional gender roles and IPV, also experience such violence to a higher extent than women with intolerance towards violence 7 8.

Although gender discrimination happens to both men and women in individual situations, discrimination against women is an entrenched, global pandemic 2. It stems from social structures where institutionalised conceptions of gender differences and women's subordination are formed 9 10. Such cultural stereotypes are engrained in both men and women, and form the foundation for the differing life circumstances that men and women face. However, the gender inequality expressions do vary considerably between cultures and countries, being more overt in some cultures and considerably less prominent in others.

In Pakistan, gender roles are constructed of a combination of traditional roots and social values 11, primarily based on the concepts of production and reproduction, taken to mirror masculine and feminine traits of an individual 12. More than 50% of the women lack basic education and approximately 30% do earn some income, 13 but most women in Pakistan are confined to their homes to do housework for the extended family and are excluded from main decision making 14.

Our point of departure in this study was that gender inequality manifests itself differently according to culture, politics, religion and economic situation, and is further strongly linked to violence against women. The aim was therefore to explore current gender roles, how these are reproduced and maintained and influence men's and women's life circumstances.

This was explored among female informants living in urban Pakistan, as part of a larger project on violence against women and its health effects.

Subjects and methods

The study was carried out in five areas of differing socioeconomic status (SES) in urban Karachi, Pakistan. Five focus group discussions (FGD) with females were conducted using a qualitative study design. The study employed purposive sampling, with the following criteria: 20–60 years of age; employed or unemployed; and residence in different socioeconomic areas (upper, middle and lower socioeconomic locales). The informants were invited through teachers or by community health workers in non-governmental organisations (NGO). Fifty married women were invited and 28 agreed to participate. Informants between 20 and 40 years of age were considered ‘younger’ and women between 41 and 60 years of age were considered ‘older’. Background information of the informants is presented in Table 1. The FGD were conducted from June to August 2010, mostly in a home of one of the participating women or at an NGO office to ensure privacy. Data collection continued until data saturation was reached. Each focus group was homogenous in terms of the participants’ age, SES, and employment status. The FGD lasted from 80 to 120 min and was led by a moderator (TSA) and a field supervisor taking notes and making observations. All FGD were tape-recorded with the participants’ permission and transcribed within 7–10 days. The recorded discussions were then compared with the transcripts for verification by the first author. The documents were thereafter translated to English.

Table 1. Characteristics of informants in the focus group discussions (FGD)

FGD no.	Number of informants	Employment status	Mean age (min–max; years)	Mean number of children (min–max)	Geographic area in Karachi and socioeconomic status (SES)	Schooling in years
FGD 1	7	Housewives	33.7 (25–40)	2.0 (1–5)	Haideri, Aysha, Manzil (middle SES)	10–14 years
FGD 2	5	Employed	45.0 (40–60)	2.6 (2–3)	Defence (upper SES)	12–16 years
FGD 3	5	Housewives	30.2 (27–34)	0.6 (0–2)	Koi Goth (lower and middle SES)	10–16 years
FGD 4	6	Employed	36.2 (25–45)	1.7 (0–3)	Nazimabad, Karimabad (middle and upper SES)	12–16 years
FGD 5	5	Temporary work	44.6 (38–53)	2.6 (0–5)	Orangi Town (lower SES)	No formal schooling

A thematic FGD guide was created by the research team. It included the following questions among others: Describe/what are the societal role expectations of a man/husband/father and a woman/wife/mother? Describe/what characterises a good/bad wife and a good/bad husband? What are women feeling when they practise their expected roles? What situations enhance violence against women? How do women cope with their situation?

Qualitative content analysis was used to interpret the manifest content (what the text says) and the latent content (the interpreted meaning) 15. Content analysis is a stepwise analytical process 15. At the first step, the data were read several times in order to reach an understanding. Data were thereafter divided into meaning units that were condensed and labelled with a code independently by the first author. The last author and the third author coded part of the material. The coding made by the first, third and the last authors was then compared and consensus was reached. The codes were subsequently analysed and grouped into sub-categories and categories. In the final step, two themes, six categories and their 20 sub-categories were identified. All authors read, discussed and agreed on the final categorisation and themes.

Findings

Two underlying themes emerged during the analysis: ‘Reiteration of traditional gender roles’ and ‘Agents of change’ (Table 2).

Table 2. Themes, categories and sub-categories describing the perceptions by women on gender role expectations and differing life circumstances for women and men in urban Karachi, Pakistan

Themes	Categories	Sub-categories
Reiteration of traditional gender roles	How to behave as a female and male	A good woman, wife, daughter-in-law, mother and daughter
		A good man, husband and father
	When females and males behave badly	A bad woman, wife and daughter-in-law
		A bad man and husband
	Perceptions of female and male power	Power of women
		Mother reinforcing the controlling role of father
		Power of men
		Women's experiences of practising traditional gender roles
	The role of culture and the extended family	Suppression of women within the extended family
		Religion used to legitimise the denial of women rights
		Older generation's attitudes and approach to gender roles
		Restricting herself to retain the family honour
Agents of change	Societal change	Education in society brings change
		Public media as supportive agent
		Women support system
	Individuals’ capacity and attitudes	Capability and performance of girls
		Younger generation's attitudes to gender roles
		Balancing gender roles and opportunity
		Professional women and awareness of rights
		Extended families’ supportive function

Reiteration of traditional gender roles

This first main theme emerged from the descriptions given by the women of how their life is influenced by the institutionalised gender inequalities in society. This is described below in categories and sub-categories, and further presented in Table 2.

How to behave as a female and male

A good woman, wife, daughter-in-law, mother and daughter

A ‘good woman’ could be either educated or uneducated, characterised as being unselfish, calm, tolerant, empathetic, reliable, able to organise, compromise, coordinate and maintain hospitality within the house and in keeping good relationships. A good woman was expected to do household chores, care for her children, husband and in-laws and when needed provide the home with external income. A woman was expected to hide her emotions, to compromise with her opinions and to sacrifice her own dreams. The informants reported that some women perceived their husband to be their owner and ruler and therefore they should acquire their husbands’ permission to perform any activity:

Basically, we (women) are made for them (men). We are made to serve them. We die serving them and there is nothing in between. (FGD no. 2)

Lower SES informants reported that a good wife was a ‘good daughter-in-law’ if she treated her mother-in-law as her own mother and tolerated any mistreatment. A ‘good mother’ should impart values of gender equality, humanity and religion to her children and take care of her children's basic and educational needs. A good mother was seen as responsible for teaching her daughter to become good, by placing social restrictions on her:

Yes, a daughter's parents decide what she should wear, how she should live her life. This leaves a woman with no autonomy and she might get depressed. When such a depressed daughter enters marital life, she faces further challenges such as her husband's superiority and own inferiority. This suffering she cannot even discuss with her parents. (FGD no. 3)

A good man, husband and father

A ‘good man’ was expected to be financially stable. He should also be a good leader and advisor, a fair decision maker, sincere, unbiased, cooperative, sensible, strong, composed and elegant. A ‘good husband’ was described as being trustworthy, maintaining gender equity and giving decision-making autonomy to his wife. Upper SES informants reported that the ‘good husband’ would support a woman's employment, even if it caused family conflicts, whereas lower and middle SES informants reported that a good husband would permit a woman to work outside the household but not at the expense of her domestic responsibilities. A ‘good father’ would support his daughter's education and professional work before marriage. A ‘good son’ was considered to be responsible for fulfiling his parents’ needs and wishes, and to provide them with comfort. The ‘good son’ was also expected to encourage his wife to please his parents:

If [his] parents ask him to bring grocery from the market and he brings them then he is a good man. (FGD no. 1)

When females and males behave badly

A bad woman, wife and daughter-in-law

A ‘bad woman’ was selfish, critical, dominant, argumentative, fussy and blamed others. She would rear her children poorly by involving them in family conflicts, resulting in unmannered and disrespectful children. If a woman spoke up for her rights, she would be considered a ‘bad woman’ as silence was considered to be an appropriate behaviour. A ‘bad wife’ was faithless, careless about domestic responsibilities, disobedient, demanding more than husbands’ earnings and non-hospitable. A ‘bad daughter-in-law’ was a woman who would gossip and get involved in trivial issues, and who would fail to reach a respectable place within her family:

If she tries to say something to safeguard her rights or protect herself from any unnecessary stress, they [husband and in-laws] start blaming her: ‘your parents don't teach you manners how to behave with elders or others’. (FGD no. 4)

A bad man and husband

Informants generally characterised a ‘bad man’ as someone with a strong ego, a ‘dirty’ mentality, unfaithful, uncooperative, verbally abusive and suspicious. Disrespecting women by calling out their names in public, harassing them by staring, making inappropriate comments or luring a woman into a relationship and, if she became pregnant, refusing to acknowledge the child were all characteristics of a ‘bad man’. A ‘bad husband’ was a man who would yell at his wife when she shared her problems and beat her if frustrated. A ‘bad husband’ was further described as exploiting his wife's earnings, her services at home, exploiting her sexuality and sometimes restricting his wife's ambition to work outside the home:

No matter how much a husband is educated and understands his wife, somehow his ego appears. He wants to receive more respect from his wife. (FGD no. 1)

Perceptions of female and male power

Power of women

Education was considered a key issue related to the power of women, and educated women had better marriage prospects, management skills and could financially contribute to the family:

A woman is the foundation of the family. If she is educated and sensible she can run her household very well not only when she is married, but she can also stay unmarried. (FGD no.1)

Housewives were considered having less power if they were financially dependent on husbands. Women with lower education were considered powerless, with little decision-making capability, and unaware of their rights. Before marriage, decisions were taken by the woman's parents and after marriage by her husband and in-laws:

When I initially started working, my mother was getting irritated and hated my job because I had small children. (FGD no. 2)

Mother reinforcing the controlling role of father

Informants perceived that women tended to use the dominating role of the father (i.e. their husband) to be able to control the children. Using threats and referring to the father ensured that the children stayed quiet and controlled. The mother might manipulate the situation by forcing the father to scold the children and to remain stern in front of them:

The children don't even realise it, but I have created fear of their father in them. He doesn't do anything (to harm them), but I have maintained this standard.(FGD no. 2)

Power of men

Men are the principal decision makers in the family. A strong ego and an aggressive temperament directed towards his wife and family was perceived as accepted by society. A man might take out his anger on his wife without fear of reprisals from other family members. When a male person had marital problems, he would receive little support from society:

The husband also beats his wife and keeps her in pain to ensure that she respects his parents. He also beats when he becomes frustrated. (FGD no. 4)

Women's experiences of practising traditional gender roles

Both men and women were perceived as being central parts in a family. Informants from upper and middle SES perceived that both could put equal effort into professional life, but a woman also had the additional burden of household work and to fulfil the sexual needs of the husband. This could result in feelings of stress, powerlessness, frustration, depression and anxiety. A woman was expected to hide her emotions, to compromise with her opinions and to sacrifice her own dreams. Women commonly felt pride by providing comfort to their husband at home. Young girls faced many restrictions concerning their education, career and marriage, in contrast to young boys:

When the couple returns from office, the woman has to fulfil her fully loaded responsibility at home, while her husband has the chance to physically relax and insists on sexual contact that makes him mentally relaxed. (FGD no.3)

In many families girls are not encouraged to get an education even if they want to. She is pressurized to become married at 17 or 18 years age, and then she becomes a young mother. (FGD no. 4)

The role of culture and the extended family

Suppression of women within the extended family

The extended family was perceived as having a potentially negative impact on women's lives. The extended family often did not provide space for spousal understanding and an extended family could prevent the husband from being supportive towards his wife. The son preference attitude was strong:

In early childhood so many things are linked. From pre-conception, the hope is to conceive a son; a woman's status will increase if she gives birth to a male. If an ultrasound indicates a male baby, then the women starts getting privileged treatment (better food, more rest) until the end of her pregnancy but if they identify a girl then the treatment is just the opposite. She may be insulted or ignored. (FGD no. 4)

Religion used to legitimise the denial of women rights

Societal and religious misconceptions about women were used to reinforce the suppression of women's rights. Mothers and mothers-in-law were said to teach misinterpretations of religious doctrines to their daughters; most commonly that a woman cannot refuse the will of her husband:

In religion it has been clearly said that the woman is made for the man, that she doesn't have the choice to say no. But all this is part of traditional thinking. (FGD no.2)

Older generation's attitudes and approach to gender roles

Previously, older generations emphasised men's education but not women's. However, it was stated that in some cases, the older generation would promote the education of young women primarily for the sake of good marriage prospects. Nevertheless, grandparents would still take more interest in the grandson than in the granddaughter:

 … [my] mother-in-law does not prefer higher education for [her] grand daughter. She is looking for my daughter's good proposals … but we say we don't want to get her married now, but she [mother-in-law] says time will run out and then good proposals will not be available. (FGD no. 2)

Restricting herself to retain the family honour

The informants further pointed to Asian cultural norms in which parents teach daughters the importance of compromising her own interests and avoid asking for the parent's help, when in marital conflict. Moreover, the informants underscored how difficult it is for a married woman to return to her family of birth as it would compromise her parents’ honour, and her sisters’ future marriage prospects:

If the elder daughter returns to [her parents] home, people will say that the younger daughter will be the same [as her elder sister], and they wouldn't accept her to be part of their respectable family. So the younger sister will not get marriage proposals. (FGD no. 4)

Agents of change

This theme includes the two categories ‘Societal change’ and ‘Individuals capacity and attitudes’ and it points at some positive signs towards the modernisation of society and a change of gender roles that so far is mainly embraced by the middle and higher educated strata.

Societal change

Education in society brings change

Educated people were considered independent, trustworthy and mature. Education ensured future security by enhancing the capacity for women to fight for their rights. Generally, it was considered that an educated mother could act as a change agent towards a higher level of gender equity by enhancing her daughter's professional education. An educated man was considered to have a more supportive approach to education, and would help his wife manage the family:

A good husband and an educated family give freedom to the wife to pursue higher education, and the woman's life will be good and fruitful. (FGD no. 1)

Public media as a supportive agent

A woman of today was considered more visible in the public sphere, having a different role in society as compared to previous generations. Mass media was perceived as playing a supportive role for women's empowerment and gender equality:

Media can play a significant role in bringing gender equity by portraying respect and freedom of both sexes equally. (FGD no. 4)

Women support system

Informants perceived that there was a need for a women's support system in the society, such as proper legal support, sheltered homes, organisations and social networks, to protect the rights of women, particularly in the case of family violence. However, it was perceived that few women requested external help due to the taboo and stigma related to disclosure of such events:

They [women] don't have proper support and network systems so they move within their same friendship and family circle, and it is difficult to break this circle. (FGD no. 4)

Individuals capacity and attitudes

Capability and performance of girls

Some parents aimed to get their daughters educated, and girls were thought to undertake their studies more seriously than boys. Informants suggested that girls were more capable in professional roles than boys and that this competition between females and males had excluded some males from educational institutions. However, it was stated that many educated girls did not work professionally:

If you have a look around, girls are taking over the seats at the universities over boys as they are more intelligent. (FGD no. 3)

Younger generation's attitudes to gender roles

The younger generation was perceived to be more intellectual, to request more information before making decisions and to be more aware about their opportunities. Expectations for the near future were that young women would be able to choose a partner and become more visible in public life. Some educated families were praised for breaking cultural taboos such as not accepting adolescent marriage:

We [our generation] did what we were told to do, now the new generation ask questions like why, how? (FGD no. 2)

Balancing gender roles and opportunity

Informants defined gender equity as when the sexes were assigned equal rights and responsibilities in society and before the law. It was further suggested that equity and equality teaching should be incorporated into the school curriculum from the primary education level. Good parents were said to be those who practised equality among their children by treating boys and girls the same:

I think equality is the basic thing we need to teach, that everybody is equal. (FGD no.2)

Professional women and awareness of rights

Professional women were considered to be role models, with higher awareness of their rights and capabilities. A professional woman was likely to postpone marriage and also find an educated partner, and further, more likely to participate more in the society. It was also reported that a professional woman might be more highly valued by men in general due to her skills as a professional and as a mother of the household. However, it was acknowledged that a professional woman might be criticised for neglecting her obligations in relation to her family and children.

Extended families’ supportive function

Among the higher educated modern extended families, the daughter-in-law was in some cases given the freedom to decide about her education and to take on paid employment. Mothers-in-law contribute by taking care of the grandchildren. Sometimes, separate living arrangements were made for each son's family in order to give them privacy:

I have lived in an extended family system and I have a good experience of it. Many extended families allow their daughter-in-law to work and they supervise maids for home chores, but in-laws take care of children themselves. (FGD no. 2)

Discussion

A significant finding of this study was that female informants from different socioeconomic strata shared similar perceptions and expectations of female and male gender roles and how these were practised in the Pakistani society. Irrespective of the level of education, the participating women described how girls and boys are socialised into their gender roles and expected to fulfil traditional male and female responsibilities within the family and in society at large. A woman's subordinate position was considered to be reproduced and maintained, generation by generation, through adherence to cultural and religious norms, reinforced especially by the extended family. Most women from higher SES groups reported not to be prepared to compromise their rights to paid employment, whereas those from lower SES groups pointed at the importance of paid employment but not to the expense of household duties.

The more educated people in the younger generation stressed the role of education for future change towards more equal gender roles and relationship patterns. For an educated woman, the expectations for the near future could be to be able to postpone marriage, choose her partner and become more visible in public life. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment and gender equality.

The participating women's descriptions of gender roles and the differing life circumstances women and men face in urban Pakistan point at serious gender discrimination. Examples given embraced all stages of the life cycle, starting from early childhood with access to education being less for girls at all levels and age groups. Such policy in a society will inevitably result in illiteracy rates for women being considerably higher than for men, which is the case in Pakistan 16. Early and forced marriages with subsequent early pregnancies and childbirths were further described, which constitute serious threats to women's health. In addition, the ‘boy preference’ attitude is pronounced in the Pakistani society 17. To bear and give birth to a daughter might result in seriously stressful situations for women, including violence, neglect and threat of divorce 18 that was also described by our informants.

Women's dependency on others over the entire life course, with little own decision-making authority, should be viewed as violation of women's human rights. We found that a woman was regarded as being married not only to her husband but also to his entire family and expected to fulfil the needs of all other members of the household, such a situation is described also in other studies 19. Just being female symbolised care taking, subordination and sacrificing one's own needs, whereas men's aggressive behaviour in the household was perceived as accepted by society. While men in general were described as being in the power of making decisions also for the wife, men on the other hand were expected to care for, obey and pay respect to their parents and elderly relatives.

When a woman failed to behave according to the gender norm, some informants perceived it as acceptable if a man used physical abuse. This phenomenon has been detected in several countries, interpreted as a sign of women's subordination 20 21. For many women in Pakistan and in other Muslim societies, exposure to violence and controlling behaviours is part of everyday life 12 14 22. The need of a support system, organised for women only, was emphasised as women at times feared their husbands but avoided seeking help from health care services or aid organisations due to the risk of subsequent repression.

Furthermore, women are discriminated against on legal grounds with men and women being treated differently according to the law 23. In situations of divorce, women have few legal institutions to turn to for assistance, and the divorce rate in Pakistan is extremely low due to the associated stigma 11 12. Religious misconceptions were also mentioned as reinforcing the suppression of women's rights.

However, our study also indicated various positive signs towards modifying existing gender roles. Girls were considered more serious in studying than boys, and education in general was seen as crucial to not only improve awareness among women but also to benefit men in society. Another study expresses that higher levels of educational attainment in both men and women are associated with increased knowledge, an enhanced capacity to access and to use information, more autonomy and more liberal ideas about the status of women 24.

The general perception was also that professional women were better informed and therefore better able to safeguard their rights and responsibilities, hence looked upon as role models. A study from neighbouring India verifies this in that women's education is shown to be a strong and independent leverage for reducing the risk of IPV 25.

Children of professional women were considered well mannered, intellectual and disciplined due to mothers teaching them equity, equality and respect for others. This is in line with previous findings that educated women provide better upbringing for their children 26. Mass media was seen as a change agent contributing to increased awareness regarding the rights of women and men. In an earlier study, it was shown that mass media contributes to women's empowerment by giving prominence to women's human rights 18.

Trustworthiness

Obtaining such sensitive data as is presented in this study demands thorough planning throughout the research process. Three of the authors were competent in the local language and the cultural meaning of the content (TSA, NA and RG). Credibility was maintained by selection of context, informants and well-structured FGD. Three of the authors (TSA, IM and NA) agreed in the way the codes and categories were labelled and categorised, which in later stages were verified by the other three authors (GK, RG and EJ). Transferability was achieved through purposive selection of informants with different background characteristics such as sex, age, parity, profession, educational level and SES 27. Dependability was enhanced by conducting the FGD over 2 months, to ensure that the phenomena under study did not change 15. All FGD were conducted in Urdu, moderated by local researchers well versed with the context, transcribed into English by the field supervisor and analysed within 6 months. Verification of transcriptions was done by the first author who listened to the audio-tapes twice. Conformability was achieved through separate coding by the first, third and last author, whereby similarities and dissimilarities were discussed. Consensus on codes and sub-categories was thereafter reached. During the analytical process, the first, second and last author thoroughly discussed the structure of sub-categories, categories and themes. All authors read, discussed and agreed on the final categorisation and themes. One weakness of the study might be that the data were initially collected in Urdu, translated to English and analysed in the English version. However, a multi-disciplinary team with experienced Pakistani and Swedish qualitative researchers took part at all stages of the research process.

Another weakness of the study was that of 55 married women who were invited to participate in the study, out of which 22 women declined participation. The views of these women would probably have added to the value of this study. As only female informants were included in the study, the study only reflects female views on female and male gender roles in urban Pakistan. A corresponding study with male informants might have yielded somewhat different results and would be equally important to investigate the topic in its whole.

The findings of this study may be transferable to similar socioeconomic and cultural settings.

Conclusions

The current study describes gender roles and various expressions of serious gender inequalities present in urban Pakistan. The government should take immediate action to change policy, rules and regulations towards equal rights and responsibilities for women and men, with universal access to education as a most important step. The protective effect of education against gender inequality is strong and unambiguous. Mass media has a role to play in advancing such a strategy.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Acknowledgements

This study was made possible by a grant from the Swedish Foundation for International Cooperation in Research and Higher education (STINT) and by support from the Swedish Institute. This study was also supported by the Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden, Department of Public Health and Community Medicine, The Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden and the School of Nursing and The Community Health Department at Aga Khan University, Karachi, Pakistan. Gynaecology and Obstetrics, Department of Clinical Science, at Umeå University gave support during the article preparation. The authors would especially like to thank participants of this study who provided in-depth information.

Notes

Tazeen S Ali, Gunilla Krantz and Ingrid Mogren contributed equally to this work