Background: Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care-seeking behavior and other predictors of diarrhea-related mortality in children in selected low-income peri-urban communities of Karachi, Pakistan.Methods: A mixed methods study (qualitative and quantitative) using matched case-control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children Demographic, clinical, and care-related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported.Results: Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR=0.2, 95% confidence interval (CI) 0.05-0.91). Refusal for hospital admission (OR=8.9, 95% CI 2.6-30.8), and delays in reaching the health facility (OR=3.6, 95% CI 1.0-12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common.Conclusion: Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan
