Based on our analyses we identified three broad categories of barriers impacting the utilization of maternal and newborn healthcare services. These were conceptualized through the socio-ecological framework as individual, socio-cultural, and structural level barriers (figure 1). These findings were divided into further subthemes and are presented below. The background characteristics of lady health workers are illustrated in table 2. The socio-demographic characteristics of community participants are presented in table 03.
1. Individual barriers
Individual barriers refer to the personal beliefs and attitudes held by individuals that impact their ability to utilize health services. These included: mistrust towards public health facilities and inadequate symptom recognition.
Mistrust towards public health facilities
Both public and private health facilities are available within district Thatta. The public health facilities present in the district include: district hospitals, rural health centers, basic health units and dispensaries. In addition, several private hospitals and clinics also provide pregnancy and delivery care services to women. While many participants were keen to receive free treatment from public health facilities they did so as a last resort and often cited the poor treatment they received
“We are poor and so we visit public health facilities to get free treatment. However, we face long waiting times, and the doctors treat us very poorly. Imagine waiting for four hours and then the doctor only gives you 30 seconds of his time” (Men, 34 years, FGD).
It is likely that repeated cases of poor treatment have made individuals skeptical of the intentions of the staff. This was illustrated by a female respondent who felt that the hospital was sabotaging her attempts to get an ultrasound
“I went to a public health facility for an ultrasound. The staff told me that the machine was not working, and I had to come again. Later, I found out that they are not operating the machine because the operator had decided to leave work early (Woman, 29 years, FGD).
Further building on this notion of skepticism a male participant highlighted his views on the medication dispensed at public health facilities
“No matter what illness you go to the public hospital for they give you the same medication. Hypertension…diabetes…stomach pain it is the same medicine every time. What is worse is that these medicines don’t work. When we go to the private clinic, we get a different medicine and it always works” (Woman, 29 years, FGD).
These excerpts indicate that the residents of Thatta are reluctant to use public health facilities due to repeated experiences of inadequate service delivery. It is likely that these experiences have created a notion of mistrust which has further exasperated the issue of service utilization.
Inadequate Symptom Recognition
Inadequate symptom recognition was another individual level barrier to service utilization. In short, this refers to the inability for mothers to recognize complications in their early by ignoring bodily signs. This is illustrated in the account provided below
“My face and hands were swollen for weeks and I was having headache and abdominal pain, but I thought it was nothing and just a part of pregnancy. It was only after my body starting shaking that I went to the hospital” (Woman, 24 years, FGD).
By not being in the habit of recognizing symptoms women often neglect routine visits to the hospital and only to seek the doctor in case of a severe emergency. This was indicated in the account of a LHW who stated:
“Women do not go to any doctor or any clinic during pregnancy. They only go when something severe happens such as bleeding. They (pregnant women) take abdominal pain and headaches as a routine part of life and ignore them” (LHW, 48 years, FGD).
These results indicate that the inability to recognize illness symptoms along with an attitude that positions doctors are last minute saviors prevents service utilization in Thatta.
2. Socio-cultural barriers
Socio-cultural barriers refer to certain man-made constructs that stem from cultural norms and values. While these constructs need not universally held by all members of society, they exert their influence on health seeking behavior and service utilization. In this study we identified two such barriers: aversion towards biomedical interventions, and gendered imbalances in decision making.
Aversion to biomedical interventions
Many respondents held the view that all forms of biomedical interventions have certain side effects. They felt that while in the short run these interventions may alleviate symptoms, in the long run they would cause other complications. In contrast, they felt that home remedies were ideal as they would address the underlying problem without causing any side effects. This was illustrated by a man having five children who sated:
“The local cure (Desi Ilaj) is always the best approach. If you take these medicines and injections, you will be worse off than you were. They (doctors) fix things in the short term. Using herbs such as Kalonji and Moringa are best” (Man, 48 years, FGD).
As a possible result of this belief, our interviews revealed that pregnant women rarely take advantage of nutritional supplements such as: folic acid, vitamins, and iron pills that are provided free of cost by the LHWs and at the time of antenatal visits.
“During our door to door visits, we provide free folic acid and iron tablets. Pregnant women usually refuse because they think the micronutrients will cause pregnancy complications” (LHW, 37 years, IDI).
When we questioned pregnant mothers on their reluctance to use vitamins and supplements, they highlighted that these pills would abnormally increase the size of their fetus and eventually cause a difficult delivery. According to a woman:
“Vitamin pills increase the size of the fetus. Since they have started giving us these pills, we are having to deliver our babies through cesarean. I cannot afford such a complicated delivery, I have no money” (Woman, 39 years, IDI).
The aversion towards biomedical interventions was not limited to vitamins and supplements. Our interviews also revealed that mothers were hesitant to get vaccinated against tetanus injections. In particular, they felt that the vaccine would result in miscarriages and stillbirths.
“We should not be vaccinating pregnant mothers. Their bodies cannot take what is in these injections. I will only get vaccinated in the 7th month of my pregnancy because it will cause an abortion in the first two trimesters” (Woman, 29 years, FGD).
To sum up, many commonly held practices such as dietary supplementation and vaccination that are considered essential to maternal and newborn health are not practiced in Thatta. Instead pregnant mothers and their families show an apprehension towards biomedical interventions and associate them with negative consequences.
Gendered imbalances in decision making
Our research revealed gendered differences in selecting the place of delivery. For example, all the interviewed men preferred home deliveries, whereas most of the women aspired to deliver their babies at health facilities. Primarily, males preferred to have their children delivered at home for financial reasons.
“I prefer that my wife deliver our child at home because the Dai charges only 500-1,000 rupees. If I were to take her to the hospital, I would have to spend close to 10,000 rupees for a routine delivery and more in case of any complications (Man, 48 years, FGD).
Building on this point another man stated:
I will try and have the baby delivered at home and if there are any complications then I will rush my wife to the hospital” (Man, 40 years, FGD).
In contrast to male respondents, women emphasized the importance of safeguarding the health of their child and depicted a preference for institutional deliveries. According to one mother:
“I would like to deliver all my children at the hospital. The medicine, injections and trained staff that are available at private health facilities are better than what we get from TBAs at home” (Woman, 33 years, FGD).
Our research also indicated that many women are unable to exert their influence on this vital decision. Despite desiring to deliver their babies at medical institutions, they face resistance from their husbands who exert their authority.
“Many women confide in me that they would like to deliver their children at the private hospital, but they are not permitted. They ask me to speak to their husbands. Sometimes they listen but usually the man refuses” (LHW, 45 year, IDI).
Similarly, another woman reported
“I have had a really big argument with my mother-in-law and my husband over the delivery of our second child. I want to go to the private medical clinic, but they will not let me. They say that it is too expensive and ask me why I should get special treatment” (Woman, 40 year, FGD).
Despite having a strong desire to utilize health services, many women are prevented from doing so. This occurs through a combination of financial constraints and uneven power relations.
3. Structural barriers
Structural barriers refer to the presence of macro-level factors such as policies, practices, and procedures that prevent people from accessing health services. In our study we identified two such barriers: prohibitively expensive transportation services, and ineffective referral systems.
Prohibitively expensive transportation services
Both men and women pointed out that they were unable to access care during pregnancy because of prohibitively expensive transportation services. While the basic health unit is located in close proximity to rural residents, patients are often referred to the district hospitals for scans and treatment. These can be located 20-100km away from these villages. With no public transportation facilities present, patients must hire private transportation services which are costly. This point was highlighted by a man who stated:
“When I go to the filed to sell my labor, they pay me Rs.400 for the day. If I have to transport my wife to the district hospital it will cost me Rs. 1500. These are nearly my wages for the whole week (Man, 40 year, FGD).
In many cases families have to sell off important assets in order to afford access to basic services. According to one woman:
“When we found out that our child was positioned the wrong way, we knew that this would be a complicated delivery and that we would have to make many visits to the hospital. In anticipation my husband sold one of our goats so that we could have some many to make arraignments” (Woman, 32 years, FGD).
The responses from these interviews indicate that despite the presence of clinics and government hospitals, pregnant women in Thatta are not be able to access services due to expensive transportation services.
Ineffective referral systems
The basic health united located in close proximity to the village serves as the first point of contact with the health system. It is from the basic health unit that patients are referred to other health facilities based upon their needs. However, due to a lack of coordination between different levels of health facilities, patients are often left frustrated and eventually opt for home-based care. According to a mother:
“When I went to the basic health unit, I was referred to the district hospital for ultrasound scan. We took four days to arrange money for my visit and when we reached the hospital, we were told that they had not functional ultrasound machine” (Woman, 32 years, FGD).
Further highlighting this point, a man shared his experience:
Whenever the basic health unit refers us to a doctor he is not present. We make arrangements for transportation and accommodation only to find out that these services are unavailable. At the end it is best to just opt for home care (Man, 32 years, FGD).
To conclude, our interviews indicate that a lack of coordination between various levels of health facilities leads to a weak and ineffective referral system. This leads to a highly frustrating experience for patients and eventually poor service utilization.