Exploring Challenges in Accessing Primary Healthcare for Pregnant Women in Pakistan: A Qualitative Descriptive Study

doi:10.21203/rs.3.rs-3563310/v1

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Exploring Challenges in Accessing Primary Healthcare for Pregnant Women in Pakistan: A Qualitative Descriptive Study

https://doi.org/10.21203/rs.3.rs-3563310/v1

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Introduction: Maternal and newborn mortality are pressing global health concerns, with the Sustainable Development Goal 3.8 (SDGs) aiming to improve these outcomes however the poor quality of care in health facilities is a significant barrier to utilizing ANC services in Pakistan. Thus, this study aimed to understand the barriers to the underutilization of antenatal care (ANC) services in Tehsil Hazro, Punjab, Pakistan, from the perspective of pregnant women.

Method: The study employed four focus group discussions (FGDs) with 36 pregnant women who had attended at least three ANC visits. Data was collected through purposive sampling and analyzed using Nvivo 12, maintaining rigor through Guba and Lincoln's principles.

Result: The findings revealed three key themes. First, women often made the decision to seek care with support from their spouse, family, and lady health workers, emphasizing the importance of their decision-making autonomy. Financial constraints did not deter them from accessing healthcare services. Second, delays in reaching healthcare facilities were attributed to long distances, travel time, and associated costs. Additionally, women lacked awareness of danger signs and the importance of timely medical help. Lastly, delays in receiving quality care were linked to the unavailability of healthcare personnel, staff attitudes, insufficient medicines and equipment, and a lack of referral services.

Conclusion: In conclusion, this descriptive study underscores the necessity of providing affordable, accessible, and responsive maternal and child healthcare. To address these issues, stakeholders, including policymakers, the Ministry of Health, public health experts, and maternal, neonatal, and child health (MNCH) providers, must prioritize MNCH initiatives and reforms. Their collaborative efforts are vital for translating MNCH policies into effective community-level strategies.

Maternal & Child health

Three delays model

and Antenatal care

Maternal and child health is not only a local or regional concern but a universal issue that resonates across the globe, profoundly impacting societies and nations alike. The well-being of mothers and infants is an essential component of public health, and access to quality maternal healthcare is pivotal in the collective endeavor to reduce maternal and neonatal mortality rates. This fundamental issue is underscored and championed by Sustainable Development Goal 3.8 (SDGs), which sets forth ambitious targets to improve maternal and child health on a global scale(1) (2). Despite tireless and concerted global efforts to enhance maternal healthcare and reduce maternal and neonatal mortality, Pakistan continues to grapple with alarming statistics. The reported maternal mortality rate in Pakistan stands at a staggering 178 deaths per 100,000 live births, while the neonatal mortality rate is equally concerning, with 42 deaths per 10,000 live births (3). These stark figures emphasize the pressing need for further attention, research, and action to overcome the challenges that persist in the realm of maternal and child health in Pakistan.

The landscape of maternal healthcare in Pakistan is undeniably complex, characterized by a multifaceted interplay of sociocultural, economic, and healthcare system factors(4). The journey that pregnant women embark upon in this context is fraught with hurdles and obstacles that often deter them from seeking timely antenatal care (ANC) services and skilled birth attendance. The consequences of these hindrances are profound, leading to delayed care and adverse outcomes for mothers and their newborns (5). Maternal and child health services, when effectively and efficiently delivered, hold the potential to significantly reduce maternal and neonatal deaths (3). These interventions are recognized for their cost-effectiveness, accessibility, and low-technology nature, all of which make them pivotal in addressing the complex challenge of maternal and child mortality. Yet, the utilization of these services varies greatly on a global scale, particularly in developing nations, where they are less frequently accessed due to a complex web of social and cultural barriers as well as resource constraints(4). A glimmer of hope arises from the data reported by the United Nations Development Programme (UNDP), which indicates a positive trend in the ratio of mothers visiting ANC clinics during pregnancy. This ratio increased from 37% in 1990 to 52% in 2012, highlighting a positive step forward(5). While progress is being made, the gap in healthcare access and utilization still looms large, necessitating further exploration and intervention. Pakistan's consistently high maternal and neonatal mortality rates underscore the urgent and imperative need to improve maternal healthcare access and utilization within the country (6). However, the path to achieving this goal is fraught with complexity, as the healthcare landscape in Pakistan is profoundly influenced by a complex interplay of sociocultural, economic, and healthcare system factors(4). These factors, working together in intricate ways, give rise to a multitude of challenges, affecting pregnant women's access to and utilization of maternal health services.

It is within this intricate backdrop that this research takes shape. By investigating the perceived hindrances faced by pregnant mothers when accessing primary healthcare facilities in Pakistan, this study aims to shed light on the multifaceted challenges they encounter. These challenges are not unique to Pakistan but are echoed in varying degrees across numerous other developing countries. Thus, the findings and insights drawn from this research have the potential to transcend national borders and offer valuable lessons for other regions confronting similar challenges.

In pursuit of a comprehensive understanding of these barriers, qualitative research methods, particularly focus group discussions (FGDs), provide a unique opportunity to delve into the lived experiences and perspectives of pregnant women. Engaging directly with these women enables the research to uncover nuanced, context-specific barriers that quantitative methods might overlook. The stories, experiences, and perceptions of the women themselves are at the heart of this research, offering a more holistic and insightful view of the challenges they face.

The implications of this research extend far beyond the boundaries of Pakistan. The maternal healthcare challenges faced by pregnant women in Pakistan are not unique, and this study seeks to contribute to the global maternal health agenda. The humanitarian principle that every pregnant woman deserves safe and accessible healthcare is a shared commitment, transcending national and cultural boundaries. Thus, this research holds the potential to make a significant and meaningful contribution to the improvement of maternal and child health in Pakistan. By comprehending the perceived hindrances faced by pregnant mothers, we can work towards creating a healthcare system that is not only accessible but responsive and supportive of their unique needs. Ultimately, this research has the potential to lead to improved maternal and neonatal health outcomes in Pakistan and contribute to the country's progress in achieving its Sustainable Development Goals. The journey begins with understanding the challenges and the experiences of pregnant women, and this research is a step in that direction.

In the qualitative descriptive study, we conducted four Focus Group Discussions (FGDs) with a total of thirty-six participants. Eligibility criteria for participant selection required pregnant women who had attended a minimum of three antenatal visits at the study site, and those who did not meet this criterion were excluded. Data collection involved obtaining informed consent from eligible individuals using a purposive sampling technique.

During the FGDs, a qualitative expert guided the discussions using a focus group interview guide, encouraging a free exchange of information through the use of conversation probes. Each session was recorded, and field notes were taken. Interviews lasted approximately one hour each. To ensure data rigor and thoroughness, a summary of the information was shared and discussed with the participants.

Data confidentiality was maintained by securing all collected data on a password-protected device accessible only to the research team. The interviews were conducted in both Urdu and English, with subsequent translation and transcription of the two FGDs into English for analysis.

The initial step in the data analysis process involved transcription, wherein detailed handwritten notes were recorded and retained. A manual analysis of the transcribed interviews was performed, including the creation of codes, categories, and themes. Any identifying information related to the participants was removed before transcription for analysis. The entire FGDs were transcribed as a whole for analysis.

Inductive analysis was employed to code each recording, and for validation, two independent team members assigned distinct labels to significant text segments representing the participants' perspectives. The thesis committee reviewed the codes to resolve any discrepancies. NVivo 12 was used to generate categories and themes. As a final step, the raw data was compared with the emerging themes. Two independent investigators conducted coding, category creation, and thematic analysis, resolving conflicts to minimize researcher bias.

The "Three delays" model of maternal mortality served as a framework for identifying barriers to the use of mother and child health services in the selected area.

Factors associated with the underutilization of antenatal services were analyzed with the help of the 3-delay module of high-risk mortality of pregnant mothers.

Theme I: Decision to Seek Care

1. Valued Women's Decision for Seeking Health

Husbands and family members are more supportive of antenatal care at the healthcare facility before any complication occurs. It shows that these people are supporting the mother in her decision. Moreover, they have good knowledge and sense of a pregnant woman. But the concern remains on the part of a community that doesn’t know what is more important in this condition. Pregnant mothers cannot and do not settle all alone to look for care; the choice has a place with mates or senior relatives.

All participants answered positively by saying “that their decision was valued, and they did take part in the decision-making process for ANC care”- (FGD 1, 2, 3, & 4)

However, Participant five from FGD 3 said “Me and my husband do take part in decision-making, but the ultimate decision is made by the mother-in-law” – (FGD 3)

2. Supported By Family and LHWs For ANC Visit

Firstly, there is always someone who takes the woman to the facility for an ANC visit. Secondly, it must be understood that women also have the right to go to the healthcare facility and get the relevant treatment when they get sick. Participants ensured that whenever they wanted to visit the hospital and or facility, their husband or any family member went with them. However, a few participants relied on lady health workers for their ANC visits to the facility.

“If we say that I am unwell and want to go to a doctor, I request my husband or mother-in-law to consider it and take us especially when pregnant or when unwell” --- ( FGD 1, 2, 3, & 4 )

However, a few participants said, “Usually, my family trusts LHWs, so all ladies of my family visit the ANC clinic with them”.

3. Financial Implications of ANC Visits

Primary hindrances included in the framework are poverty and the financial crisis of the family in the utilization of ANC care. Although medical consultation is free at BHUs, RHCs, and government hospitals, people can hardly bear the expense of medical care. Few women mentioned that they had to walk for more than 15–20 minutes to reach the health care facility, but they managed as seeking antenatal care is important for the well-being of the mother and the baby.

In this support, my participants from all four FGDs responded “It is difficult to meet the expenses, but health is also important and it’s the only option. (Refer to Fig. 1 for theme I)

Theme II: Delay in Reaching Healthcare Facilities

1. Distance To Healthcare Centers and Hospitals

The use of rural health centers or basic health units is faced with major challenges such as distance and no transport facilities. Pregnant women mentioned a variety of obstacles that hinder their right to seek ANC care, including insufficient funding for transportation, particularly amongst those patients who live a long distance from the nearest healthcare center; unpaved or non-existent roads (which can delay access); and uncertain hours of service and operation at facilities.

Reasons of mothers for not coming to the healthcare facility “Someone has to go with us can’t go alone as BHU Khagwani is very far away, and it took them 30 minutes or so to reach the facility”- ( FGD1 )

“Participants preferred to go THQ tertiary set-up and it is about 5 km and it takes around 30 minutes.” – ( FGD 4 )

2. Availability And Cost of Transportation

Household deterrents, such as financial state of affairs and resources, domestic variance and discords, or lack of knowledge about danger signs related to childbirth, were mentioned occasionally in focus group discussions across all types of communities compared to the citation of geographic access, facility assets and goods, manpower and staffing, and infrastructure development barriers.

Participants said it was difficult to organize transportation for ANC and intrapartum care, but that they used a local vehicle like a rickshaw that cost approximately 1000 rupees and that a few were accompanied by family members and used motorbikes to get services.

Participant Nine said, “I rent transport facility mostly rickshaw to reach BHU Khagwani which cost about 1000rs” However, Participant four reported, “We commute on our family members motorbikes to the health care facility” – (FGD 3)

3. Poor Understanding in Seeking Care

All responders were asked a variety of response questions to gauge their understanding of obstetric problems and their outcomes. Intrapartum drain keeping the placenta, pre- and post-pregnancy discharge, puerperal fever, and convulsions were among the complications. Women and their partner’s ability to make an informed decision about whether to seek medical help might also be harmed by a lack of knowledge about danger signs and symptoms. Most of the women reported a lack of understanding, empathy, or counseling by the health care providers at the primary health care centers. This reason led to the women approaching TBAs at private setups for delivery.

Only a few participants knew the danger signs “fever, convulsions, blood discharge and extreme pain” however the rest reported “only pain near due date” – (FGD 1,2,3, & 4)

However, one participant from FGD 3 said, “I would prefer that the following are made available in their vicinity, especially BHU and RHC— to avoid referrals— save their time and money and not put the mother and the baby at risk”. --- (FGD 3) (Refer to Fig. 2 for theme II)

Theme III: Delay in Acquiring Satisfactory and Appropriate Health Care

1. Poor Facilities and Lack of Medical Supplies

Because of inadequate administration and quality care, many of the pregnant women who were transported to the primary healthcare centers did not use public facilities. Participants claimed that there was a lack of staff and diagnostic tests, no c-section facilities, and a long wait.

“Go to THQ— less distance, less time, relatively less money, the journey is not very uncomfortable---- all investigations carried out under one roof- Blood tests, C-section and other procedures can be performed.” ( FGD 1, 2, 3, & 4 )

Blood tests and anomaly scans were not accessible at BHU, Khagwani, and other BHUs, according to participants. According to the respondents, C-sections were not accessible at any of the BHUs or RHCs, therefore the women were directed to other healthcare institutions for their deliveries, a doctor's assessment generally takes 30 to 60 minutes, she added. Despite this fact, few women are still satisfied and using BHU services.

One woman said from FGD 1, “At BHU and RHC first no one answers, no one comes early to help us, we are in pain, do not take care of us, then after that their attitude is so bad that it seems that we are troubling them, we are not doing anything to them. That is, all it happens, nothing special happens, okay just can say this.” (FGD 1)

2. Reasons for Preference of Women towards Private Clinics

They further said that the private clinics and hospitals had uninterrupted electricity supply and the setup was spacious and well ventilated. During the discussion, the women pointed out that the private sector had a well-versed strategy to reach the community and encourage families to opt for treatment at their facilities. They further convinced the women and their families by supplying all the medical facilities under one roof, A few women added that the doctor at the private setup was more skilled and trained to perform delivery procedures, and their attitude was better than the healthcare personnel in the government sector. Therefore, despite the high cost of treatment in the private sector, certain women and their families were compelled to avail of their services.

One woman said, “Some people call us in a private clinic and say that you have come here, we will guide and serve you in a better way like you” -- (FGD 4)

One woman said, “When we go to her, she also takes care of us and works too, so we go to her more happily and we do not have much difficulty.” -- (FGD 2)

3. Weak referral system:

In this support, many participants responded that there is no ambulance, in case of emergency community women and family members have to arrange transport, i.e., rickshaw, to reach the higher facility. However, there is no connection between BHU and THQ to track the patient record. Most of the women did not prefer to go to referral sites as there was no one to provide emergency care. This fear is the main reason that women do not prefer delivery at BHUs or the public sector.

“There are no ambulance services and at the time of many mishaps husband and brother were arranging transport and that’s why the community don’t prefer BHUs/ THQ” ---- (FGD 3)

A woman said that “no one entertains them when they are in emergency care” – ( FGD 2 ) (Refer to Fig. 3 for theme III)

In the qualitative part of our study, we found positive family support and LHW help for females seeking care. Poverty and financial crises are hindrances to seeking care. Distance, cost of transport, and road conditions are the barriers to reaching healthcare facilities. Inadequate knowledge about obstetric care, inappropriate behavior of human resources to community women, poor medical facilities, and the absence of ambulances are also important barriers to seeking and availing of healthcare services at the community level. These findings are similar to Nisar, Aurangzeb (6) study carried out in the district of Swabi, KPK, Pakistan(7). However, after 5 years, the barriers and mortality rates were stagnant. Negative attitudes towards ANC, poverty, lack of knowledge, family problems, long waits in getting ANC at a health facility, cost of care, long distance, previous unsatisfactory experience, mother education, lack of support from husband and family support, early marriage, low income, parity, lack of female physicians, poor and unsatisfactory quality of responsiveness of health care services, and shortage of facilities at healthcare providing centers Roozbeh, Nahidi (8). Surprisingly, these findings are not only barriers in Pakistan but also in other LMICs such as Myanmar Milkowska-Shibata, Aye (9) showed that 41.7% of the antenatal care was not being used, and the attendance of antenatal care services and visits was associated primarily with household income, geographical surroundings, transportation access, and education status. Moreover, another study in the Zimbabwe district Chipinge by Gore, Muza (10) identified barriers such as long distances, unwanted pregnancies, lack of public transport to the health facility, low level of knowledge, poverty, poor services at health facilities, and religious beliefs. This study highlights the demand of community women for non-medical care and the availability of 24/7 attendants at medical facilities.

Partners, mothers-in-law, and senior family members decide to take antenatal treatment rather than the pregnant woman herself. It has been shown in several studies that a husband's positive and friendly behavior towards antenatal care participation significantly affected women's decisions to access antenatal care facilities (11). This study also showed community trust in lady health works to facilitate their positive experience throughout the pregnancy.

Overall, the Three Delays Model can help identify barriers to emergency care seeking and delivery in Pakistan (12). Addressing these barriers requires improving maternal health awareness, addressing socioeconomic and cultural factors, improving transportation infrastructure, increasing the number of healthcare providers, improving their training and motivation, and strengthening referral systems (13). These efforts can help reduce maternal and neonatal mortality rates and improve the quality of emergency care in Pakistan (14).

Several pregnant females, especially inhabitants of rural areas, do not seek prenatal care due to the long distance to the health center for ANC visits and services, which transcends the drive to go for antenatal care services (15) similar findings this study reported. Women's decisions are influenced by the travel distance of one hour to ANC. Women's awareness of health care has been influenced by travel as well as choices to search for treatment (16). The cost of getting antenatal care facilities was seen as one of the constraining factors that affected the decision of the women and their families to seek antenatal treatment, particularly in rural areas. Similarly, Uldbjerg, Schramm (17) in Uganda identified poor quality care, medical staff, poor attitude, practices of socio-cultural, lack of husbands and their family support, institutional structures, and health center procedures regarding HIV testing and transportation were major barriers. This study well-articulated the existing barriers to underutilization of public facilities, which lead to an increase in the risk of three delays for pregnant mothers. However, it is a qualitative research, which is not aimed at generalizability. To support maternal health, lady health workers' programs they need more expansion and need to deal with their referred clients with respect. The budget is distributed to the primary health care level and ambulatory service so that mothers can easily access and afford prenatal care. Focused training in health human resources is needed to enhance empathetic communication and responsive behavior with their clients. Special effort has to be made to intensify the concept of birth preparedness and complication readiness. By promoting this message amongst the women and their families, the delay caused in decision making will be minimized. Trusted and recognized community leaders/champions can be engaged for this purpose to encourage community participation. To ease the transition and uptake of this concept, familiar non-harmful practices can be found and incorporated. Improve and strengthen the linkage between the trained birth attendant (TBA) and health care facility as they play an important role in delivery preference. When skilled TBAs are available, it will encourage the women and their families to make positive decisions towards seeking antenatal care. In LMICs and Pakistan, the insufficient referral system for ANC treatment is a serious problem that can result in poor service use and bad health outcomes for expectant mothers. Increasing access to community-based health professionals, enhancing mother literacy, removing socioeconomic and cultural obstacles to maternity and neonatal referral, and improving emergency care data are all necessary to meet this issue.(18, 19) These initiatives can enhance ANC care quality and lower maternal and newborn death rates in Pakistan (20) and LMICs.

In conclusion, this qualitative research shows that mothers need affordable, accessible, and responsive care. By using the three-delay pregnancy risk module, the first theme was a delay in decision-making; however, most of the women, with the support of spouses, family, and Lady Health workers, confidently attended the ANC clinic, while transport unavailability and fear were also reported as constraints. The second theme of delay in seeking care also highlighted the long distance to the health facility as a barrier, especially the tertiary care hospital at the time of delivery. On the other hand, women were also not able to understand danger signs and had a poor understanding of seeking medical help promptly. The third theme of delay in receiving adequate quality care was found to be the major failure of the health system at the BHU level, such as inadequate medical equipment and medicine, the behavior of staff, and no ambulatory services to refer patients for special care. Stakeholders such as policymakers, the Ministry of Health, public health specialists, and MNCH providers need to prioritize MNCH initiatives. Reforms are needed to translate MNCH policy into communities.

Ethical consideration & consent to participate:

The research presented in this manuscript received ethical approval from the Ethical Review Committee of the Armed Forces Post Graduate Medical Institute under the reference number 208-AAA-ERC-AFPGMI. Prior to enrollment in the study, written informed consent was obtained from all participants. The consent process involved a comprehensive explanation of the study's background, rationale, as well as the associated advantages and disadvantages to the mothers. It is important to note that throughout the entire research process, adherence to ethical principles was maintained in accordance with the guidelines outlined in the Declaration of Helsinki.

Consent for Publication:

Not applicable

Conflict of Interest:

The authors declared no compelling interest.

Availability of data and materials:

The datasets generated and/or analyzed during the current study are not publicly available due to privacy and confidentiality but are available from the corresponding author on reasonable request.

Funding:

Not Applicable

Authors Contribution:

BK was the Principal Investigator (PI) who conceptualized the study and was involved in study design; BK, HM, and BA designed the study protocol and obtained IRB approval. BK, BA, and HM were involved in formulating the study methodology, developing study tools, and finalizing the data analysis plan; JMA, RJ, and BK were involved in article writing. BK and HM conducted a review of the literature and were involved in reviewing and editing the study tools. JMA, AM, and RJ were involved in editing manuscripts. All authors reviewed the manuscript several times and provided critical feedback. All authors read and approved the final version of the manuscript.

Acknowledgement:

This master's thesis, authored by BK, is dedicated to expressing our deep appreciation to Dr. HM and all the co-authors for her invaluable guidance and support throughout this research. We are also grateful to all the participants and to the Deputy District Officer of Health in Hazro, and the Senior Medical Officer at THQ Hazro, who generously contributed their time and insights, which played a crucial role in the success of this study.

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No competing interests reported.

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You are reading this latest preprint version

Exploring Challenges in Accessing Primary Healthcare for Pregnant Women in Pakistan: A Qualitative Descriptive Study

Status:

Version 1

Abstract

Figures

Introduction

Method

Findings

1. Valued Women's Decision for Seeking Health

2. Supported By Family and LHWs For ANC Visit

3. Financial Implications of ANC Visits

1. Distance To Healthcare Centers and Hospitals

2. Availability And Cost of Transportation

3. Poor Understanding in Seeking Care

1. Poor Facilities and Lack of Medical Supplies

2. Reasons for Preference of Women towards Private Clinics

3. Weak referral system:

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1