We conducted a study involving thirty-six pregnant women, all residing in rural areas. The study highlights a predominant presence of joint family structures and lower levels of education among pregnant women in rural areas. Additionally, a significant portion of the participants had multiple children, suggesting varying experiences in terms of childbirth and family size.
Table 2
Socio-demographic characteristics of the study participants
Socio demographic profile (n = 36) | n (%) |
Type of family |
Nuclear | 6 (17%) |
Joint | 30 (83%) |
Occupation of female |
Working | 16 (44%) |
Non-working | 20 (55%) |
Education of female |
Illiterate or read and write | 10 (27%) |
Primary | 14 (38%) |
Secondary | 12 (33%) |
Current Pregnancy |
Primigravida | 8 (22%) |
2–3 | 18 (50%) |
More than three | 10 (27%) |
Table 3 presents the predetermined themes and corresponding sub-themes utilized for data analysis. The overarching themes encompassed individual-level factors, interpersonal factors, community-level factors, and systemic factors. A comprehensive breakdown of each theme and its associated sub-themes is elaborated upon in subsequent sections.
Table 3
Predefined themes and corresponding sub-theme
Themes | Sub-themes |
Individual level factors | Limited knowledge of ultrasound technology Personal beliefs Financial constraints Concerns regarding ultrasound procedure |
Interpersonal factors | Communication with HCPs Partner involvement & support |
Community level factors | Cultural and societal norms Concerns Regarding Ultrasound Procedure/Perceptions related to ultrasound use/ Stigma or taboos associated with ultrasound/ Perceptions of ultrasound's benefits and risks |
Systemic factors | Human resource and infrastructure issues |
Theme I: Individual level factors:
Exploring these individual-level factors uncovers how these personal aspects influence a woman's decision-making process regarding seeking and utilizing prenatal ultrasound services, contributing to a comprehensive understanding of the barriers or facilitators at the individual level within the broader framework of prenatal ultrasound access.
Personal beliefs:
The sub-theme "Personal Beliefs" emerged as a pivotal category, encompassing diverse codes reflecting pregnant women's individual convictions and perceptions regarding prenatal ultrasound services. The finding revealed such as perceived importance, showing, how women valued prenatal ultrasounds in monitoring fetal health and identifying potential complications.
During FGD 1, a pregnant participant, referred to as Pregnant Woman 2, emphasized the significance of ultrasounds in ensuring her baby's well-being. She expressed, "I've had three ultrasounds so far, and I'm seven months pregnant. I always wanted reassurance that my baby is healthy and progressing well, especially after experiencing two miscarriages and one stillbirth previously."
While in FGD 4, Pregnant Woman 5 conveyed a sense of reassurance and emotional attachment when discussing the importance of ultrasounds. She expressed, "Since this is my first pregnancy, I went for an ultrasound. I feel a strong emotional connection when I see my baby on the screen, it makes me feel more bonded to my pregnancy."
In FGD 3, a pregnant participant 3 expressed skepticism regarding the necessity of ultrasounds during pregnancy. She conveyed a belief that ultrasounds are not always essential and viewed them as optional procedures. Furthermore, she articulated a lack of trust in healthcare providers (HCPs), suggesting a perception that HCPs might prescribe ultrasounds primarily for financial gain. Her statement reflected a strong reliance on her body's intuition, stating, "I don’t think ultrasound is always needed. I trust my body to tell me if something is wrong." This viewpoint highlights a personal conviction in her ability to sense any potential issues without relying on medical imaging procedures during pregnancy.
In the same discussion, another participant, labeled Participant 6 from FGD 2, echoed a similar sentiment by stating, "I trust my intuitions and instincts." This concise statement highlighted a deep-seated confidence in her instincts and inner feelings, indicating a preference for relying on personal intuition in decision-making, potentially extending to matters related to prenatal care and healthcare choices.
During FGD 2, Pregnant Woman 1 expressed a perspective asserting pregnancy as a natural process. She conveyed a reluctance toward relying excessively on technology, stating that “undergoing ultrasounds might foster an undue dependency on technology”. Additionally, she highlighted concerns about the potential for ultrasounds to induce unnecessary anxiety, expressing a desire to focus solely on the emotions and experience of motherhood. Other participant from FGD 4 pregnant woman 6 shared her views, suggesting that “ultrasounds are often perceived as a means to determine the baby's gender”. They indicated societal pressures, mentioning instances where families insist on ultrasounds to know the baby's gender for the purpose of planning and shopping accordingly. Moreover, these participants highlighted situations where females might feel compelled to undergo ultrasounds due to familial expectations to fulfill specific gender preferences, potentially influencing family size and dynamics.
Limited knowledge about ultrasound:
This sub-theme illuminated the widespread knowledge deficit surrounding prenatal ultrasounds among participants. Their understanding varied greatly, ranging from incomplete information to outright misconceptions about the purpose, importance, and implications of these scans. Exploring this sub-theme provided valuable insights into the diverse perspectives and levels of awareness among participants concerning the use and impact of ultrasounds in the context of prenatal care.
When questioned about their understanding of ultrasound and its relevance in pregnancy, Pregnant Woman 2 from FGD 1 expressed a viewpoint considering “ultrasound as an unnecessary intervention”, citing that, “it tends to induce anxiety among expecting mothers”. On the other hand, another pregnant women 3 from FGD 3 conveyed uncertainty regarding the widespread need for ultrasounds, expressing, "I don’t know why everyone needs ultrasound; it seems necessary only in complex pregnancies or for females experiencing recurrent miscarriages." She added further, "Ultrasound releases harmful radiation, which isn't safe for the baby. That's why expecting mothers should limit unnecessary exposure to these radiations."
Amidst a landscape of limited knowledge about ultrasounds in focus group 4, one pregnant woman 5 understanding stood out. She confidently explained the value of ultrasounds in “monitoring a baby's heartbeat, size, and overall growth”. When asked how she learned this, she credited her healthcare provider. "My doctor told me this multiple times during antenatal visits, really emphasizing its importance," she explained. Notably, she further shared that, “ultrasounds can reveal potential issues like a lack of heartbeat or delayed growth, which, if identified, might necessitate prompt pregnancy termination to safeguard both mother and baby from potential health complications”.
Most participants of FGDs mentioned that they did not have a set schedule for ultrasounds during their pregnancies. Instead, they underwent one or two scans based on the necessity arising from the baby's condition. Doctors usually advise having an ultrasound scan sometime between the first and fourth months of pregnancy. However, participants often chose to schedule these scans based on their convenience rather than following this suggested timeline. During the discussions (FGDs 1–4), participants mentioned that “their doctors suggested having ultrasounds in the first and fourth months of pregnancy. However, they didn't consider it urgent and chose to delay these scans. Instead, they decided to have the ultrasounds during later visits or whenever it was convenient for them”.
This decision to postpone the scans might indicate a lack of immediate concern or perceived urgency about the suggested timing for ultrasounds during specific stages of pregnancy as advised by their doctors.
This suggests that there's a lack of adherence to a structured ultrasound schedule recommended by healthcare professionals. Instead, participants arranged scans based on their own perceived need. This approach might result in variations in the timing of important scans, especially during the early stages of pregnancy.
During FGD 3, a woman shared a distressing experience by stating, “I missed the chance for an anomaly scan because of a delay caused by insufficient information”. Sadly, healthcare professionals didn't advise her in time, revealing a significant lack of their support.
Financial constraints
This sub-theme encapsulated the various financial challenges and limitations faced by participants when accessing ultrasound services during pregnancy. Exploring this sub-theme sheds light on the impact of financial constraints, which hindered participants' ability to access and afford essential ultrasound services, ultimately affecting their prenatal care experiences.
Many women expressed their intention to use the ultrasound system at the Primary Healthcare level (PHC) for diagnostic purposes. They explained that the lack of maintenance in the public sector caused this issue with the equipment. As a result, their doctors advised them to go to private hospitals, which came with significant costs. This situation caused delays in getting important tests done within the required time. The unreliable public healthcare system's machinery created financial barriers, forcing women to opt for expensive alternatives and causing delays in their diagnostic processes.
Participants across all four FGDs shared a similar feeling: "Managing expenses is tough, but our health is crucial, and seeking medical care is the only viable choice." This indicates their understanding of the financial challenges but emphasizes the importance they place on health; despite the difficulties they encounter in paying for necessary healthcare.
Theme II: Interpersonal factors
Interpersonal factors refer to the influence of social relationships, interactions, and communication among individuals within the context of accessing prenatal ultrasound services. This theme explores the interpersonal relationships and interactions that influenced participants' perspectives, decisions, and experiences regarding prenatal ultrasound services, highlighting the role of communication and social influences in shaping their choices.
Communication with healthcare providers:
When asked about how healthcare providers communicate the importance of ultrasounds, participants had mixed responses. Participants from FGD 2 and 4 mentioned that their doctors and antenatal nurses were attentive listeners, addressing all their concerns and making them feel heard and comfortable. They specifically highlighted that “these healthcare professionals listened to our worries and provided clear explanations, which significantly improved our understanding of ultrasound scans”. This positive communication experience enhanced their comprehension of the importance of undergoing ultrasound examinations during pregnancy.
Participants from FGD 1 and 3 mentioned that “their antenatal care providers do listen to them, but they often feel rushed during appointments.” Due to a large number of patients waiting in the lounge, the healthcare providers sometimes suggest discussing queries outside the ultrasound room.
Partner involvement & support:
Overall, the sub-theme emphasizes the crucial role of partners in the decision-making process, their emotional support, and their involvement in discussions regarding ultrasounds, highlighting the impact of their presence and support on the pregnant woman's ultrasound experience and decision-making.
Although family members and husbands possess a good understanding of pregnant women's experiences, a lasting concern exists regarding the safety of ultrasound procedures and their possible connection to miscarriages. This worry stems from a prevalent misconception or fear within the family and among husbands about the safety of these imaging techniques. As a result, it acts as a barrier, preventing their complete support for pregnant women undergoing ultrasounds during pregnancy.
During FGD 1, a participant shared, "I can visit the ANC only when I'm unwell, and I'm always accompanied by my mother-in-law or other family members for support. However, if the doctor recommends an ultrasound test, I need to call and ask for permission from my husband."
This means that while she has some freedom to seek care when feeling unwell, decisions about undergoing ultrasounds specifically require her husband's approval, indicating a different level of decision-making authority in her pregnancy care.
During FGD 3, one participant mentioned “her doctor referred her to a specialized hospital for an advanced scan due to concerns about potential genetic issues in her child.” This referral suggests the necessity for a detailed examination to thoroughly evaluate and potentially identify any genetic conditions or abnormalities in the baby.
During FGD 4, a participant mentioned that "the doctor recommended a Doppler ultrasound at another hospital, despite the cost, stressing the importance of checking for potential illnesses in the child. " She further said, "My partner expects me to follow doctor's orders without question."
The participant followed the doctor's advice, accompanied by her husband, highlighting their shared concern for their child's health. This instance underscores the participant's commitment to prioritizing the doctor's recommendation for the Doppler ultrasound, despite the expense, showing a deep care for their child's well-being.
Theme III: Community level factors
This theme explores societal attitudes towards pregnancy and healthcare, prevailing cultural beliefs regarding ultrasound safety or necessity, and the influence of community members, such as family, friends, or community elders, in shaping perceptions about ultrasounds.
Concerns Regarding Ultrasound Procedure
The women in the community expressed fear and reluctance towards undergoing ultrasound procedures early in their pregnancies, preferring to visit the ANC clinic after the third month instead. Most of the pregnant women mentioned that “while most women typically go through the initial months or trimesters of pregnancy, they hadn't personally encountered this”.
Their hesitation seemed to stem from a belief held by a few participants that “ultrasound or x-ray procedures could potentially harm the health and growth of the child”. This perception contributed to their reluctance to undergo these scans during the early stages of pregnancy.
This reluctance to engage with ultrasound procedures at the onset of pregnancy, coupled with a preference to seek ANC care later, highlights a significant barrier in their approach to prenatal health. The fear and misconception surrounding the perceived harms of ultrasound or x-rays impacted their decision-making about when to initiate prenatal care and undergo necessary medical procedures.
During FGD 2, a participant mentioned that “her mother-in-law strongly suggested keeping the pregnancy confidential until three months, fearing that an early ANC clinic visit might involve an ultrasound, which she believed could lead to a miscarriage.” This advice exposes a prevalent misconception within society and family circles about the safety of early ultrasounds during pregnancy. It underscores the existence of myths and misunderstandings regarding the potential risks associated with undergoing ultrasounds in the early stages, contributing to the delay in seeking crucial prenatal care.
During FGD 4, a participant expressed the belief that “X-rays aren't helpful for a child's growth”. This viewpoint highlights a common misunderstanding among some people that procedures like X-rays, and sometimes even ultrasounds, might negatively impact a child's development during pregnancy. This misconception often leads to fear and hesitation among expectant mothers when it comes to undergoing these imaging procedures, even though they're essential for monitoring the baby's health and growth. The concern specifically relates to myths and misconceptions surrounding X-rays and their potential effects during pregnancy, contributing to apprehension about these medical imaging procedures.
Cultural & Societal Norms
According to a participant in FGD 1, in her community, “women who opt for ultrasounds are viewed as neglecting their babies.” This perception sheds light on the societal attitude prevalent in her community, where seeking ultrasounds might be seen as neglectful or unnecessary care for the unborn child.
Conversely, participants in FGD 3 expressed a different perspective. They shared that “their families anticipate at least one ultrasound to confirm the pregnancy.” This view highlights the contrasting societal expectation within their families, emphasizing the importance placed on undergoing at least one ultrasound for pregnancy confirmation. This suggests variations in community perceptions regarding the necessity or neglectfulness of ultrasounds during pregnancy.
Theme IV Systemic factors:
Human resource and infrastructure issues
Pregnant women shared their challenges in accessing ultrasound services within the community. They mentioned that doctors were available at the facility for scans only a few days per week, leaving technicians responsible for conducting the tests. This led to longer waiting times to complete their examinations.
During FGD 2, A participant mentioned that “Most doctors were unavailable, so we had to wait for them”.
Furthermore, the lack of sufficient restroom facilities and access to water made the women feel uncomfortable during their visits. The combination of limited doctor availability, reliance on technicians, and inadequate amenities at the facility created a less-than-ideal experience for women seeking ultrasounds.
During FGD 4, “Participants decided against undergoing the test at the ultrasound room due to extended waiting periods and the unavailability of a clean restroom”.
This prolonged their waiting periods and negatively impacted their overall comfort and convenience during these important medical appointments.
Accessibility and availability of the services:
The subtheme within systemic factors pertains to the difficulties women face when trying to access ultrasound services in healthcare settings. It covers challenges related to physically reaching these facilities, the availability of services when needed, and the logistical barriers that pregnant women encounter in obtaining ultrasound examinations. This subtheme highlights the struggles women undergo to physically reach healthcare centers providing ultrasounds and the issues they face regarding the timing and availability of these essential services.
When asked about clinic timings, every participant from all FGDs mentioned that “Primary Healthcare level (PHC)s (BHUs) offered basic ultrasound services only from 9 am to 2 pm. However, they frequently experienced issues with the machine being out of order, leading to delays in getting it repaired, sometimes taking days or even weeks. This situation compelled them to seek fetal anomaly scans at private clinics, which posed financial burdens. The process involved visiting a doctor first to get a referral for the ultrasound and then scheduling the appointment, often requiring accompaniment by their husband or mother-in-law. If these family members weren't available, it would have caused further delays in accessing the ultrasound services”.
Primary Healthcare level (PHC)