Abstract
While women in low- and middle-income countries face a range of barriers to accessing care for hypertensive disorders of pregnancy, there is little understanding of the pathways taken to overcome these constraints and reach the services they need. This study explores the perspectives of women and communities on the influences that impact care-seeking decisions and pathways to health services. To understand individual perspectives, we conducted 22 in-depth interviews (IDIs) with pre-eclampsia and eclampsia survivors (PE/E) in a tertiary hospital, where they received care after initiating PE/E services in different parts of the country. In four districts, we conducted one male and one female focus group discussion (FGD) to unearth care-seeking pathways and explore normative perspectives and the range of internal and external influences. Careful thematic analysis using Atlas-ti was applied. Prevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels. Internal influences draw on women's own awareness of hypertension complications and options, and their ability to decide to seek care. External factors include social influences like family and community norms, culturally-accepted alternatives, and community perceptions of the health system's capacity to provide quality care. The interaction of these factors often delay care seeking and can lead to complex pathways to care. Women's individual pathways to care were diverse, despite the homogenous community perceptions of the influences on women's care-seeking behaviors. This finding supports the need for improving quality of care in primary healthcare facilities and strengthening gender equity and community-based promotion activities through targeted policy and programming.
Highlights
The ways in which women access pregnancy-related healthcare services, including services for complications like pre-eclampsia and eclampsia (PE/E), has garnered increasing attention globally
Prevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels
Respondents lived in rural settings, and similar to other research [14] that examined the impact rurality has on maternal health outcomes, this influenced their pathways to care and the ways in which they traveled to health facilities, including diverse transportation methods that ranged from cars to rickshaws to buses
Summary
The ways in which women access pregnancy-related healthcare services, including services for complications like pre-eclampsia and eclampsia (PE/E), has garnered increasing attention globally. When symptoms of PE/E occur, women may not immediately seek care through the formal health system due to a lack of knowledge of complications, preparedness, decision-making power, and real or perceived poor-quality care at healthcare facilities [1]. Hypertensive disorders of pregnancy (HDPs), PE/E, increasingly contribute to global maternal and newborn mortality and morbidity. Their etiology and manifestations are often misunderstood, which challenges communities’ and health systems’ ability to effectively prevent adverse outcomes. As countries’ maternal mortality burdens decrease, non-communicable diseases (NCDs), including HDPs, comprise a larger portion of pregnancy-related deaths and morbidities [2]. Demographic transitions, including changes in lifestyle and diet, that contribute to the burden of NCDs, as well as the management of other causes of maternal mortality—postpartum hemorrhage and sepsis—compound the difficulties that health systems [3] face in preventing, detecting and treating HDPs
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