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Objective If Rajasthan, India was a country, it would rank 148th out of 192 for maternal mortality. Early identification of high-risk pregnant women, timely referral care, early intervention and delivery planning are key factors in reducing maternal mortality. To our knowledge, this is the first study to qualitatively assess the barriers and facilitators to uptake of referral services amongst high-risk pregnant women in rural Rajasthan. Methods Active pregnant women tracked digitally through the Khushi Baby platform in Udaipur, Rajasthan were considered from the sample frame. Pregnant women who had either severe hypertension or moderate/severe anemia were considered for inclusion. A purposive sample was approached to ensure a diversity of perspectives. In-depth individual interviews were conducted in the local dialect, Mewari. Interviews were transcribed, coded, and used for thematic generation, and organized as per the analytical framework described in the socio-ecological model. Results 19 high risk pregnant women of low socioeconomic backgrounds across 15 villages were interviewed. Barriers to referral care included lack of transportation, household responsibilities, and limited awareness, education, and social support. The most prominent barrier was lack of accompaniment to the referral center by a family member or health worker. Facilitators included available husbands, engaged heath workers, supportive neighbors, and other female family members who shared past experiences. Social support through accompaniment was noted to have the ability to overcome barriers. Conclusions Social support at the interpersonal and community level is key to overcoming referral care barriers faced by high-risk pregnant women in rural Rajasthan. Completion of antenatal referral care visits is essential to improvement in maternal and child health outcomes. A multi-faceted approach is needed to improve referral care completion for maternal health in rural Rajasthan. The following interventions are likely to be effective: a) targeted awareness campaigns for ambulance availability for high-risk conditions; b) digital tools to improve planning and coordination among health workers; c) inclusion of screening indicators for social isolation as a risk factor; and d) incentivization of beneficiaries for referral completion. We are in the process of sharing these findings with the district and state government of Rajasthan. |
