Exploring Barriers to Obstetric Care: A Case Report on High-Risk Pregnancy in a Limited-resource Primary Care Setting in West Bengal, India

INTRODUCTION

High-risk pregnancies (HRPs) are a significant global public health concern, particularly in low-resource primary care settings. These pregnancies are fraught with increased risks of morbidity and mortality for both mother and child, necessitating early detection and effective management to mitigate adverse fetomaternal outcomes.¹ The complexity of HRPs is underscored by myriad factors that can elevate pregnancy risk, including pre-existing medical conditions, complications arising during the perinatal period, and the sequelae of previous pregnancies. The Indian healthcare system has made strides in addressing these challenges through initiatives such as Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Pradhan Mantri Matru Vandana Yojana, Janani Suraksha Yojana (JSY), and Janani Shishu Suraksha Karyakram which collectively provide a robust framework to support and manage HRPs by offering comprehensive maternal care.² Despite such efforts, nearly 30% of pregnancies in India belong to high-risk groups, contributing to more than two-thirds of perinatal morbidity and mortality.³ This highlights the need to identify the gaps to effectively manage HRP cases, especially in limited-resource primary care settings in India.⁴

The case report highlights the challenges faced by a high-risk pregnant mother and potential barriers associated with managing such pregnancies in these settings, including limited access to specialized care and resources. By analyzing the factors contributing to this specific HRP, we aim to emphasize the importance of early detection, regular antenatal and postnatal care, and the need for collaborative efforts to improve maternal and fetal health outcomes.

CASE REPORT

This case study involves a 26-year-old high-risk pregnant mother with second gravida, parity one residing in a lower socioeconomic, five-membered joint family in a rural area of Uttar Dinajpur district of West Bengal, India. During a visit to her family, she was in her 38 weeks of gestation with several HRP-related risks, including previous history of low birth weight (LBW) delivery through cesarean section 4 years back, persistent anemia (hemoglobin [Hb] level <10 g/dL), lately diagnosed hypothyroidism during third trimester, and suboptimal weight gain of only 6 kg during the pregnancy (significantly below the recommended 9–11 kg gain).⁵

Data were collected through in-depth interviews in the local dialect (Bengali) at the participant’s residence and lasted for about 2 h. The interview followed a semi-structured guide, which included open-ended questions on personal background information, socioeconomic status, past experiences in accessing public health services, and family and community support toward family planning and pregnancy. A review of medical records related to current and past pregnancy was also made during the visit.

Potential barriers

An in-depth interview and discussion with the mother revealed potential barriers that can be attributed to persistent anemia, lately diagnosed hypothyroidism during the third trimester, and suboptimal weight gain in the HRP woman with a previous history of LBW delivery through LSCS. Ishikawa fishbone diagram has been used to illustrate the various categories and factors contributing to barriers to obstetric care [Figure 1].

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Figure 1:

Fish Bone diagram illustrating potential barriers to obstetric care in the high-risk pregnancy case; BPCR: Birth Preparedness and Complication Readiness, HCP: Health Care Provider, OPD: Out Patient Department.

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DISCUSSION

HRPs account for nearly half of all pregnancies in India, with 33% of women having a single high-risk factor and 16.4% having multiple risks.¹ Our case report delved into the intricacies of an HRP, examining the multifaceted barriers encountered by a woman as she navigates the complexities of seeking care within a limited-resource primary healthcare setting. This exploration sheds light on the critical need for systemic improvements to support and manage HRPs effectively, ensuring the health and safety of both mother and child. Existing maternal healthcare initiatives such as PMSMA and JSY need to be strengthened so that no mothers are left behind. It is to be ensured that every pregnancy-related risk is detected early and every woman receives at least four antenatal check-ups during her pregnancy. Collaborative efforts involving primary care providers [Accredited Social Health Activist (ASHA), Auxiliary Nurse and Midwife (ANM)], community physicians, and obstetricians are crucial in the timely identification and management of HRPs, such as those complicated by hypothyroidism, iron deficiency anemia, and malnutrition.⁶ Reportedly, in India, the prevalence of hypothyroidism in pregnancy ranges from 4.8 to 11.0%, of which the majority are subclinical and often are left untreated.⁷ Universal screening for hypothyroidism may be incorporated in the guidelines so that serious complications that may arise out of hypothyroidism- LBW, preterm birth, and cognitive and developmental disabilities in the child may be averted.⁸ Adhering to HRP management guidelines throughout the care continuum (e.g., mandating the use of a color-coded sticker system on the MCP card, even if there is a single risk factor that can lead to HRP status, timely follow-up, iron and folic acid (IFA) supplementation in therapeutic dosage, pre-identification of referral transport, and facility) may potentially improve fetomaternal health outcome. Addressing the family, community, and health system level barriers may further improve the quality of obstetric care provided.

CONCLUSION

Negative maternal and fetal outcomes can be significantly decreased by early detection and effective management of HRPs, thereby reducing maternal and perinatal mortality and morbidity. Capacity building of HCPs, addressing structural issues related to the workforce and supply chain along with focused educational intervention that is aimed to improve awareness among pregnant mothers, bring in positive change in their attitude, and enable them to seek formal care may be effective in realizing Sustainable Developmental Goal targets by 2030.