Experiences of Low-Income Indonesian Pregnant Women Regarding the Challenges of Receiving Health Services

INTRODUCTION

Pregnancy is a complex condition involving the interaction of various physiological, psychological, and social factors. Sufficient health literacy during the pre-pregnancy, pregnancy, and postnatal phases directly influences the health status of both the mother and developing fetus, ¹ diminishes disparities during pregnancy, and informs the maternity care plans of healthcare systems. ²

Numerous studies have indicated limited health literacy in countries below the poverty line. The low rate of health literacy among pregnant women in low-income countries is primarily attributed to low educational attainment, ³ low reading ability, ³ cultural domination, ⁴ stigmas of women as weak, ⁵ and insufficient proficiency in information and communication technology. ⁶ This indicates that pregnant mothers from low-income families are a vulnerable group with multisectoral needs, both regarding pregnancy-related information and beyond the context of pregnancy.

Maternal health literacy is a key factor in empowering low-income pregnant women. Health literacy enables mothers to access, understand, evaluate, and utilize the information needed to maintain and improve their health status. ⁷ In this regard, the role of midwives in providing health education is a key factor in meeting the information needs of mothers and empowering pregnant women. ⁸

Women consider midwives the most reliable primary source of health information compared to other channels because they can provide credible and trustworthy information consistently based on literature, which becomes their decision-making source during pregnancy. ⁹ Therefore, midwives play a crucial role in facilitating women’s empowerment in decision-making. However, it would be detrimental if women inquire about topics that are of interest to them, but healthcare providers may discontinue the conversation later.

Midwives providing effective health education can improve the health literacy of pregnant women. ⁷ However, communication gaps between midwives and pregnant women hinder the reception of health information. ¹⁰ Some women expressed dissatisfaction with the information received from midwives. ¹¹ Midwives ignore pregnant mothers’ questions, even being harsh towards them. ¹¹ This can reduce the mother’s ability to understand the health information provided disrupt the empowerment process and proper decision-making. Midwives are also difficult to reach due to their busy work schedules. ¹² On the other hand, many women still have questions and express uncertainty about various health issues, including nutrition, weight gain, and physical activity; however, they dare not asked. ¹³

Additionally, the lack of access to adequate healthcare information is a barrier for pregnant women. Low-income pregnant women have limited access to health information from complex learning materials, whether from digital sources or written health messages. Research in Thailand shows that migrant mothers are unable to read written health messages containing complex images, subtle concepts, and taboo images on posters, causing widespread misunderstandings of the visuals used in the campaign; ¹⁴ also, research in the United States indicates that vulnerable pregnant women are not motivated to use the MyCare app due to its complex interface and limited language options. ¹⁵ Furthermore, the lack of prenatal knowledge among mothers drives them to rely heavily on information from family members and husbands, leading to potential misunderstandings and exacerbation of complications or issues that could have been avoided by seeking accurate information. ¹⁶

Factors surrounding mothers, such as beliefs, culture, and low socioeconomic status, also hinder them from properly applying health practices according to pregnancy guidelines. ¹⁷ In South Sudan, women reported that they could naturally give birth to their babies anywhere without prior preparation. They consider the use of maternal health facilities limited to complicated pregnancies. Moreover, economically, low-income families (LIFs) face ongoing challenges in accessing healthcare facilities, ultimately pushing them to seek medical care only in critical situations. However, this results in increased healthcare costs. ¹⁸

Although previous research has shown low health literacy among low-income mothers, there is still insufficient evidence regarding effective sources of information, behaviors in applying health information, and barriers to receiving health information for pregnant women with low income in Low- and Middle-Income Countries (LMICs), especially in Indonesia. Understanding effective sources of information, barriers to receiving information, and conditions influencing mothers in applying health information can guide policymakers in taking necessary steps toward providing appropriate and equitable healthcare services for pregnant women from LIFs. Therefore, this study aimed to explore the experiences of low-income indonesian pregnant women regarding the challenges of access to health information.

MATERIALS AND METHODS

This is a qualitative conventional content analysis study conducted from January to June 2022. The location of the research interviews was two community health centers, namely Kalimanah Health Center and Padamara Health Center, which are in Central Java, Indonesia. The research setting was selected because it is a rural area, and most of its population is in a low socioeconomic status.

A total of 17 women comprising 11 pregnant women, 1 postpartum woman, and 5 mothers of babies had referred to village midwives during their pregnancy and had incomes below the minimum wage according to the amounts determined by the government. In this study, postpartum mothers and mothers of infants intended to explore their experiences in obtaining information during pregnancy. The inclusion criteria were i) pregnant women in their 3rd trimester, postpartum women within 1-42 days after labor, or mothers of babies aged 0-1 year; ii) confirmation of their pregnancy through village midwives’ services, and iii) adherence to pregnancy check-ups from the village midwives. The village midwives have a Diploma 3 in midwifery education and interact with mothers by providing health education during pregnancy services at the Community Health Center or sub-district health center in their supervised villages. Participants who were unwilling to participate after the interview were excluded from the study.

Interviews were conducted following an interview guide with open-ended questions designed and recorded using an audio recording device with the participants’ consent. Most interviews were conducted in the respondents’ residence and lasted about 45 to 60 minutes each, depending on the participants’ availability and the extent of information shared on each topic. The in-depth interviews aimed to collect comprehensive data and commenced with demographic questions, including name, age, education, history of previous pregnancies and childbirth, and pregnancy experience. By using a topic guide, the participants were asked some questions, such as How do you acquire information about pregnancy?, How do you trust in the information?, How do you evaluate the information?, How do you implement various information?, and How has your experience been when interacting with healthcare providers? Researchers made an attempt to conduct in-depth interviews during the process, using probing questions such “What do you mean by this?”, “Why?”, and “How?” to understand the experiences participants. The interviews continued until we reached data saturation. This indicates that the interview provided no new information. None of the participants withdrew from the data collection process.

After each interview, the o-transcribe software was used to help us transcribe the tapes, and the finished product was copied and pasted into Microsoft Office Word. Conventional content analysis was used to analyze the data in this study. Concurrent coding and analysis were done. The data analysis process was conducted based on the steps proposed by Graneheim and Lundman. ¹⁹ Data were read and understood as a preparation step, and then a coding system was developed. The coding process was conducted on relevant units of information, followed by the development of sub-themes based on their similarities and differences until the themes were identified. The first researcher conducted the interview process and transcribed the interviews verbatim. Data coding was carried out by the first and third researchers, who had experience in maternity nursing and had undergone qualitative research training. The second and fourth researchers, experienced in qualitative research data analysis, reviewed the coding process and its results to ensure the quality and accuracy of the analysis. NVivo software version March 2020 was used to facilitate the data analysis process, particularly in data grouping and the formulation of sub-themes/themes. Additionally, the authors adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) as a guide for presenting the research results. ²⁰

The researchers utilized four ways to improve the accuracy and reliability of data analysis: dependability, credibility, conformability, and transferability, following Lincoln and Guba’s methodology. ²¹ Credibility was ensured through member checking, which involved verifying research findings with participants in face-to-face meetings. Specialized faculty experts in qualitative research and health literacy who were not involved in the research conducted external checking to ensure dependability. Furthermore, for conformability, all study procedures were carefully documented and published to ensure consistency and provide a detailed record for future research. Detailed explanations of all research steps were provided to enhance transferability, making the findings relevant to other populations with similar characteristics.

The fieldwork began after obtaining ethical approval from the Research Ethics Committee at Universitas Gadjah Mada Faculty of Medicine, Public Health, and Nursing. The approval code is KE/FK/0756/EC/2021. Before participant recruitment, meetings were held with the director of the community health center and staff members to provide information about the study. A roster of potential participants was compiled with the assistance of supervising midwives. Subsequently, the researcher personally met those who met the inclusion criteria, explaining the objectives of the study and emphasizing voluntary participation with freedom to withdraw at any time. Participants were given written informed consent and asked to participate. The research objectives and procedural steps were explained to the participants. After obtaining signed informed consent from each participant, interviews were conducted and recorded.

RESULTS

A total of 17 participants comprised women from low-income households. The mother’s age range was 22- 39 years. Most of the participants (70,6%) were unemployed. Five participants (29,4%) had completed their Junior High School. Nine of them (52,9%) were multigravida. The characteristics of the participants are detailed in Table 1. The data analysis from interview transcriptions texts revealed the derivation of 8 sub-themes and 3 themes resulting in the experiences articulated by the participants regarding maternal health literacy. The sub-themes and themes extracted from the data are presented in Table 2.

Theme 1: Encountering Barriers to Accessing Information and Care

This topic focuses on how mothers encountered various barriers that prevented them from accessing sufficient information and care. Within this theme, three sub-themes were explored in-depth.

1.a. Creating nonconductive learning environment by midwives

This sub-theme indicates that midwives do not create a conducive learning environment to enhance the health literacy skills of pregnant women. One participant inquired whether consuming ice could result in a larger fetus, but the midwife’s response did not promote health literacy for pregnant women: “Is it true that if we consume too much ice, the baby will be big?” The midwife answered, “Saying it is just a myth, unfortunately. Believe in the Creator of life; trust in the Almighty” (P1). Another mother mentioned that a midwife became upset when she was asked why weight decreased during pregnancy due to nausea and vomiting: “Many friends complain about the same thing... especially if they have complaints like this, for example, weight loss... because of nausea and vomiting, whatever they eat comes out, and the midwife scold them, saying you should eat more, like that”. (P12)

1.b. Barrier to Obtaining Optimum Counseling from a Midwife

This sub-theme underscores the challenges faced by low-income pregnant women in obtaining education during counseling sessions due to midwives being busy and difficult to reach, with limited time available for meetings between mothers and midwives. One participant mentioned the midwife was very busy, making it hard to arrange a meeting: “When I wanted to meet, it was challenging to find her. I went to the midwife’s house in the afternoon, but she didn’t want to meet me... there was always some reason... eventually, I hesitated to go there for a check-up again” (P6). Another mother stated that the time spent during midwife check-ups was brief, allowing limited room for discussion: “The midwife has to examine not just one or two patients, but many... so, the midwife cannot spend a long time with each examination” (P1). A mother expressed reluctance to ask too many questions due to the waiting time for other patients: “Sometimes, the desire is there [explained by the provider], but if it goes beyond a lengthy examination... it seems like those outside might be waiting for a long time.” (P16)

1.c. Mothers’ Limitation to Asking the Provider

This sub-theme highlights the limitations of pregnant women from LIFs when consulting with healthcare providers. They feel embarrassed to inquire about the issues that are difficult to understand from the service providers. One participant wanted to have certain information but, due to embarrassment, eventually she refrained from asking: “I wonder why I am not allowed to drink traditional herbal medicine; sometimes, I want to ask, but I am embarrassed.” (P1)

Theme 2: Access to Ineffective Information Sources

Interviews with participants revealed diverse perspectives of mothers from LIFs on accessing information, involving both online and offline learning materials through spouses, family, friends, healthcare providers, and social media. Three sub-themes are elucidated in detail.

2.a. Unable to Operate the e-Health Pregnancy Application

This sub-theme highlights the challenges of low-income mothers in seeking complex online information through pregnancy application platforms that require multiple instructional steps and a connection to email. A participant expressed her inability to operate the E-Health Pregnancy application: “I never read anything. I just accessed the pregnancy application, but I forgot its name [frowning, trying to recall]. Sometimes, I connect to their email and receive some information from the email only. At this advanced pregnancy stage, I only read that.” (P17)

2.b. Ambiguous and Confused Information in Educational Sources

Women find reading the book more tedious than using social media. The content of the Maternal and Child Health (MCH) handbook is written in formal language and includes illustrations that are ambiguous and confusing. One participant said: “For example, if it is about [picture] bleeding, is [the picture] about post-delivery bleeding or something else? I mean, if it is [a picture] about post-delivery, but it looks like [a picture] of a pregnant woman experiencing bleeding like that, right?” (P16).

2.c. Limitations of Husband and Family Informational Support

This sub-theme highlights the lack of understanding between families and husbands regarding certain information, hindering pregnant women from obtaining assistance in accessing information from their surrounding family. One mother revealed that “When I complained about back pain and asked my husband how to deal with it... my husband replied... just be patient [imitating her husband’s words]”. (P15)

Theme 3. Difficulties in Applying the Pregnancy Health Information

This topic centers on how pregnant women can modify their health behavior by implementing the information obtained from learning materials or oral sources. Within this theme, two sub-themes will be explored.

3.a. Unable to Apply Pregnancy Guidelines Correctly

This sub-theme highlights the limitations mothers face in identifying and taking necessary actions to maintain their own and their unborn baby’s health, as well as preventing potential complications during pregnancy. Mothers may struggle to meet their needs due to cultural factors, economic constraints, household responsibilities, and limited knowledge about pregnancy practices. One participant mentioned she continued to lift a heavy water-filled bucket during her pregnancy due to domestic limitations: “I still perform my routine activities, like carrying a bucket of water while doing the laundry. I fetch water from the well, as usual” (P17). Another mother mentioned being unable to undergo prenatal check-ups due to financial constraints: “Yes, I want to have a check-up to confirm whether I am really pregnant or not; I want to do an ultrasound, but there is no budget for it, so I just let it be for now” (P17).

3.b. Unable to Prevent Pregnancy Discomforts

This sub-theme underscores the tendency of mothers from LIFs to prefer treating rather than preventing discomforts during pregnancy. A participant mentioned that when experiencing swollen feet, she prefered massaging them by rubbing oil: “When my feet swell, I rub them with oil. My husband sometimes gives me a massage, but it feels painful, and the oil cannot reduce the pain” (P16).

DISCUSSION

This study revealed the challenges of pregnant women from low-income families in accessing health information, and how mothers received antenatal counseling from midwives. This is crucial as the availability of information and the ability to access, comprehend, and evaluate information influence the attitudes and behaviors of mothers in making informed decisions for themselves and their unborn children. ²²

In this study, pregnant women from LIFs placed more trust in healthcare providers than in other sources of information such as social media, family, and friends, and more often referred to village midwives. In this study, it was found that during counseling, village midwives had not succeeded in creating an atmosphere that impacted the improvement of maternal health literacy; midwives may respond angrily, provide casual answers, or lack scientific explanations. This finding is supported by studies in Nigeria, where midwives’ negligent and harsh attitudes toward pregnant patients drive some women away. ²³ This study indicates the mothers’ tendency to obtain more information, but the midwives’ role reveals a gap between what women expect and what they receive.

Furthermore, the study reveals that village midwives are frequently busy and difficult to contact; they also have limited counseling availability, resulting in pregnant women receiving insufficient information and feeling unsatisfied with the services offered by village midwives. A narrative review study in different countries such as Ghana, Uganda, Indonesia, Malawi, and Philippines reports that midwives do not function optimally in providing counseling due to high workload, limited knowledge, and low level of experience. ^{24 , 25} This research has implications where interventions focus on improving midwives’ communication competence, especially in empowering vulnerable groups and meeting maternal literacy needs. In addition, future policies that reduce the workload of village midwives also need to be considered.

The next barrier to accessing information is that mothers from LIFs feel embarrassed to discuss their pregnancies with healthcare providers and are hesitant to ask too many questions due to queues of other patients. Communication dysfunction between mothers and village midwives is a source of concern and frustration for mothers. These barriers also occur in Kenya where mothers fear reprimand from healthcare staff and service rejection. The negative attitudes of healthcare workers become reasons for mothers to avoid visits, leading to low antenatal care coverage. ²⁶ This finding indicates a need to establish a trust-filled and respectful relationship between village midwives and pregnant women from LIFs, and a woman’s experience in care is acknowledged as the key to the success of treatment. ²⁷

The findings in this research highlight the limitations faced by pregnant women from LIFs in accessing health information, both online and offline. Pregnant women from LIF face constraints in struggle with the use of e-Health pregnancy applications, exhibit disinterest in reading MCH handbooks, and experience limited support for information from family and spouses.

This study indicates that pregnant women face difficulties in operating the e-Health Pregnancy application, which involves several instructional steps and connectivity with email. As reported by other studies, poor and less educated women have low access to information on websites, mobile devices, and e-health platforms; they are less skilled in online information searching. ^{28 , 29} These findings emphasize the importance of digital literacy for pregnant women, especially in e-health knowledge and skills in using devices and e-health service providers, focusing on minimizing e-health service disparities by adhering to literacy principles. ³⁰

Furthermore, this study indicated that pregnant women from LIF expressed a lack of interest in accessing information from the MCH Handbook. They stated that reading the book is more tedious. The formal language and ambiguous illustrations in the MCH handbook were perceived as confusing. This finding emphasizes that utilization of the MCH handbook is suboptimal as an information source, and mothers have limited access to knowledge for self-care and fetal well-being during pregnancy. ³¹ This is in the same line with the results of previous research in Indonesia, showing that mothers with low educational levels may limit their understanding of the messages in the handbook, and/or the ability to follow the advice that is given to them. Therefore, each handbook in each country should have a variation; that is, they can solely focus on pictures and diagrams. However, in this study, mothers still complained that handbooks containing illustrations were not understandable. Using both illustrations and additional explanations from nurses and midwives help us better understand the information in the MCH handbooks and make it more accessible to a broader population. ³²

The low literacy skills of husbands and families hinder the mother’s access to information from the family regarding health services. In India, women from LIFs rely on their husbands for health service information, irrespective of the husband’s knowledge of health services or pregnancy. Communication with healthcare practitioners mainly revolves around consultations for pregnancy difficulties. ¹⁶ By understanding these barriers, engaging family members or husbands in prenatal visits and discussions with healthcare practitioners improves their comprehension of the care and requirements of pregnant women. ³³

Subsequently, regarding the application of pregnancy information, this study found that low-income pregnant women faced difficulties in implementing information according to pregnancy guidelines. A study in Ghana identified women understanding and recognizing dangerous signs of pregnancy and in the newborn, but they had difficulty interpreting and operationalizing information they received during antenatal care visits, indicating that health education did not translate to appropriate health behaviors. ³⁴ Several issues, including cultural attitudes, household duties, lack of awareness, and economic constraints, can hinder the ability to apply pregnancy care. ¹⁷

The obstacle in applying further information is that mothers tend to treat with ineffective methods rather than prevent discomfort during pregnancy. Some pregnant women experience this condition due to a lack of awareness of the importance of preventive measures in maintaining their and their baby’s health. They are more interested in traditional remedies or herbal medicine as the primary approach to addressing discomfort during pregnancy and fear of unknown health conditions. These barriers are also found in some pregnant , where they cannot effectively express complaints due to a lack of knowledge about pregnancy danger signs. ³⁵

The limitation of this study is that the researcher did not do interviews with healthcare providers involved in giving care from pregnant women. This restricts insights from the perspective of midwives during the counseling and pregnancy care process. Future research is recommended to explore the communication processes, barriers, and challenges in providing information for low-income pregnant women from the perspective of midwives would be valuable. However, this study also has strengths. To the best of our knowledge, this is the first study in Indonesia which explored receiving health information in a vulnerable group, namely low-income pregnant women.

CONCLUSION

The current study indicates that low-income pregnant women face various challenges in receiving health information during pregnancy. Additionally, the midwife counseling process during antenatal care does not support information improvement. Several concepts were identified, including limitations in accessing learning materials, limitations of family and husbands in informational support, communication dysfunction with village midwives, and difficulties in operationalizing of information due to external factors such as culture, domestic work, low education, and limited economic conditions. These findings provide an important basis for district-level maternal and child health program managers and midwifery professional associations to prioritize the issue of low health information in maternal policy and actions.

ACKNOWLEDGEMENT

All authors are very grateful to pregnant women for participating in this study. Thanks to health providers in the community health center for the endless support and permission given to the researchers. This research is supported by the Education Fund Management Institution of the Ministry of Finance of the Republic of Indonesia.

Authors’ Contribution

E.WN, MH were responsible for the conceptualization and design of this study. The data analysis and interpretation were carried out by LL and EWN. EH drafted the initial manuscript. All authors critically reviewed, revised the manuscript, and approved the final version for publication. All authors take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding Source

This study was funded by The Education Fund Management Institution of the Ministry of Finance of the Republic of Indonesia. Grant Number (0005001/TRP/D/BUDI-2019).

Conflict of Interest:

None declared.

References

1. Charoghchian Khorasani E, Peyman N, Esmaily H. Measuring Maternal Health Literacy in Pregnant Women Referred to the Healthcare Centers of Mashhad, Iran, in 2015. Journal of Midwifery and Reproductive Health. 2018; 6:1157-62.
2. Meldgaard M, Jensen AL, Johansen AD, et al. Health literacy and related behaviour among pregnant women with obesity: a qualitative interpretive description study. BMC Pregnancy and Childbirth. 2022; 22:712.
3. Taheri S, Tavousi M, Momenimovahed Z, et al. Determining Health Literacy Level and Its Related Factors Among Pregnant Women Referred to Medical and Health Centers of Tehran in 2019: A Cross-sectional Study. Shiraz E-Medical Journal. 2021; 22:e109592.
4. Riggs E, Yelland J, Szwarc J, et al. Afghan families and health professionals’ access to health information during and after pregnancy. Women and Birth. 2020; 33:e209-15.
5. Rouhi M, Stirling C, Ayton J, Crisp EP. Women’s help-seeking behaviours within the first twelve months after childbirth: A systematic qualitative meta-aggregation review. Midwifery. 2019; 72:39-49.
6. Mantwill S, Monestel-Umaña S, Schulz PJ. The relationship between health literacy and health disparities: A systematic review. PLoS One. 2015; 10:e0145455.
7. Tavananezhad N, Bolbanabad AM, Ghelichkhani F, et al. The relationship between health literacy and empowerment in pregnant women: a cross-sectional study. BMC Pregnancy and Childbirth. 2022; 22:351.
8. Kolak M, Jensen C, Johansson M. Midwives’ experiences of providing contraception counselling to immigrant women. Sexual and Reproductive Healthcare. 2017; 12:100-6.
9. Wittink H, Oosterhaven J. Patient education and health literacy. Musculoskeletal Science and Practice. 2018; 38:120-7.
10. Wilmore M, Rodger D, Humphreys S, et al. How midwives tailor health information used in antenatal care. Midwifery. 2015; 31:74-9.
11. Janke TM, Makarova N, Schmittinger J, et al. Women’s needs and expectations in midwifery care – Results from the qualitative MiCa (midwifery care) study. Part 1: Preconception and pregnancy. Heliyon 2024; 10:e25862.
12. Mannava P, Durrant K, Fisher J, et al. Attitudes and behaviours of maternal health care providers in interactions with clients: A systematic review. Globalization and Health. 2015; 11:36.
13. Baron R, Heesterbeek Q, Manniën J, et al. Exploring health education with midwives, as perceived by pregnant women in primary care: A qualitative study in the Netherlands. Midwifery. 2017; 46:37-44.
14. Gilder ME, Moo P, Hashmi A, et al. “I can’t read and don’t understand”: Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border. PLoS One. 2019; 14:e0218138.
15. Pierce P, Whitten M, Hillman S. The impact of digital healthcare on vulnerable pregnant women: A review of the use of the MyCare app in the maternity department at a central London tertiary unit. Frontiers in Digital Health. 2023; 5:1155708.
16. Das A, Sarkar M. Pregnancy-related health information-seeking behaviors among rural pregnant women in India: Validating the Wilson Model in the Indian context. Yale Journal of Biology and Medicine. 2014; 87:251-62.
17. Dahab R, Sakellariou D. Barriers to accessing maternal care in low income countries in Africa: A systematic review. International Journal of Environmental Research and Public Health. 2020; 17:4292.
18. Ridpath JR, Larson EB, Greene SM. Can integrating health literacy into the patient-centered medical home help us weather the perfect storm?. Journal of General Internal Medicine. 2012; 27:588-94.
19. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004; 24:105-12.
20. Albury C, Pope C, Shaw S, et al. Gender in the consolidated criteria for reporting qualitative research (COREQ) checklist. International Journal for Quality in Health Care. 2021; 33:mzab123.
21. Forero R, Nahidi S, De Costa J, et al. Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. BMC Health Services Research. 2018; 18:120.
22. Habte A, Dessu S, Endale F, Gizachew A. Level of Maternal Health Literacy ( MHL ) and Associated Factors among Pregnant Women Attending Antenatal Care Clinics of Public Health Facilities in Southern Ethiopia , 2021 : A Facility Based Crossectional Study with Linear Models. Research Square. 2022. DOI
23. Akin-Otiko BO, Bhengu BR. Client education experiences and expectations of women at the first level of maternal and child care in Kaduna state, Nigeria. Midwifery. 2012; 28:e893-9.
24. Filby A, McConville F, Portela A. What Prevents Quality Midwifery Care? A Systematic Mapping of Barriers in Low and Middle Income Countries from the Provider Perspective. PLoS One. 2016; 11:e0153391.
25. Viveiros CJ, Darling EK. Barriers and facilitators of accessing perinatal mental health services: The perspectives of women receiving continuity of care midwifery. Midwifery. 2018; 65:8-15.
26. Ochieng CA, Odhiambo AS. Barriers to formal health care seeking during pregnancy, childbirth and postnatal period: A qualitative study in Siaya County in rural Kenya. BMC Pregnancy and Childbirth. 2019; 19:339.
27. Grand-Guillaume-Perrenoud JA, Origlia P, Cignacco E. Barriers and facilitators of maternal healthcare utilisation in the perinatal period among women with social disadvantage: A theory-guided systematic review. Midwifery. 2022; 105:103237.
28. Anstey Watkins JOT, Goudge J, Gómez-Olivé FX, Griffiths F. Mobile phone use among patients and health workers to enhance primary healthcare: A qualitative study in rural South Africa. Social Science and Medicine. 2018; 198:139-47.
29. Bervell B, Al-Samarraie H. A comparative review of mobile health and electronic health utilization in sub-Saharan African countries. Social Science and Medicine. 2019; 232:1-16.
30. Sayed MI, Mamun-Ur-Rashid M. Factors influencing e-Health service in regional Bangladesh. International Journal of Health Sciences. 2021; 15:12-9.
31. Tjandraprawira KD, Ghozali I. Knowledge of Pregnancy and Its Danger Signs Not Improved by Maternal and Child Health Handbook. Journal of Obstetrics and Gynaecology of India. 2019; 69:218-24.
32. Wignarajah S, Bhuiyan SU, Gugathasan A. The Maternal and Child Health (MCH) Handbook and its Influence on Health Behaviors: A Literature Review. European Journal of Environment and Public Health. 2022; 6:em0092.
33. Dehshiri M, Ghorashi Z, Lotfipur SM. Effects of husband involvement in prenatal care on couples’ intimacy and postpartum blues in primiparous women: A quasi-experimental study. International Journal of Community Based Nursing and Midwifery. 2023; 11:179-89.
34. Lori JR, Dahlem CHY, Ackah JV, Adanu RMK. Examining Antenatal Health Literacy in Ghana. Journal of Nursing Scholarship. 2014; 46:432-40.
35. Jonkers M, Richters A, Zwart J, et al. Severe maternal morbidity among immigrant women in the Netherlands: Patients’ perspectives. Reproductive Health Matters. 2011; 19:144-53.