Facilitators of and barriers to accessing prenatal care services in primary healthcare facilities during the COVID-19 pandemic in Manila, Philippines: a qualitative study

Introduction

The coronavirus disease 2019 (COVID-19) is a global pandemic from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that brought unprecedented challenges to healthcare systems worldwide. The rapid spread of the virus, coupled with the strain on healthcare resources, has disrupted the delivery of critical services. The COVID-19 pandemic has significantly influenced many parts of the healthcare system (1). World Health Organization (WHO)’s 2021 pulse survey revealed fragmented healthcare delivery and inadequate local/community stakeholder perspectives during the early COVID-19 pandemic (2).

WHO studies suggest country-level strategic approaches and reforms to address COVID-19 healthcare service disruptions (3). Case fatality and mortality rates have varied greatly between countries and continents; the majority of cases have been documented in high-income countries in the European and American regions (4,5). Even though these nations possess adequate resources and capability to allocate funds to their healthcare systems, this situation contrasts sharply with lower- and middle-income countries.

Among the various aspects of healthcare affected, maternal and child health (MCH) services have faced unique challenges during this global health crisis. The COVID-19 pandemic has exposed the vulnerabilities of MCH services in the face of a health crisis. Pregnant women and infants, already a high-risk population, are faced with additional health threats due to disruptions in healthcare access and delivery (6). The pandemic strained healthcare systems, diverting resources and personnel towards the urgent response to the virus, often leading to a reduction in routine MCH services (7). Prenatal check-ups, vaccinations, and essential maternal and pediatric care faced disruptions due to lockdowns, overwhelmed hospitals, and patient reluctance to seek care.

While COVID-19 response efforts are a national priority, it is crucial to acknowledge the unique initiatives at the local level ensuring the continuous delivery of routine public health services, including prenatal healthcare (8). In the Philippines, the Inter-Agency Task Force (IATF) was established in 2020 to manage emerging infectious diseases and formulate national strategies for the pandemic response (9-11). These strategies are informed by the best available evidence relevant to the Philippine setting and health system (12).

However, the country lacks unified and strengthened local frameworks outlining strategies and methods for sustaining non-COVID healthcare services, including prenatal care visits and consultations, within the local government units such as healthcare centers during the COVID-19 pandemic. This study aimed to explore the facilitators of and barriers to accessing prenatal care services in primary healthcare centers during the COVID-19 pandemic in Manila, Philippines. By analyzing the barriers and facilitators faced in maintaining non-COVID healthcare services, including prenatal care, and evaluating the responses and adaptations made by local government healthcare centers, this research can inform the development of robust healthcare crisis management strategies. We present this article in accordance with the COREQ reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-144/rc).

Methods

Study design

The study was a facility-based qualitative study that explored the perceptions of pregnant women and healthcare providers on the barriers and facilitators to accessing prenatal care services during the COVID-19 pandemic.

Study area

We conducted the study in the City of Manila, comprising six legislative districts. According to the Philippine Statistics Authority, among the cities in the National Capital Region, Manila City had the highest rate of live births in 2020 with a record of 48,208 registered live births despite being in the middle of the COVID-19 pandemic (13). For each district, we selected one primary healthcare facility based on the reported highest number of pregnant women as of the month of October 2022 according to each Health District Office of the Manila Health Department - Division of Planning and Coordination. In the current scenario, Manila operates under the New Normal Guidelines, with localized lockdowns implemented at both the barangay (community) and “purok” levels—the latter being the smallest unit within the community.

Study participants

We gathered data from two participant groups. The first group comprised pregnant women aged 15 to 49 with co-signed informed consent (for minors), regardless of prior pregnancies, seeking prenatal care in Manila City, and free from comorbidities. We have chosen this age group because they represent women of reproductive age. Ineligible participants are pregnant women below 15, those with medical conditions, and those receiving prenatal care outside Manila City. Individuals with comorbidities or medical conditions (e.g., diabetes, hypertension) were deliberately excluded from the focus group discussions for safety reasons, aiming to prevent stress or harm. Additionally, to exclusively focus on prenatal care services within Manila, pregnant women receiving care outside Manila City were excluded from the study. The second group includes healthcare providers aged 21 to 65 (based on the Philippine Labor Code), working as registered licensed professionals (e.g., physicians, nurses, and midwives) at Manila City healthcare centers. To ensure a comprehensive understanding of perspectives on prenatal care services, healthcare providers participating in the study must be involved explicitly in prenatal care.

We conducted two focused group discussions (FGDs) in selected healthcare facilities in each legislative district of Manila City. We used convenience sampling for participant recruitment, a non-probability sampling method, following the criteria above. The availability of participants at a designated time and their willingness to engage in the research study were the key factors that contributed to obtaining insights from pregnant women and healthcare providers.

Data collection

Two semi-structured topic guides were constructed by the authors for both pregnant women and healthcare providers based on the accessibility and implementation of prenatal care services during the COVID-19 pandemic (Tables S1,S2). Subject matter experts, such as local physicians, nurses, and midwives, validated these topic guides. Afterward, we pretested with five pregnant women and five healthcare providers as our participants. Pretesting was conducted to determine if our initial topic guides would be applicable as appropriate and not deemed overly sensitive to our participants. Their responses determined the proper approach and improvement when we collected the data during the FGDs.

We conducted 12 face-to-face FGDs, with two sessions (one FGD for pregnant women and one FGD for the healthcare providers) held at each of the six healthcare centers. Each FGD included 3–5 participants and took place in a private room to ensure participants’ preservation of their privacy. The sessions typically lasted around 60 minutes, with three male and four female researchers. Two authors (P.D.M. and K.M.) facilitated the FGDs, while the other two (A.B.D. and K.Z.M.) documented field notes. The first four authors underwent training in research methodologies and ethical considerations. The entire study was supervised by experienced researchers and professors (M.J.M., K.J.M., and R.R.C.).

We concluded the FGDs when we achieved data saturation. Data saturation is a widely accepted rule in qualitative research wherein the researchers have gathered and studied enough data and have no need to collect or analyze more (14). As we conducted the reviews, we sent a copy of the transcribed data and preliminary findings to the six healthcare centers for member checking and clarification. All six healthcare centers did not provide any feedback for any revisions and or further comments. The research took place for over 11 months in total (August 2022–July 2023), with data collection done in January 2023. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the University Ethics Review Committee of Adamson University (2022-02-PHA-10) and informed consent was obtained from all individual participants.

Data analysis

All FGDs were recorded in audio and transcribed verbatim in Filipino. The transcription, analysis, and coding were carried out collaboratively by two authors (A.B.D. and K.Z.M.). To enhance the accuracy and authenticity of our findings, a participant feedback process (member checking) was meticulously integrated into the data analysis phase. This involved sharing the transcripts and results with the participants, enabling them to verify the accuracy and resonance with their own experiences. The purpose of this method was to incorporate the comprehensive insights and recommendations provided by the participants into our final results.

This study utilized Braun and Clark’s thematic analysis methodology and inductive reasoning, focusing on a specific phenomenon (15). MAXQDA (VERBI Software, Berlin, Germany) was used as a coding program which aided the researchers in analyzing the themes that emerged from the transcribed data. Thematic analysis is a systematic approach to analyzing the data acquired from FGDs (16). Clarity and transparency are crucial in exploring the findings of the thematic analysis (17). Such a method allowed us to explore and interpret the patterns within the data. We laid out the interpretation of the data with familiarization of the contents by immersing ourselves through repeatedly reading and re-reading the data. Following the familiarization stage, codes, tags, and labels were assigned to each specific data point, representing their respective concepts or ideas. Subsequently, careful classification techniques were consistently applied to condense codes and classify them into a unified primary category, referred to as sub-themes. Themes were then assigned by analyzing each primary category and grouping those with similar meanings. The concluding phase of this thematic analysis involved reporting all emerging findings and presenting coherent narratives that illustrate the five identified themes.

Findings from the FGDs were divided into two sections. The first section was based on facilitators, while the second section was on the barriers to accessing prenatal care services during the COVID-19 pandemic. Throughout the results, quotes are presented to illustrate the findings.

Results

General characteristics of participants

Table 1 provides an overview of the participants’ characteristics. There were 22 pregnant women aged between 20 and 36 years who actively participated in all six FGDs. Additionally, there were 21 healthcare providers involved in the six FGDs distributed across different professions: 6 midwives, 6 nurses, 3 dentists, 4 physicians, and 2 pharmacists. Altogether, the study involved a total of 43 participants.

Facilitators of accessing prenatal care services in primary healthcare facilities during the COVID-19 pandemic

Table 2 shows the facilitators of accessing prenatal care services. Three themes emerged: (I) health-seeking behavior, such as compliance; (II) social support, such as provider support and peer support; and (III) organizational performance, such as efficient delivery of prenatal care services and up-to-date prenatal care equipment and devices.

Health-seeking behavior

Compliance

Based on the observations of the healthcare providers, pregnant women are compliant with their prenatal checkups. Patient compliance is a crucial part of an individual’s interaction with the healthcare system. This compliance is closely tied to health-seeking behavior, as it reflects a patient’s commitment to their healthcare.

“There are some mothers who have persevered to visit (healthcare centers) and to adhere to their schedules because, as much as possible, they make most of the free services we provide.” (Nurse, 32 years, District III).

“I have been compliant with my scheduled check-ups since day 1 and as far as I’ve experienced, my whole pregnancy journey has been nothing but comfortability and safety.” (Pregnant woman, 35 years, District III).

Social support

Provider support

Healthcare providers provided lectures, seminars, and house-to-house checkups to support pregnant women during the COVID-19 pandemic, ensuring safe delivery and accommodating those unable to visit centers.

“Sometimes we conduct seminars titled ‘Safe Motherhood Program’. They usually comply as long as we explain the needed information to them. Even our midwives, doctors, and nurses also provide health teachings to our pregnant women so they can fully understand the benefits they are receiving.” (Midwife, 32 years, District IV).

Peer support

Pregnant women would engage in conversations to provide social and peer support, sharing information about healthcare services to enhance safety, reliability, and overall well-being during delivery and postpartum care.

“Of course, to encourage other fellow pregnant women like me, I tell them that all their services are free and they have nothing to spend. Instead of having their checkup at the hospitals, they should go here instead. It’s more practical that way.” (Pregnant woman, 29 years, District II).

Organizational performance

Efficient delivery of prenatal care services

Healthcare providers delivered the most efficient assistance throughout pregnant women’s check-ups. They made sure to give out numerous seminars, constant reminders, house-to-house visits, free vitamins and vaccines, and use of the overall service.

“In our healthcare center, we ensure that everything is accessible within our services to our pregnant women whenever they visit us. Even before we start the day, we have to prepare and assess what needs to be done and what can be improved to boost the health of our pregnant women within our area.” (Midwife, 24 years, District II).

Up-to-date prenatal care equipment and devices

Healthcare centers offer modern prenatal care services, equipped with government-supplied equipment and renovations for comfortable, efficient delivery of care.

“Before, we didn’t even have sufficient beds or strollers to carry patients. We used to only refer pregnant mothers to hospitals around the area but now, we have ultrasound machines, and enough equipment that help these mothers have a safe delivery.” (Nursing Attendant, 40 years, District I).

Barriers to accessing prenatal care services during the COVID-19 pandemic

Table 3 shows the analytical framework of barriers to accessing prenatal care services during the COVID-19 pandemic. Two themes emerged: (I) personal challenges, with three sub-themes such as financial issues, geographical location, and fear of the unknown; and (II) organizational challenges, with four sub-themes such as limited supplies of personal protective equipments (PPEs), the toxic healthcare environment, understaffing, and insufficient distribution of maternal care programs.

Personal challenges

Financial issues

Pregnant women encounter financial challenges when seeking additional prenatal services not offered at healthcare centers, necessitating referrals to private hospitals that come with additional fees.

“I hope that the services provided by the center will be completely free so that we no longer need to go to the hospital.” (Pregnant woman, 31 years, District VI).

Geographical location

Pregnant women face barriers in accessing prenatal care due to living in remote areas and limited service outreach, many pregnant women face challenges in accessing timely health information.

“I live very far away compared to other pregnant women here. Sometimes, I’m not even informed that some schedule changed. Every time I visit, they still tell me the changes but not as fast as how others received the news. Some pregnant women that live nearby immediately received an ultrasound the moment the center announced that they have that service.” (Pregnant woman, 24 years, District I).

Fear of the unknown

Most healthcare providers shared that they had encountered challenging experiences in providing maternal healthcare services, especially during check-ups, as it negatively affected and hindered the safety of pregnant women.

“The restrictions were very daunting and scary for us during that time when the pandemic was still rampant, as it was very hard for us to do anything when we were limited, and we couldn’t do anything about it.” (Midwife, 41 years, District II).

“It was very difficult for most of us healthcare providers to assist and help every pregnant woman during those times as there were restrictions, and we wouldn’t want to risk our health and ensure our safety instead of helping in other ways.” (Nurse, 47 years, District III).

Organizational challenges

Limited supply of PPEs

For the healthcare providers, the PPEs’ lack of supplies was a hindrance in providing prenatal care services to pregnant women, as they had to wait for the PPEs to avoid the risk of spreading the COVID-19 virus to themselves along with the mother and child.

“It was very difficult for us working in the healthcare center as we were very limited with the medical supplies we had during those times, especially face masks and face shields. We wouldn’t want to risk the health of both the mother and the baby whenever they would have their required check-ups.” (Nurse, 32 years, District V).

“Personally, for me, I was not able to accommodate our pregnant women for their check-ups at that time as we had an insufficient supply of PPEs. Similar to my other colleagues, we had to wait for the supplies to come before providing close-contact services.” (Midwife, 25 years, District III).

Toxic healthcare environment

Pregnant women face barriers to proper prenatal care due to healthcare providers’ inappropriate communication and professional behaviors, leading to concerns.

“During my third scheduled check-up, I saw a high number of struggling patients at the center who were not being catered to properly by the health staff. The system was too hectic to manage, but the proper protocol should have been implemented to assist everyone with kindness and professionalism.” (Pregnant woman, 35 years, District III).

Understaffing

Pregnant women have experienced insufficient staffing of healthcare providers, which can lead to impatience during the pregnant women’s checkups as they wish to conclude quickly due to other priorities outside the healthcare center.

“When I was at the health center for my checkup, I had to wait a long time, and I noticed that there are a few healthcare providers in the healthcare center to take care of our needs.” (Pregnant woman, 25 years, District V).

Insufficient distribution of maternal care programs

When it comes to the provision of the programs stipulated under the “National Safe Motherhood Program” implemented by the Department of Health (DOH), there are instances wherein some health centers were not able to provide these services (e.g., check-ups, ultrasound scans, prenatal vitamins, immunizations, education and counseling, and home visits) due to a lack of planning or insufficient dissemination of information.

“We also noticed, whenever we have an overall meeting with other personnel from different health centers, that some of them have services that others do not have access to. Some health centers also provide more services and seminars for pregnant women compared to us.” (Physician, 46 years, District II).

Discussion

This study identified five main findings centered on the facilitators and barriers perceived by pregnant women and healthcare providers in accessing prenatal care services during the COVID-19 pandemic. The initial two findings center on the barriers experienced by pregnant women: (I) encountering geographic obstacles in accessing prenatal care and (II) facing inadequacy in reliable and convenient prenatal care services. Conversely, the remaining three findings revolve around observed facilitators: (III) pregnant women experiencing enhanced and convenient prenatal services in their healthcare centers; (IV) community and social support influencing effective prenatal care decision-making and planning; and (V) improved adherence to COVID-19 protocols by both pregnant women and healthcare providers. These findings underscore the need for enhanced healthcare access and support for pregnant women.

Pregnant women’s geographic location hinders access to prenatal care in primary healthcare facilities and deters them from seeking care. Distant locations hinder pregnant women from accessing prenatal care in remote facilities with limited transportation options (18). Indeed, geographical barriers can impede obstetric care adoption. This information is supported by the United States Accountability Office stating how the increase in hospital births among rural women might be driven in a negative way by the closure of local maternity wards and the limited availability of comprehensive prenatal care services, leading to decreased access to obstetric care for rural communities (19). Geographical barriers during the COVID-19 pandemic worsened prenatal care access. Remote areas face limited healthcare access, transportation issues, and exposure concerns, potentially harming maternal and fetal health.

Inadequate prenatal services in healthcare are linked to systemic challenges like limited PPE during COVID-19, a toxic healthcare environment affecting care quality, understaffing causing delays, and inequities in maternal care programs. Recent studies show that healthcare centers often lack comprehensive maternal care programs, affecting pregnant women’s trust and their access to essential services (20). DOH-equipped centers may not offer the same benefits as hospitals and private clinics, which many pregnant women prefer for better amenities and systems (21). Addressing these issues is essential for accessible, high-quality prenatal care. To tackle these interconnected challenges, the country may adapt the WHO’s “Maternal and Child Health Life Cycle Model” in the primary healthcare centers. In this model, it addresses the holistic health needs of women and children at various life stages (22). By integrating these elements into primary healthcare centers and engaging communities, we can create a comprehensive MCH strategy that caters to the diverse needs of the dispersed Philippine population.

Manila’s healthcare centers, as rated by pregnant women, offer reliable prenatal care services. Before the COVID-19 pandemic, these centers improved facilities by training healthcare providers and upgrading equipment. Consistent with our findings, an Eastern Ethiopia study indicates that the quality of healthcare services at health centers impacts pregnant women’s prenatal-seeking behaviors (23). However, healthcare provider incompetence and incomplete services hinder pregnant women’s access to care, which is supported by studies from Zambia and Mexico (24,25). Pregnant women’s satisfaction with improved prenatal care positively influences their willingness to seek and utilize prenatal care services.

During the COVID-19 pandemic, pregnant women sought prenatal care more often due to support from fellow pregnant women, impacting attendance and trust in healthcare providers. Our findings show similarity in other studies that state how receiving both provider and peer support greatly improved the mood of pregnant women throughout their gestation period (26,27). Evidence from another study also noted that receiving education from healthcare centers and peer encouragement positively addresses pregnant women’s needs before childbirth (28). A study from the Bicol Region, Philippines, in 2022 suggests that strong patient-provider relationships and trust are vital for patient comfort in healthcare (29). Healthcare providers need effective communication and compassion to ensure the comfort of pregnant women and other patients.

Healthcare providers noted high adherence among pregnant women to COVID-19 protocols, with the majority attending at least four prenatal care visits and consultations during pregnancy. However, it is important to note that this observation is not universally supported. Some studies during the COVID-19 pandemic have indicated a reduction in the original four required prenatal checkups for women. Factors such as limited in-person visits, overwhelmed healthcare systems, and the implementation of quarantine protocols contributed to a potential decrease in the frequency of essential prenatal care. This highlights the pandemic’s impact on prenatal care and reduced check-up frequency (30). Enhanced adherence to COVID-19 protocols among pregnant women and healthcare providers shows a collective commitment to safety. This explains why pregnant women in this study could comply with prenatal care visits. It is crucial to sustain and promote adherence to following COVID-19 protocols while also attending the required number of prenatal care visits for the well-being of this vulnerable population and their caregivers.

This study acknowledges certain limitations that need consideration. First, the data collection method faced challenges, including difficulty locating healthcare centers, particularly in secluded areas. Despite this, efforts were made to ensure diversity in geographic locations within Manila City to encompass various perspectives. Second, some pregnant women may have been hesitant to express their honest opinions, potentially leading to gaps or unaddressed issues. Additional follow-up interviews were conducted to mitigate this, emphasizing building trust and creating a private and comfortable environment during FGDs.

Despite these limitations, the study has significant strengths, particularly in its methodological approach. The utilization of in-person FGDs allowed for the direct observation of participants’ raw reactions, behaviors, and attitudes toward the provided topic guide. This dynamic interaction enriched the collected data and provided a nuanced understanding of participants’ responses and interactions within their respective groups. FGDs provided a conducive platform for participants to express themselves, fostering detailed responses and opinions freely.

The study’s strength extends beyond its methodology. Establishing connections with local government units and healthcare providers facilitated collaboration and validated the relevance and linguistic appropriateness of the topic guide. Additionally, a rigorous validation process involving healthcare providers and academic experts further ensured the credibility of the study findings, enhancing the overall robustness of the study.

Conclusions

Pregnant women encountered difficulties accessing prenatal care during the COVID-19 pandemic, particularly in hard-to-reach areas with limited services. Prenatal care services in the Philippines faced challenges, with effective MCH services not consistently reaching all healthcare facilities. Addressing these barriers requires a comprehensive approach to tackling personal and organizational challenges. To enhance facilitators of care, there should be a concentrated effort to improve the availability of prenatal services in underserved areas and promote better coordination among healthcare providers. This ensures that all expectant mothers have access to quality MCH services.

Acknowledgments

We would like to sincerely thank all our participants (pregnant women, healthcare providers), the Manila Health Department, and Health District Officers for sparing their time and accompanying us in gathering our data.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-144/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-144/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-144/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-144/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the University Ethics Review Committee of Adamson University (2022-02-PHA-10) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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