Patterns of care-seeking for postpartum symptoms in urban Karachi, Pakistan: implications for intervention design

Background: In Pakistan, the maternal mortality rate is 186/100,000 live births, with postpartum (PP) or maternal sepsis being the third leading cause of maternal deaths. Delays in early identification and timely management of PP sepsis are associated with mortality and severe maternal outcomes, including septicemia, neonatal deaths, infertility, etc. In this study, we aim to explore patterns of care-seeking of maternal health services by recently delivered women (RDW) in semi-urban Karachi, Pakistan. Insights of this study will help in identifying and addressing the barriers in care-seeking to minimize delay to improve clinical outcomes. Methods: We conducted 32 semi-structured qualitative interviews with RDW with PP sepsis, traditional birth attendants (TBAs), health care providers, and family relatives of RDW to characterize the patterns of care-seeking behaviors, sources of care, and treatment modalities. Community interviews were conducted in Bilal Colony, an urban squatter settlement, and facility interviews were conducted at a high-volume tertiary care facility in Karachi, Pakistan. All interviews were conducted face to face by trained data collectors which were then audio recorded. A codebook was developed manually by reviewing all transcripts and identifying emerging themes. Coded transcripts were entered into NVivo software to develop quotation summaries and models that identified subthemes. Results: This study utilized a 3-delay model to determine care utilization in RDW with PP sepsis. Phase 1 indicated limited awareness about PP symptoms, cultural norms, and lack of decision autonomy led to delayed care-seeking, as women depended on male or older female relatives for approval. Two of the most common symptoms of PP sepsis were high-grade fever and foul-smelling discharge, which were deemed as non-severe. Phase 2 findings implied that women initially sought care from TBAs, chemists, and faith healers, or self-medication and tertiary care was their last resort. Financial constraints were also determining care-seeking; Phase 3 indicated that women who sought care at the hospitals were in critical conditions due to prior unskilled care or traditional treatment choices. Conclusion: Increasing awareness of PP sepsis and its symptoms via educational programs is essential for not only women but also their family members who play roles in decision-making, Training community health workers and TBAs to recognize signs of PP sepsis and promptly refer women to appropriate facilities could also significantly reduce reliance on inappropriate care sources and ensure timely treatment.