“Attitude is the fifth delay”: Perspectives of obstetric near-miss survivors and health care professionals on continuity and coordination of maternal care

Abstract

<title>Abstract</title> Background Fragmentation in maternal healthcare contributes to preventable maternal deaths. Improving continuity and coordination can mitigate this issue by influencing interactions among providers, interdisciplinary teams, and patient-provider relationships. The obstetric near-miss approach has the potential to offer insights into continuity and coordination in maternal health. The aim of this study was to explore the perspectives of near-miss survivors and health care professionals on continuity and coordination of care in a primary health care system in Uasin Ngishu region, Kenya. Methods This was a descriptive qualitative single case study with two embedded units of analysis, building on an exploratory quantitative phase. Data was collected through individual interviews focus group discussions, and observation. Results Four deductively identified themes emerged: <italic>sequential coordination, continuity, parallel coordination, and access.</italic> Longitudinal and interpersonal continuity were driven by positive interactions between women and healthcare providers, characterized by availability, willingness to listen, and addressing personal issues. Sequential coordination was influenced by antagonistic relationships between healthcare providers in primary care facilities and the main referral hospital. Parallel coordination was affected by heavy workloads and ineffective task shifting within primary care facilities. Finally, access-related issues included accommodation strategies such as telephone hotlines for pregnant women, out-of-pocket payments for specialist consultation, and alternative referral pathways different from the formal pathways in the health system. Conclusion To promote continuity in primary health care for pregnant women, there is a need to focus on social competencies and skills among health care professionals providing obstetric care, encourage accommodation strategies in facilities, reduce or eliminate out-of-pocket payments for referred women, address professional conflicts among midwives at different levels in the referral pathway and address workloads and task shifting in primary care facilities.