Barriers and enablers of early health-seeking behaviour among women with preeclampsia and eclampsia: a qualitative study at a National referral hospital in Uganda

Abstract

Background

Globally, 2–8% of women experience hypertensive disorders in pregnancy (HDPs), including preeclampsia and eclampsia, which are the second leading cause of maternal mortality and morbidity. According to the management protocol for preeclampsia in Uganda, weekly follow-up is recommended for women with preeclampsia without severe features who are below 37weeks of gestation; however, this has not been feasible to most cases of preeclampsia/eclampsia (PE/E). There is still limited information describing barriers and enablers of early health-seeking behaviour amongst women with PE/E, yet this is needed to improve their healthcare.

This study explored the barriers and enablers of early health-seeking behaviour among women with PE/E.

Methods

We employed an exploratory descriptive qualitative design, involving 18 participants previously diagnosed with PE/E during antenatal, intrapartum, or postnatal periods, sampled using maximum variation sampling. This involved searching for a variation in the special aspects of the study population, including age, condition/diagnosis of either preeclampsia or eclampsia and the timing of diagnosis. Data were collected using a semi-structured interview guide from July to August 2023 and analysed manually through inductive content analysis.

Results

The interviews revealed three main themes as barriers: individual barriers; structural and logistical and socio-cultural barriers. Limited knowledge and awareness about PE/E, financial constraints, drug stockouts, beliefs and misconceptions were reported to be key barriers to early health-seeking behaviour. Social support, perceived good health care services and compliance with medical advice emerged as enablers.

Conclusion

This research implicates healthcare workers, including doctors and midwives, to create awareness and teaching about hypertensive disorders in pregnancy among the community through packaging relevant educational messages and sessions. This can be during antenatal contacts, community sensitisation outreaches and over media platforms like TV and FM radio stations. Furthermore, care for pregnant women should be more client-centred and flexible to allow the drop-in clients, especially those with complications in pregnancy, to enhance timely diagnosis and better health service delivery. Our study further highlights the social need for partners, family members, friends and other community members to support women with preeclampsia, accept and consider them like any other client/patient.

Background

Globally, about 2–8% of women experience hypertensive disorders in pregnancy (HDPs) [1]. These disorders are the second leading cause of maternal mortality and morbidity and predispose women to an increased risk of cardiovascular, cerebrovascular, and renal disease later in life [2]. HDPs include preeclampsia and eclampsia, gestational hypertension, and chronic hypertension [3]. Preeclampsia is a pregnancy complication that presents with high blood pressure ≥ 140mmHg systolic blood pressure (sBP) and > 90mmHg diastolic blood pressure (dBP) [4]. Eclampsia is a life-threatening complication of preeclampsia where high blood pressure results in the occurrence of seizures during pregnancy [5] and signs of multi-organ damage, especially in the liver and kidneys [4].

Research has revealed that PE/E is associated with a 4-fold increase in the future incidence of heart failure and a 2-fold increase in the risk of coronary heart disease, stroke, and death from a cardiovascular disease-related occurrence [5]. Yet health-seeking behaviour is still poor among the affected women [5].

In Uganda, early healthcare seeking among women with hypertensive disorders in pregnancy still has a paucity of local data, and has resulted in delayed healthcare interventions, leading to high risks of maternal and fetal morbidity and mortality, with outcomes that are not reassuring [6]. Findings from a study at Mulago National Referral Hospital about the burden of PE/E revealed that the high burden is associated with delayed recognition of hypertensive disorders, delay in accessing vital services and prompt care, which could be due to several barriers [7]. This leaves PE/E accounting for 6% of maternal deaths among pregnant women [8]. According to the management protocol for preeclampsia in Uganda, weekly follow-up is recommended for women with preeclampsia without severe features who are below 37weeks of gestation [9]; however, the frequency of ANC visits can be individualised; this has not been feasible for most cases of PE/E.

Despite PE/E being one of the most serious forms of HDPs, and while much work has been done in establishing clinical guidelines for the management of preeclampsia in the hospitals, there is still limited information in Uganda describing barriers and enablers of early healthcare-seeking amongst women with PE/E, especially associated with delay in seeking care. In a qualitative study, women held several myths regarding the cause of PE/E, for example, little blood, witchcraft, ghost attacks, and stress from strained relationships, including marital tension, and they were generally aware of the outcomes of eclampsia, mainly that it kills [10]. These studies still highlight an unmet need for information and understanding of the complexities of health-seeking particularly to women with PE/E. The only study that was done in Uganda, as stated above, only focused on the perspective of women regarding the cause of PE/E, but did not dig deeper into the barriers and enablers of early health-seeking behaviour. Therefore, this study aimed to explore barriers and enablers of early health-seeking behaviour among pregnant women with PE/E.

Methods

This study used an explorative qualitative design. Eighteen [11] women with a previous diagnosis of PE/E were enrolled using maximum variation sampling, which involved searching for a variation in the special aspects of the study population, including age, condition/diagnosis of either preeclampsia or eclampsia and the timing of diagnosis. A priori sample size of 25 participants was initially considered, based on recommendations for qualitative research by Charmaz K and Cresswell. JW. However, thematic saturation was achieved after 18 interviews, and recruitment was therefore concluded. Participants were sampled from two inpatient units for PE/E.

Data were collected using a semi-structured in-depth interview guide (IDI) for a period of two months from July to August 2023. The IDI was both in English and the commonly used language, Luganda. A research assistant experienced in qualitative data collection and maternal child health and had no prior established relationship with participants was trained about the research topic, IDIs and the ethics governing the research study. Administrative permission from the study area was obtained to allow access to potential participants. After obtaining verbal and written informed consent, data were collected from participants in a private room to protect participants’ privacy. With permission, interviews were audio-recorded; verbatim transcription was done. A thorough reading of the transcripts was done, and codes were extracted manually; researchers further grouped codes into categories and themes, and analysed the primary findings manually using inductive content analysis; analysis was often checked with study team members for coherence. Member checking was done to ensure the accuracy and credibility of results.

The study adhered to the Declaration of Helsinki by considering the following: Ethical approval by Makerere University School of Health Sciences and Research Ethics Committee (REC), numbered MAKSHSREC-2023-49, and administrative clearance from the Research Ethics Committee of Kawempe National Referral Hospital (an urban and specialised women’s hospital). The participants provided both verbal and written informed consent, and they were guaranteed to withdraw from the study at any time. Participants were assured of maximum privacy and confidentiality of the findings.

Results

Participants’ demographic characteristics

The 18 participants interviewed were aged between 20 and 40 years, with a median age of 25.5. Among them, 4(22.2%) had primary education, 10(55.6%) had secondary education, and 4(22.2%) had tertiary education. The majority, 15(83.3%) were married, and 3 were cohabiting. Ten (55.6%) participants were self-employed in private business, while 4(22.2%) were formally employed. Half of the participants had at most two pregnancies; of these, more than three-quarters, 7(77.8%) were pregnant for the first time. The gestational age of participants ranged between 24 and 38 weeks of gestation, with a median gestational age of 28 weeks. The majority, 11(61.1%) of the participants stayed within less than 2 km, 3(16.7%) stayed 5 km or more from the nearest health facility, and slightly less than half 8(44.4%) were Born Again Christians (Table 1).

Table 1.

Demographic characteristics of the participants (N = 18)

Participants’ characteristics	Frequency	Percentage (100%)
Age
20–24	9	50
25–29	1	5.6
30–34	1	5.6
35–39	6	33.3
40 and above	1	5.6
Level of education
Primary	4	22.2
Secondary	10	55.6
Tertiary	4	22.2
Marital status
Married	15	83.3
Cohabiting	3	16.7
Occupation
Self-employed	10	55.6
Formally employed	4	22.2
Housewife	4	22.2
Number of pregnancies carried
1-2	9	50
3-4	6	33.3
5-6	3	16.7
Number of living children
No child	7	38.9
1–2	5	27.8
3–4	6	33.3
Weeks of gestation
20–24	3	16.7
25–29	8	44.4
30–34	4	22.2
Above 34	3	16.7
Distance from home to the nearest health facility
Less than 2 km	11	61.1
2–4 km	4	22.2
5 km or more	3	16.7
Religion
Anglican	2	11.1
Roman Catholic	4	22.2
Born-again Christians	8	44.4
Muslim	4	22.2

In this study, we explored barriers and enablers to early health-seeking behaviour among women with PE/E.

Barriers to early health-seeking behaviour among women with PE/E

The interviews revealed three themes: individual barriers, health system barriers, and community barriers to early health-seeking behaviour among women with PE/E, as illustrated below (Table 2).

Table 2.

Coding tree for barriers to early health-seeking behaviour among women with PE/E

Themes	Categories
Individual barriers	Limited awareness and knowledge about PE/E
	Preconception about the effectiveness of care
	Financial constraints
	Concerns about intolerable side effects of drugs
	Patient’s tight work schedules
Healthcare system barriers	Structural and Logistical Barriers
	Inadequate assessment by healthcare workers
	Drug stock-outs
Community barriers	Beliefs and misconceptions

Individual barriers

Limited awareness and knowledge about PE/E

Almost all participants reported delays in seeking care for PE/E due to limited or no awareness of the condition, particularly its signs and symptoms, potential outcomes, and risk factors. Many participants had experienced symptoms at some point but didn’t associate them with PE/E because they were unaware, as reflected in their responses below:

“I can’t lie to you because even for me, it was after checking me that I knew I had it. Otherwise, I wouldn’t have known; I had no clue on any of the symptoms” (Participant 10, 40 years). “I would get a lot of pains as if I had Ulcers but not. Here at the upper part of the stomach pained me so much” (Participant 2, 23years).

Some participants did not recognise the signs and symptoms they experienced as preeclampsia because they generally believed that high blood pressure is associated with older or overweight individuals. This is evident in the following responses.

“Nothing, it’s only a headache that was paining me within the eyes, yeah, even the feet got swollen, only that. I knew it was malaria” (Participant 9, 21years).

“I understood on myself when they measured me and they said I have it. But I thought that pressure is for very fat people and the elderly” (Participant 4, 35 years).

Some participants reported not taking the condition seriously enough to see it as life-threatening or to ask about it, as indicated in the responses below.

“I had not taken it seriously. I thought it was something like someone suffering from a cough and getting well. I did not take it seriously because I did not know the effects of pressure” (Participant 2, 23years).

Preconception about the effectiveness of care

This sub-theme highlights patients’ emotional and mental concerns affecting their healthcare decisions. Some participants reported fear of receiving unfavourable results, along with frustration and demotivation when they don’t see immediate improvements in their blood pressure readings. One stated,

“I rarely go there because I know that when I go there, it’s obvious, they will tell me it is high” (Participant 8, 22 years).

Another participant mentioned her disappointment in how the treatment did not seem to be working for her, and she was not experiencing any improvement.

“I felt so disappointed because it is like someone giving you medication and it doesn’t benefit you, meaning that it hasn’t worked however much it has worked for others but not for me. Also, every time I went back, it was still high, so I was personally discouraged and decided to stop it. I stopped it” (Participant 18, 35 years).

Some participants delayed seeking healthcare due to a fear of medical intervention, especially the necessity of undergoing an operation to save both the baby’s and the mother’s lives. Two participants narrated,

“Yes, I didn’t come because I never wanted to undergo an operation to remove the baby as they had scared me that once I reach here, they will have to operate and remove the baby. So, I got scared” (Participant 1, 27 years).

“I delayed and never paid attention to be operated” (Participant 5, 37 years).

Financial constraints

Nearly all participants mentioned financial constraints that affected their ability to cover transportation expenses, purchase drugs when out of stock, pay for investigations and laboratory tests, and afford healthcare, especially for those who preferred private health facilities, as two participants narrated below.

“My husband and I didn’t have any money to transport us to here; we didn’t have the money yet from where we were to here we needed money. He had lost his job and yet I also don’t have one” (Participant 10, 40 years).

“At that time I didn’t have money, this was one of the issues that prohibited me from going to the hospital” (Participant 5, 37 years).

Concerns about the intolerable side effects of drugs

Some participants reported challenges due to the side effects of the drugs they were taking to manage preeclampsia. Intolerable side effects, such as severe headaches, led some participants to skip or discontinue their medication, as described below.

“….they look like painkillers and make me feel very bad; I even get a headache so, you can’t give them to me and I take them. If a health worker forces me, I don’t argue; I just take and keep them at home because they give me a terrible headache” (Participant 1, 27 years).

“Sometimes when you are swallowing this medicine, you find it smells so badly for you, and you feel fed-up of it, then you start missing” (Participant 2, 23years).

Patient’s tight work schedules

Personal businesses and workplace schedules compromised some participants’ decision to seek healthcare, including antenatal care, when it was still early and they ended up being diagnosed late, as can be evidenced by the response given below:

“I would first attend to work before coming to the hospital, yet it is wrong, you would first go to hospital for your life and the baby’s life…. I would postpone my hospital visit as long as I was feeling well for next Tuesday so time passed……” (Participant 7, 35 years).

“….my boss sometimes doesn’t want you to leave and yet you also need to go and get the medication….you therefore have to wait for the perfect time either to get permission to go get the medicine, because you aren’t allowed to leave work during working hours” (Participant 14, 36years).

Healthcare system barriers

Participants also reported encountering barriers within the healthcare system that hindered their ability to seek healthcare and adhere to best practices. These barriers include structural and logistical barriers, delays in inadequate assessment by healthcare workers, and drug stock-out as described below.

Structural and logistical barriers

Due to the fixed structure of client schedules, some participants reported delaying their decision to seek care out of fear that they wouldn’t receive attention on that particular day. Even those who attempted to seek care encountered challenges due to the drop in patient numbers, as the day was designated for a different category of client visits. This issue is evident in the responses provided below:

“I came to the hospital on a Monday and I was told they were only working on people with 35 weeks and above, so I went back home” (Participant 7, 35 years).

Another participant narrated how it was tiresome and costly when the patient needed to come frequently to the health facility.

“……as in it was hard for me to keep on moving all the time, I think just over moving, yeah… over moving, coz she (doctor) would tell you come in the morning, at times even in the evening the same day; then that transport of every day, yeah…., at times I could not feel like going (laughs) to be honest….” (Participant 16, 34years).

Inadequate assessment by healthcare workers

A participant reported that she had not been adequately assessed and had only been reassured without the opportunity to share the truth about her situation. She believes this led to wasting time at the lower facility (Health Centre III level), as timely referrals could have prevented possible complications.

“….despite not feeling well; they (midwives) told me to go back home, they would manage that hypertension during the process of labour. It hurt me as a person because I had taken the initiative and explained to them (midwives) but I think they didn’t think about me” (Participant 11, 23 years).

Drug stock-outs

Many of the participants reported that, at times, the health facilities lacked necessary medications. Consequently, they had to purchase them, but due to financial constraints, some were unable to do so. As a result, they missed taking their prescribed drugs and failed to adhere to the treatment regimen.

“….sometimes you reach there (health facility), and they say the medicine isn’t available, thus you end up not taking the drugs on time” (Participant 14, 36years).

“….when they (health-workers) say that they don’t have the medicine, you are supposed to buy, it is very expensive” (Participant 6, 35years).

Community barriers

This theme underscores how beliefs, perceptions, and external influences hinder women with preeclampsia from engaging with healthcare services promptly.

Some participants mentioned receiving incorrect information and reassurance from family and community members regarding the likely cause of their health status and the use of herbal concoctions instead of prescribed medicines. This left them confused and conflicted when trying to find appropriate healthcare. Two mothers narrated,

“When I started swelling the legs, my mother told me that I should not mind because she also used to experience the same. “My legs swell, my legs swell but I produced you all” said the mum. I wondered because I consulted with the elder women and they said it was normal” (Participant 2, 23 years).

“Because they tell you to use this medicine, try this, eeh you keep on trying, but there is no sign that it (blood pressure) will reduce, you take herbs, these local herbs, drinking them” (Participant 8, 22 years).

Another participant narrated being informed that blood pressure isn’t for pregnant women and thus was advised to take herbs, and out of fear, she took the herbs for some time.

“….they also know that pressure is not for those people who are pregnant; they knew that it is for old people and thus got scared, they said you take those herbals, I tried it, but was taking both, but later I stopped” (Participant 6, 35years).

Enablers of early health-seeking behaviour among women with PE/E

The enablers of early health-seeking behaviour were a result of social support, individual and health care system factors, which emerged as the categories as presented in (Fig. 1) below;

Fig. 1.

showing themes and categories for enablers of early health-seeking behaviour among women with PE/E

Social enablers

Two main categories were generated, highlighting the impact of social support and empowerment of self and shared decision-making at the family level to seek healthcare.

Social support

Nearly all participants emphasised that the support they received from their husbands, family members, and friends, including the provision of necessary resources, encouragement, and counsel, played a significant role in motivating them to seek healthcare for preeclampsia, as described in the responses provided below:

“They (family members) have minded plus the friends, they have encouraged me in the condition I am in. My husband can send me transport and tell me to go to the health facility” (Participant 3, 20years).

“My husband is so supportive, he would support me financially, he buys medication and also counsels me and tells me that you will go through the situation or let’s try out something else” (Participant 5, 37years).

“….of course my family members who know about it, the friends and well-wishers they just encourage me, they say don’t give up, yeah….” (Participant 8, 22years).

Increased Autonomy in healthcare seeking

Almost all participants reported feeling empowered to make decisions regarding their healthcare for preeclampsia. This is reflected in the following responses.

“I go to the hospital because it is my life, he doesn’t need to decide for me” (Participant 1, 27years).

“I am the one who decides that I go to the hospital because he (husband) is not the one carrying the pregnancy” (Participant 4, 35years).

“We always discuss and arrange which hospital to go to depending on our financial status” (Participant 5, 37years).

Individual enablers

Compliance with Medical Advice

Participants mentioned that listening to and following advice from healthcare providers helped them seek healthcare. Two participants narrate,

“I think so, listening to the doctors’ advice, because it is another thing going there (Health Centre) and it is another thing doing what they (health workers) tell you, someone can go there they tell you do this do that and they don’t do it, but I kept on following whatever the doctor told me” (Participant 16, 34 years).

“….as you know, if they (health workers) tell us this, possibly something is missing, we could go and buy” (Participant 9, 21years).

Fear of negative outcomes

Some participants mentioned that their fear of potential consequences, such as the worsening of the condition and the risk of losing their lives, heightened women’s motivation to seek healthcare for preeclampsia. This desire to avoid such uncertainties is evident in the responses provided below:

“What could have helped me is that you can stay home and preeclampsia takes your life or sometimes the baby could get complications. So, to avoid all that, you need to seek medical help very early” (Participant 15, 23 years).

Another participant explained that being alone at home and fearing her condition might worsen prompted her to seek preeclampsia care.

“What worried me the most was that I was sleeping alone in the house and I wondered that what if my situation worsens at night and I can even open the door where will my people start from because my father doesn’t even know where I am staying….so I decided to go to Kawempe Hospital” (Participant 11, 23 years).

Healthcare system enablers

Perceived good healthcare services

A significant number of participants mentioned that they were treated well by health workers. They expressed trust in health professionals and believed in the competence of the personnel, which encouraged them to seek timely care for preeclampsia. This is evident in the responses below:

“I came here knowing that surely this is a government hospital with qualified medical personnel and I also knew that since I had high blood pressure, I was going to be operated so I had to come here; the health workers were around and they attended to us” (Participant 5, 37 years).

“You see, the good thing when you are having pressure, they know that your pressure is high, you will be the first person to be attended to. At first, people could say the care is not good, I said it is okay let me reach there and I see if they have the care, but the care is not such bad at all” (Participant 6, 35years).

Timely referral by the lower health units

One participant mentioned that she received assistance in seeking higher-level healthcare for PE/E. The lower health facility assessed the situation and determined that a timely referral was necessary, as described below.

“That referral really helped me because I would be there stranded and not knowing what to do. And for most hospitals, when they see you are high risk, they get scared and keep saying we can’t manage you” (Participant 13, 22 years).

Discussion

This study gives an insight into the perspective of women with preeclampsia/eclampsia (PE/E) regarding barriers and enablers to early health-seeking behaviour.

Three [3] themes emerged as barriers to early health-seeking behaviour: individual, health system, and community barriers. Furthermore, three [3] themes were identified as enablers of early health-seeking behaviour: social enablers, individual enablers and healthcare system enablers.

Barriers to early health-seeking behaviour among women with PE/E

Limited awareness and knowledge about PE/E

Knowledge and awareness about any health condition, for example, its manifestation and associated complications, can affect the health-seeking behaviour of an individual [12]. This study revealed that women had limited awareness and knowledge about preeclampsia, especially regarding its signs and symptoms. Some of the participants had heard about PE/E during their antenatal visits. Almost all participants had experienced signs or symptoms of preeclampsia, such as headaches and swelling of the feet; unfortunately, some participants never took these signs seriously and couldn’t connect them to preeclampsia. Others believed that these signs and symptoms were not related to pregnant women but rather to overweight or adult individuals and failed to appreciate the need for treatment.

This finding suggests that health education by healthcare workers during antenatal care may need to place a greater emphasis on PE/E to bridge the knowledge gap. This is in agreement with findings from a study conducted in rural Tanzania, where insufficient awareness of the signs and symptoms, and risks associated with PE/E were a barrier to health-seeking behaviour among women with PE/E [13], this further agrees with findings from a study conducted in Ghana about Women’s knowledge, attitudes, and experiences with preeclampsia, which revealed that lack of knowledge of PE/E among pregnant women could lead to delay in health-seeking behaviour [14].

Preconception about the effectiveness of care

The mindset and conception of an individual regarding illness influence health-seeking behaviour among individuals [15]. According to this study, women expressed fear of receiving high blood pressure results after a check-up, fear of medical interventions like surgery, and the perception that their blood pressure was not normalising despite treatment. This preconception collectively influenced their decision-making regarding seeking care. This could be due to limited awareness or personal misconceptions and other social-cultural influences about the condition and respective management. This finding is in line with results from a cross-sectional analytical study conducted in Tanzania about Knowledge and Myths about Preeclampsia and Eclampsia and their influence on Antenatal Service Utilization among pregnant women and their male partners, which revealed that feelings and emotions significantly affected women’s health-seeking behaviour, with fear being reported in five of the ten included studies [16]. Similarly, the results are in agreement with findings from a qualitative study conducted in rural Tanzania, also affirming that beliefs, misconceptions, and stigmatisation are factors affecting women’s health-seeking behaviour, thus driving the high rate of undetected and untreated cases of preeclampsia and eclampsia [13]. This thus calls for health workers to have counselling sessions for women with PE/E to enhance a positive living mindset and experience that will facilitate compliance with medical attention; additionally, this finding recommends community awareness through health education to dispel all misconceptions about PE/E.

Financial constraints

Finances are essential to meet most of the needs for daily living, including Medicare [17]. Results from this study showed that women had issues in meeting the financial requirements of care for preeclampsia, including transport costs to the facility and purchase of drugs in cases where drugs were out of stock, which left most not taking the prescribed medicines or finishing the recommended dose, others didn’t carry out the recommended investigations due to costs attached. Some women wanted to access private healthcare facilities for personal reasons but could not afford the cost of care. Low incomes, unemployment, small-scale businesses, and being housewives contributed to the financial burden on these individuals, affecting their progress and their husbands. This concurs with a study done in Nigeria to explore survivor perceptions of PE/E, which revealed financial barriers to early decision-making, access to transportation and affordability of healthcare services amongst women with PE/E [18]. It is therefore argued that men and women join local community financial saving groups to save for the future and work out income-generating activities for financial survival and rescue.

Structural and logistical barriers

This study revealed that some women failed to seek preeclampsia care because of fixed schedules for antenatal visits. These schedules involved categorising and scheduling clients on specific working days of the week, particularly at higher levels of care. This approach made it challenging for women who had considered visiting the health facility as drop-ins when they didn’t feel well. Additionally, participants who arrived on a day designated for gynaecological conditions were instructed to return home and come back another day for their respective category. This significantly impacted their willingness to return for care. This was probably because medical personnel had many clients to work on. This finding agrees with findings from a study about Maternal help-seeking about early warning signs and symptoms of preeclampsia, which revealed that organisational constraints impacted maternal health-seeking for PE/E care [11]. It is recommended that clients consider their lives first than their jobs; additionally, healthcare facilities should have flexible schedules to allow drop-in cases for Medicare.

Inadequate assessment by healthcare workers

Our study further shows that inadequate assessment at Basic Emergency Obstetric and Newborn Care (BEmONC) facilities affected a woman’s timely seeking of preeclampsia care at a higher level of care. Inadequate provision of information to patients and false reassurance by health workers compromised decision-making and the need for timely referral. This finding reveals the need for future research to ascertain the barriers to adequate and effective assessment at BEmONC facilities. This concurs with results from a study by [19], which reported that some health workers did not take women’s complaints seriously, advising them not to worry as their symptoms were considered normal or similar to common pregnancy ailments. This led to late diagnoses of complications such as preeclampsia and HELLP syndrome (Haemolysis, Elevated Liver enzymes, and Low Platelets).

Enablers to early health-seeking behaviour among women with PE/E

Social support

Social support at both family and community levels positively facilitates patients’ health-seeking behaviour and recovery from any illness [20]. Findings from this study revealed that encouragement and support from partners, family members, and friends facilitated most women to seek care for PE/E at health facilities. This was likely because women felt secure and emotionally relieved after experiencing such a supportive social environment. This agrees with results from a related study, which postulated that social networks influenced women’s health-seeking behaviour; in contrast, the same study revealed the potentially harmful influence of friends and family by giving false reassurance and advice about healthcare-seeking [19]. Additionally, findings from a scoping review about experiences of women with hypertensive disorders revealed that strong social networks played a crucial role in helping women endure their situation right from the diagnosis to postpartum; women registered support from husbands/partners, family, and friends [21]. Family members and friends of women with PE/E are therefore encouraged to emotionally and physically support these women to enhance healthcare seeking.

Increased Autonomy in Healthcare Seeking

Furthermore, this study showed that women had the autonomy to seek healthcare, which included shared decision-making with their husbands and the liberty to decide by themselves to seek healthcare whenever they felt unwell. This could be attributed to increased respect for women’s rights and empowerment, which influences access to and the practice of good health-seeking behaviour; additionally, it could be attributed to the fact that they consider themselves in danger due to the pregnancy. This finding agrees with a study conducted among women in rural Tanzania, revealing increasing autonomy among women as decision-makers concerning their health [22]. However, this finding contrasts with results from a study by [23], which revealed limited autonomy among women and that husbands and mothers-in-law solely made care-seeking decisions.

Compliance with Medical Advice

In this study, compliance with medical advice given by health workers and obedience to instructions helped women to practice timely health-seeking behaviour for preeclampsia care. This involved meeting their appointment schedules and compliance with medication, as well as the encouragement to buy drugs in the event they were out of stock at the facility. This could be because women perceived health workers as the true source of information and thus trusted them for practical advice. This agrees with findings from a related study, which revealed that medical advice improved clients’ perceptions of treatment benefits and consequences of non-adherence [24]. Therefore, it indicates of the need to consider patient education regarding the care package to enhance compliance with health-seeking.

Fear of negative outcomes

This study further revealed that women’s perception of fear of the negative outcomes of failure to seek care enabled some women with preeclampsia to make decisions about seeking care. Women who had been staying alone mostly harboured the fear that their conditions could worsen or even lead to their demise in the house. This fear possibly prompted the women to perceive their condition as a threat and consider seeking care. This concurs with findings from an analysis of the meanings of preeclampsia for pregnant and postpartum women in Brazil, postulating that women who were found afraid of the condition and knew that themselves and their fetuses or infants would be in danger considered seeking agent health care [25].

Perceived good healthcare services

Women with preeclampsia had a good perception of care expected at health facilities, which facilitated many to seek care. Women declared that they sought care at the higher-level facility because they expected to find qualified personnel and experts capable of prioritising and managing women with PE/E. This preference likely stemmed from women's belief that they would be in the safe hands of caregivers, making them feel secure. This is in contrast to findings from a study in Bangladesh on pathways to service access for PE/E, which revealed that women’s perception and experience of the quality of care at the health facility was a barrier to their health-seeking behaviour for hospital-based healthcare (23). In a related study conducted in Ghana, some women felt insecure about the proficiency of the medical team and were impressed that some medical personnel were not adequately competent to offer them optimal treatment [26]. This finding encourages women with PE/E to always trust and believe in their health workers for quality care; furthermore, health workers should equally handle patients well and provide quality care.

Timely referral by the lower health units

This study revealed that the timely referral of women to the next level of care facilitated their access to appropriate care for PE/E. Some women believed that the lower health facilities they had initially visited for care continued to assess their prognosis and recognised their limitations in providing specialised care services for PE/E. Consequently, they considered timely referral to the next level of care. This finding acted as a facilitator for some women when it was timely, but it became a barrier for others when it was delayed. The latter finding agrees with a study done in India, which revealed that identifying high-risk mothers and their timely referrals improved community trust, thus positively influencing health-seeking behaviour among high-risk women [27]. Health workers at lower health units are therefore encouraged to triage their clients and know their limits of care; this will make them easily identify pregnant women who need a referral to the next level of care.

Strengths and limitations

One strength of this study is that we explored both barriers and enablers of early health-seeking behaviour compared to other studies in Uganda, which focused more on the burden of and perceptions about PE/E. Limitations of this study include the small convenience sample utilised in this study and the conduct of the study in a single urban area in Uganda may limit the transferability of the study findings. However, these limitations are offset, to some extent, by the utilisation of rigorous qualitative methods described in the study and our use of the Consolidated Criteria for Reporting Qualitative research (COREQ), to improve the rigour, comprehensiveness and credibility of the interviews.

Conclusion

This research implies the need for healthcare workers, including doctors and midwives, to create awareness and teaching about hypertensive disorders in pregnancy among the community through packaging relevant educational messages and sessions. This can be during antenatal contacts, community sensitisation outreaches and over media platforms like TV and FM radio stations.

Furthermore, Care for pregnant women should be more client-centred and flexible to allow the drop-in clients, especially those with complications in pregnancy, to enhance timely diagnosis and better health service delivery.

Our study further highlights the social need for partners, family members, friends and other community members to support women with preeclampsia, accept and consider them like any other client/patient. This will help reduce stigmatization and increase women’s confidence to live positively with their health condition.

Authors’ contributions

GM, SNM and PAM conceptualized and designed the study. GM collected, extracted and analyzed data. GM, SNM, PAM, SM, MK and MS drafted the manuscript. All authors read and approved the final manuscript.

Funding

This study was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health through the Stroke Project of Makerere University College of Health Sciences under Award Number R01NS118544. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health.

Data availability

Data of the study is available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

All study participants provided written informed consent. Ethical approval for this research protocol was granted by Makerere University School of Health Sciences and Research Ethics Committee (REC), numbered MAKSHSREC-2023-49, and administrative clearance from the Kawempe National Referral Hospital.

Competing interests

The authors declare no competing interests.

Conflicting interests

The authors declare that they have no conflicting interests.