Tracking Care-Seeking Pathways: A Qualitative Study of Maternal Complications in Uttar Pradesh, India

To understand the referral pathways followed by families, the highest level of health facility reached for care, the time taken to receive that level of maternal healthcare, and families’ experiences of care received, we conducted a qualitative study of six maternal deaths, 10 perceived postpartum hemorrhage, and 14 frontline health workers. Thematic analysis of the data showed that of the six maternal death cases, one went directly to a secondary care public hospital, four women visited four to five hospitals before they died. One of them died after visiting four hospitals in over 30 h. Of the 10 women who experienced postpartum hemorrhage, six never went to a hospital, three went to two hospitals, and one was in the hospital when the event occurred. Time taken from the first step of care-seeking outside the home to initiation of care at the highest level ranged from 11 h to 8 days. The providers of the public health system followed a hierarchical 'referral pyramid' irrespective of whether the next level hospital could provide appropriate care or not. This research provides evidence to the ‘outer setting’ domain of the Consolidated Framework for Implementation Science from families’ perspectives about their needs and the referral network. Providing information about emergency obstetric care services to all the hospitals within a district and developing a communication system through the Federation of Obstetric and Gynaecological Societies of India for care continuum through referral would help reduce mortality and improve family’s experience with the health system.