Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Reproductive Health https://doi.org/10.1186/s12978‑023‑01593‑0 RESEARCH Open Access Provision and experience of care among women with hypertension in pregnancy: a multi‑center qualitative study in Ghana Kwame Adu‑Bonsaffoh1,2,3* , Evelyn Tamma3, Adanna Nwameme4, Phyllis Dako‑Gyeke4, Emmanuel Srofenyoh1,5, Evelyn K. Ansah6, Diederick E. Grobbee1, Arie Franx7 and Joyce L. Browne1 Abstract Background Hypertensive disorders of pregnancy (HDP) remain a leading global health problem with complex clinical presentations and potentially grim birth outcomes for both mother and fetus. Improvement in the quality of maternal care provision and positive women’s experiences are indispensable measures to reduce maternal and perinatal adverse outcomes. Objective To explore the perspectives and lived experiences of healthcare provision among women with HDP and the associated challenges. Methods A multi‑center qualitative study using in‑depth interviews (IDIs) and focus group discussions (FGDs) was conducted in five major referral hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Women between 26 and 34 weeks’ gestation with confirmed HDP who received maternity care services were eligible to participate. Thematic content analysis was performed using the inductive analytic framework approach. Results Fifty IDIs and three FGDs (with 22 participants) were conducted. Most women were between 20 and 30 years, Akans (ethnicity), married/cohabiting, self‑employed and secondary school graduates. Women reported mixed (positive and negative) experiences of maternal care. Positive experiences reported include receiving optimal quality of care, satisfaction with care and good counselling and reassurance from the health professionals. Negative experiences of care comprised ineffective provider–client communication, inappropriate attitudes by the health professionals and disrespectful treatment including verbal and physical abuse. Major health system factors influenc‑ ing women’s experiences of care included lack of logistics, substandard professionalism, inefficient national health insurance system and unexplained delays at health facilities. Patient‑related factors that influenced provision of care enumerated were financial limitations, chronic psychosocial stress and inadequate awareness about HDP. Conclusion Women with HDP reported both positive and negative experiences of care stemming from the health‑ care system, health providers and individual factors. Given the importance of positive women’s experiences and respectful maternal care, dedicated multidisciplinary women‑centered care is recommended to optimize the care for pregnant women with HDP. Keywords Hypertension in pregnancy, Quality of care, Experience of care, Maternal hypertension *Correspondence: Kwame Adu‑Bonsaffoh kadu‑bonsaffoh@ug.edu.gh Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons.o rg/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 2 of 14 Plain language summary High blood pressure (hypertension) in pregnancy can have severe complications for both mother and fetus including loss of life. The outcome of pregnancy for women who develop hypertension during pregnancy can be improved by ensuring optimal quality of care. In this study, we explored the opinions and experiences of women whose pregnan‑ cies were affected by hypertension concerning the care they received during their recent admission at different hos‑ pitals in Ghana and the challenges they faced. In four major referral hospitals in the Greater Accra Region of Ghana, we interviewed the women and had focus group discussions. Women who were pregnant for 26 weeks up to 34 weeks and had hypertension in pregnancy were invited for inclusion in the study. We conducted in‑depth interviews with fifty women and three focus group discussions with 22 women. Most women who participated in the study were between 20 and 30 years old, Akans (ethnicity), married/cohabiting, self‑employed and secondary school graduates. The women reported both positive and negative experiences of care during their admission at the hospitals. Examples of positive experiences were receiving good quality of care, satis‑ faction with care, and adequate counselling from the health workers. Examples of negative experiences were poor communication between the providers and affected women, inappropriate attitudes by the healthcare providers, and disrespectful treatment such as verbal and physical abuse. The major factors in the health system that influenced women’s experiences of care were lack of logistics, substandard professionalism, inefficient national health insurance system and long delays at health facilities prior to receiving treatment. The individual women’s factors that affected the quality of care included financial constraints, psychosocial stress and inadequate knowledge about hypertension during pregnancy. In conclusion, we determined that women with hypertension in pregnancy experience both positive and negative aspects of care and these may be due to challenges associated with the healthcare system, health providers and women themselves. There is the need to ensure optimal quality and respectful maternity care considering the nature of hypertension in pregnancy. These women require dedicated hospital staff with significant experience to improve the quality of care provided to women with hypertension in pregnancy. Introduction mortality that fall short of the global ambitions [5]. For The global maternal mortality ratio is estimated at 199 instance, the maternal mortality ratio in Ghana remains per 100,000 live births, with a lifetime risk of maternal high at 308 per 100,000 live births despite demon- death of 1 in 190. The lifetime risk is substantially higher strable improvements (740 in 1990). [1] About 98% of in sub-Sahara Africa (1 in 38) compared to high-income pregnant women in Ghana receive antenatal care from countries (1 in 5400)  indicating significant healthcare skilled birth attendants and the institutional deliver- inequities [1]. Hypertensive disorders of pregnancy ies rate has increased from 54% in 2007 to 79% in 2017 (HDP) or maternal hypertension is among the major [6, 7]. The proportion of maternal deaths attributed to causes of maternal mortality, with complex clinical pres- hypertension in pregnancy has doubled over the past entations and potentially devastating birth outcomes decade in the country and it is the second largest cause for both the  woman and fetus [2]. HDP-related mater- after hemorrhage [6]. nal morbidity and mortality disproportionately affect The WHO defines quality of care as the extent to which low- and middle-income countries (LMICs) [3, 4] with healthcare services provided to individuals and patient approximately 1900 maternal deaths in high-income populations improve desired health outcomes [5]. High countries, compared to 20,900 maternal deaths in Sub- quality of care is multidimensional and incorporates Saharan Africa [3]. safety, effectiveness, timeliness, efficiency, equitability Prevention of avoidable maternal deaths through and usefulness to people [5, 8]. Thus, improvement in the improvement in obstetric and newborn care has been quality of care is critical in achieving the SDG 3’s target a long-standing priority for the World Health Organi- of reducing the global maternal mortality to less than 70 zation (WHO) and the global agenda of the Millen- per 100,000 live births [9]. Importantly, during provision nium Development Goals (2001–2015) and Sustainable of care, the rights and dignity of the women should be Development Goals (SDGs, 2015–2030). Overall, pro- respected to promote positive pregnancy and childbirth vision of care (coverage) has improved during ante- experience [10, 11]. Disrespectful care is increasingly natal, intrapartum and postpartum periods, globally. being identified as endemic in most maternity care set- However, lagging improvements to optimize the qual- tings with a direct negative impact on the quality of care ity of maternal care resulted in reductions in maternal A du‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 3 of 14 and can constitute a significant disincentive to future knowledge, attitudes and misconceptions on HDP have health-seeking behavior of women [11, 12]. been reported [18]. In this paper, we report hypertensive Recently, a WHO multi-country study with Ghana mothers’ perspectives and their lived experiences of care inclusive reported that over 40% of women experienced at health facilities in Ghana. significant mistreatment including physical, verbal, stig- matization or discrimination [13]. A key recommenda- Participants tion from this study hinges on further research into a Eligibility criteria were women with HDP diagnosed at comprehensive understanding of the drivers and struc- gestational ages between 26 and 34 weeks, who received tural dimensions of disrespectful maternity care includ- maternity services in any of the study centers and pro- ing socio-economic inequalities. As such, women’s vided written informed consent. HDPs diagnosed before perspectives and their actual experiences of care at health 34 weeks (early onset type) are considered severe disease facilities are vital to improving the existing healthcare with increased risk for poor outcomes and hospitaliza- system and the quality care for HDPs in the country. tion for an extended period. We excluded women with Therefore, the main objective of this study was to explore hypertensive disorders diagnosed after gestational ages women’s perspectives on provision and lived experiences more than 34 weeks. There is evidence that planned early of care and identify specific challenges among women delivery for women with HDP after 34  weeks’ gestation treated for hypertension during pregnancy in five health is associated with less composite maternal morbidity facilities in Ghana. and mortality compared with prolongation of the preg- nancy [19]. Hypertensive pregnancies that occurred prior Methods to 26  weeks were also excluded as conservative clinical Study design and setting management (i.e. prolongation of pregnancy) is generally This multi-center qualitative study using both in-depth not recommended due to the high risk of poor pregnancy interviews (IDIs) and focus group discussions (FGDs) outcomes [20]. was conducted in five major health facilities in the Greater Accra Region (GAR) of Ghana. The study sites Participant recruitment and interviews were Kore-Bu Teaching Hospital (KBTH), Greater Accra Data collection commenced on 1st June 2018 and was Regional Hospital, La General Hospital, Lekma Hospital completed on 31st March 2019. Study participants were and Tema General Hospital. The Greater Accra Metro- recruited via purposive sampling based on the specified politan Area of Ghana has a population of about 4 mil- inclusion criteria. Initially, a potential participants’ list lion inhabitants with different ethnic backgrounds. The was compiled comprising women with hypertension in antenatal care coverage by skilled health provider is pregnancy. Patients that met the inclusion criteria were about 97.5% comprising mainly midwives and doctors. then identified by one of the authors (ET) with the help of The region records the highest facility-based childbirth the medical doctor in the study team. The selected poten- (91.9%) in the country with the majority (71.4%) from tial participants were approached by ET who explained public institutions and about 20.5% from private health the study protocol to them individually. Women who facilities [6]. agreed to participate in the study and provided informed This qualitative synthesis was part of a large study titled consent were then assigned study identification num- “Severe Preeclampsia adverse Outcome Triage study bers. The in-depth interviews (IDIs) were carried out (SPOT study)". The overarching aim of the SPOT study immediately after discharge from the hospital. However, was to validate the fullPIERS (Pre-eclampsia Integrated if IDI was missed after discharge from the hospital, the Estimate of RiSk) and miniPIERS risk prediction Models interview was re-scheduled within the postnatal period for adverse pregnancy outcomes in women with severe (six weeks postpartum). The IDIs were started first and preeclampsia in Ghana [14, 15]. The detailed methodol- continued until the point of saturation where no new ogy of the SPOT study including the maternal outcomes information emerged from subsequent interviews. All has been published recently [16]. The main objective of the in-depth interviews (IDIs) were conducted by ET the qualitative analyses was to comprehensively explore with regular supervision and support from KAB. The the quality of care for women with maternal hyperten- FGDs were also conducted and moderated by ET and sion in the clinical setting based on the lived experiences notes were taken by another trained research assistant. of pregnant women and perspectives of health workers. We used interview guides for the IDIs and FGDs to gain The health professionals’ perspectives on clinical chal- a comprehensive understanding of the challenges during lenges associated with managing maternal hypertension provision of care and experiences of hypertensive moth- and context-specific recommendations have been pub- ers. Both the IDIs and the FGDs were either conducted lished recently [17]. In addition, hypertensive mother’s in Ga or Twi (local Ghanaian languages) and all were Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 4 of 14 audio-recorded. The notes taken during the interviews recursive manner to familiarize themselves with the data were kept in a diary and provided additional clarification and to understand the train of thoughts of the respond- and greater transparency during the data analysis. ents. During the recursive process of reading the tran- The IDIs and the FGDs were conducted in designated scripts, important notes were taken to indicate potential quiet rooms specifically allocated for the qualitative thematic areas and this resulted in the generation of the interviews in each facility to avoid frequent interrup- initial codes which were critical for the final coding of tions. There were no other people present in the inter- the transcripts. Coding was done by ET and KAB using view rooms at the time of data collection apart from NVivo software (version 12) based on the thematic con- ET and the research assistant (note taker). The IDIs and tent. During the data analysis, the notes that were scribed FGDs usually lasted for between 30 to 60 min and 60 to during the interviews provided clearly objective con- 120 min respectively. The FGDs were conducted after the tribution and understanding via comparison with the women had been discharged from the health facilities transcripts. The study team discussed the codes and the and within six weeks of childbirth so as to reduce recall emerging thematic areas until a consensus was reached. bias and provide a clear picture of the overall quality of In this study, triangulation of the results was ensured care they received during their admission at the health via the inclusion of hypertensive mothers of different facilities. backgrounds, from different health facilities (data source triangulation) and with the use of both IDIs and FGDs Ethical consideration (method triangulation) [22]. Coding was undertaken by The study protocol was reviewed and approved by the two authors (ET and KAB) and disagreements regarding Ghana Health Service Ethics Review Committee (Pro- coding were resolved via discussions by the team. The tocol ID GHSERC- GHSERC015 /09/17) and Ethical interviews were undertaken with a clear understand- and Protocol Review Committee (EPRC) of the College ing of the principle of reflexibility and active note-taking of Health Sciences, University of Ghana (Protocol ID during the IDI and FGDS. Reflexivity was ensured via GHSERC- CHS-EtM.4-P1.2/2017-2018). We obtained comparison of the interview transcripts with the notes written informed consent from all the study participants taken during the data collection to provide objective rep- prior to the interviews and they were assured of strict resentation and greater transparency of the findings. The confidentiality of the information provided. Anonym- consolidated criteria for reporting qualitative research ity was ensured by the non-inclusion of any identifiable (COREQ) were used as a guide in reporting this paper information about the respondents. [23]. Data management and analysis In this study, mixed methodological orientations of phe- Results nomenology and grounded theory were employed via Characteristics of the study participants systematic data collection and careful thematic content In this multicenter study comprising five hospitals in analysis [21]. We used an inductive analytic framework Ghana, a total of 125 women were invited to take part approach in the data analysis. In the inductive thematic out of which 72 women finally participated comprising analysis, the themes were derived mainly via coding 50 and 22 for the IDIs and FGDs respectively. For the of the data (data-driven) without being influenced by FGDs, most of the women could not be traced follow- our theoretical interest in the topic. Deductive analytic ing discharge from the hospital (Fig. 1). The FGDs were approach complemented the analysis as data coding was conducted in three out of the five hospitals: Korle-Bu not performed without any prior theoretical and episte- Teaching Hospital (n = 4 participants, 19 could not be mological background [21]. traced out of 23 women invited), Greater Accra Regional Transcription of the interviews and translation from Hospital (n = 10 participants, 5 could not be traced out Twi or Ga into English started soon after the commence- of 15 women invited) and Tema General Hospital (n = 8 ment of the data collection and continued alongside the participants, 7 could not be traced out of 15 women interviews. Prior to the data analysis, a two-day qualita- invited). Overall, 12 women (18.5%) declined to partici- tive data analysis training session was organized for ET pate in the FGDs. A total of 31 (47.7%) women (out of 65) and KAB at the School of Public Health, University of could not be traced during the postpartum period fol- Ghana, by the Social Scientists in the team headed by lowing invitation to participate in the FGDs. There was (PG and NA). After the training, the codebook was devel- some challenges in recruiting participants from the two oped by ET with input from KAB based on the semi- smaller hospitals (La General hospital and Lekma hos- structured interview guides. The transcripts were read pital) for the FGD as we could not assemble the mini- multiple times by two authors (KAB and ET) in a more mum number for the FGD on different occasions. The Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 5 of 14 Fig. 1 Flow chart for inclusion of women with hypertension in pregnancy socio-demographic characteristics of the participants ter by the women) Because that is what the doctors and the facility distributions are presented in Table 1. always write. Because we are illiterates we don’t Most of the women included in this study had Akan understand. I don’t know what it is” (FGD, 40 years, ethnicity (48.6%, n = 35), and were married/co-habit- married) ing (69.4%, n = 50), self-employed (62.5%, n = 45) and “Truth be told, I had never heard about it before. between the age group of 20 to 30 years (51.4%, n = 37). And I still really don’t even know what it is in detail. Majority had attained secondary education (58.3%, I quite remember I even use to point to the wrong n = 42) and experienced between 1 to 4 previous child- place when I was asked to point to my heart. In my births (86.1%, n = 62) and lived in urban areas in the first pregnancy, nothing about hypertension was Accra Metropolis (97.2%, n = 70). Majority of the IDIs mentioned to me (IDI, 29 years, single) were contributed by the Korle-Bu Teaching Hospital (40.0%, n = 20) and Greater Accra Regional Hospital However, few mothers had adequate knowledge of (32.0%, n = 16). Of the 60 potential participants for the hypertension and its major complications including IDIs, ten (16.7%) were excluded (4 declined and 6 could stroke. Adequate knowledge was commonly demon- not be traced). strated among women who had experienced preeclamp- In this study, we explored the women’s perspective on sia or other types of maternal hypertension in their provision and experiences of care, and specific challenges previous pregnancies. Most women diagnosed with faced by women treated for maternal hypertension. The hypertension in pregnancy had limited knowledge about major themes that emerged included (1) women’s knowl- the condition before their diagnoses were made. Other edge on hypertension in pregnancy, (2) women’s experi- women did not know that hypertension can affect preg- ences of care and (3) challenges experienced by women nant women although they had heard about hypertension while receiving care. in the general population. “Your health is the most important because your BP 1. Women’s knowledge on hypertension in pregnancy [blood pressure], when it goes up very high it can kill Most of the study participants had limited knowledge you or leave you with a stroke” (IDI, 29 years, mar- about HDP including the danger symptoms of severe ried) hypertension, especially those with limited educational “I’ve heard it because I experienced it in my previ- level. Most women indicated that they were ignorant ous pregnancy and I know what it can bring about. about preeclampsia and other HDPs and wondered why So when even someone says [s]he has headache I tell health workers do not routinely educate them on the the person to go and check, it might be hypertension subject. because it can kill you easily” (IDI, 39 years, single). “Please, I will like to ask that the name that they are “I have heard about BP before but I didn’t know that mentioning [pre-eclampsia], is it an illness? (Laugh- you could have BP when pregnant” (IDI, 31  years, Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 6 of 14 Table 1 Socio‑demographic characteristics of the study women frequently attributed hypertension in pregnancy participants to stressful situations which lead to heightened psycho- Variable IDIs n (%) FGDs n (%) Total n (%) logical stress and excessive thinking by the women. Age “Where I was staying, there were other tenants living < 20 3 (6.0) 0 3 (4.2) there who always want to argue with me. Anytime 20–30 29 (58.0) 8 (36.4) 37 (51.4) they see me they start to insult and mock at me. So 30–39 14 (28.0) 10 (45.5) 24 (33.3) because of that I decided to leave that house because 40 + 4 (8.0) 4 (18.2) 8 (11.1) I was very angry so I don’t know if that is what trig- Marital status gered the BP” (IDI, 28 years, single). Single 17 (34.0) 5 (22.7) 22 (30.6) “What I can say about it is that when we think too Married/cohabiting 33 (66.0) 17 (77.3) 50 (69.4) much that is what causes it so if you are thinking Educational status reduce it and give everything to God. He does all None/primary 14 (28.0) 3 (13.6) 17 (23.6) things but when you think too much it will not be Secondary 27 (54.0) 15 (68.2) 42 (58.3) able to solve that problem, and then also you should Tertiary 9 (18.0) 4 (18.2) 13 (4.2) find time to rest. You shouldn’t do too much work” Number of previous births (IDI, 39 years, married). 0 6 (12.0) 0 (0) 6 (8.3) 1–4 41 (82.0) 21 (95.5) 62 (86.1) 2. Women’s experiences of care 5 + 3 (6.0) 1 (4.5) 4 (5.6) Experience of care was a key recurring theme reported Residence by majority of the women with maternal hypertension. Urban 48 (96.0) 22 (100.0) 70 (97.2) The respondents had different interpretations of what Peri‑urban 2 (4.0) 0 (0) 2 (2.8) was considered “good quality of care” based on their lived Ethnicity experiences of care at their respective health facilities and Akan 28 (56.0) 7 (31.8) 35 (48.6) the outcomes of their pregnancies. The reported experi- Ewe 10 (20.0) 6 (27.3) 16 (22.2) ences by the women relating to their care at the respec- Ga 6 (12.0) 4 (18.2) 10 (13.9) tive health facilities were mixed. Few women reported Other 6 (12.0) 5 (22.7) 11 (15.3) positive experiences and perceptions of good quality Occupation of care. The hypertensive mothers narrated mixed feel- Unemployed 15 (30.0) 2 (9.1) 17 (23.6) ings regarding their care experiences, indicating sig- Formally employed 6 (12.0) 0 (0) 6 (8.3) nificant dissatisfaction among participants. However, Self‑employed 26 (52.0) 19 (86.4) 45 (62.5) some hypertensive mothers had positive experiences Casual worker 1 (2.0) 0 (0) 1 (1.4) and described the quality of care they received as opti- Others 2 (4.0) 1 (4.5) 3 (4.2) mal. The high quality of care experienced by some of Health facilities (study sites) the women commenced with excellent reception at the Korle‑Bu Teaching Hospital 20 (40.0) 4 (18.2) 24 (33.3) health facilities followed by provision of appropriate La‑General Hospital 4 (8.0) – 4 (5.6) treatment (standards of professionalism) and reassurance Lekma Hospital 5 (10.0) – 5 (6.9) by the health workers. Greater Accra Regional 16 (32.0) 10 (45.5) 36 (50.0) Hospital “As for me I was well cared for. They’ve really cared Tema General Hospital 5 (10.0) 8 (36.4) 13 (18.1) for me. The way the thing [hypertension] happened IDIs in‑depth interviews, FGDs focus group discussions to me and the way they were able to take care of me. They gave me injections when they had to. They really took very good care of me and I’m very happy” married) (FGD, 28 years, married) Majority of the respondents attributed their hyper- “On the day that I came, honestly, they gave me a tension to stressful situations they experienced during good reception because my baby’s heartbeat was up pregnancy. Other women related the occurrence of the and my Bp was also up so they calmed me down so hypertension to grudges at workplaces and the home that my Bp will come down. So they gave me excel- environment. Some participants hinted that in some situ- lent care and I was very happy” (FGD, 42  years, ations, disturbances in the home environment by family married) members resulting in ‘excessive thinking’ in pregnancy However, it was apparent that some women were were associated with hypertension in pregnancy. Most extremely unhappy with the care they received while they A du‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 7 of 14 were on admission. They enumerated the negative expe- outcomes of maternal hypertension, such as the demise riences they encountered and recommended measures to of their babies. The narratives provided by some mothers mitigate against such inappropriate treatment by health who experienced adverse outcomes clearly indicated that workers. they had some form of postpartum psychological strain “Getting up from the bed was very difficult for me. and depression. I could not raise my leg. A nurse will ask you to “For me, since they took the child out I didn’t want come to her for her to check your temperature and anyone to come to me because in my room when the something else while she is seated at the other end. babies around me cry, I panic, so I told them to let I couldn’t walk and almost fell so I had to hold unto me go home” (IDI, 29 years, single) the beds of others when I walked a little bit. On the “They did a scan and realized that the baby had other hand, there are those (nurses) who will come died in my womb. My sister signed as a witness to over to help you when you tell them you can’t get up” the death of the baby. After my vitals and blood were (FGD, 41 years, married). checked, everything was alright except my BP” (IDI, “When labour started, at the initial stages when I 28 years, married) called any nurse who was passing by, they ignored me instead of them may be encouraging me to bear Some of the patients experienced severe complications the pain. When it happens like that you think that of maternal hypertension such as convulsions or loss maybe you are going to die not knowing anybody of consciousness (eclampsia). A typical example was a there because the person who you know as a nurse woman who collapsed (had eclampsia) and was rushed to who is supposed to help you isn’t. When the baby’s the hospital in an unconscious state and was referred to head was coming out she then asked me to get up. the tertiary center for further treatment. It’s fine if you don’t know the condition in which a “After collapsing at home, I was sent to a nearby woman has to go through when in labour. When I clinic and after regaining consciousness the clinic had squatted when the baby’s head was coming, she transferred me here. When I got here, I was given was looking on but she kept urging me to get up and medicine” (FGD, 26 years, married) I told her that I couldn’t get up in that condition. There was a container under my bed, and it was in A similar occurrence of eclampsia and prolonged loss this container that I delivered into (Respondents: of consciousness was reported by a young woman who ooh!). I was very hurt and told my husband. I was regained her consciousness long after she had been oper- very hurt because I’m sure she was one of the stu- ated upon (cesarean section). dent nurses. If she had drawn closer and helped me “I remember I started eating kenkey and started with the delivery maybe I wouldn’t have lost so much vomiting and that was it. I didn’t remember any- blood. I bled a lot and suffered a lot before the baby thing again…. I saw that there was plaster on my came out” (FGD, 26 years Married). stomach and I was lying down before my mother There were mixed findings regarding provision of rel- came and I ask them what I was doing here and they evant information and counselling with respect to proce- said I had been operated because I was pregnant” dures undertaken by health professionals. Some women (IDI, 18 years, single). were given comprehensive counselling prior to the proce- dures they went through; they were satisfied with the care received and they commended the health professionals. b. Experience of mistreatment and disrespectful care Some of the participants recounted unpleasant experi- “Yes, they will tell you this is going to be painful. ences of disrespectful treatment while receiving mater- They tell you before they inject you. When I came nal care services at the health institutions. These abusive back from the theatre, I told the doctor that my but- treatments were meted by different categories of health tocks really hurt. He told me that he will mix the professionals (doctors, midwives) and took different drug with another drug to make it less painful. So he forms including verbal, neglect and physical mistreat- mixed it with another drug before injecting me and ment. Verbal abuse was rampant, and most women the pain was less” (IDI, 31 years, married). reported their experience of being shouted at, insulted or scolded during the provision of care. In addition, non- verbal abusive attitudes were displayed toward some a. Experience of complications of maternal hypertension Although the pregnancy outcomes were generally good hypertensive women. for most of the women, some experienced adverse Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 8 of 14 “Some people [health workers] talk to you in a friendly to us” (IDI, 24 years, married) “funny way” so you won’t feel it but others too will be shouting at you and you think she is doing her Lack of interactive communication between the health job so you can’t say anything about it, but some do professionals and hypertensive women was considered it in a very nice way” (IDI, 28 years, single) a major shortcoming in the process of providing care. “In all the doctors take good care of us, but the Adequate communication from the doctors and nurses nurses who work with the doctors are snobs. So you on the status and progress of their medical conditions will say that I don’t like this place because when with heartfelt expression of empathy was a major expec- you go there the nurses are snobs. They do this too tation of the women. Some women observed that the lack much” (IDI, 31 years, married) of communication was even worse for women with no or minimal educational attainment. Various instances of neglect by healthcare provid- ers were mentioned by the respondents. The affected “Hmmm I have a problem with the doctors and women felt neglected and worried especially during nurses, some don’t explain things to the patients. the times when they needed the support of the health You come and they say everything is okay and fine, professionals most. Incidents of extreme forms of unless those who have gone to school a little bit and inadequate attention or abandonment by health work- can read. But I think in everything, they should tell ers during the critical times of childbirth in the health the patients” (IDI, 26 years, married). facilities were recounted with a lot of emotions by some of the women. 3. Challenges experienced while receiving care “When I was in labour, I had to tell the nurse that Women with hypertension in pregnancy experienced she should come and check me so I can go to the myriads of challenges related to the health system and labour ward and she only told me that I should attitudes of healthcare professionals while receiving allow them to sleep because that time it was care at health facilities. Institutional challenges include around dawn, 2am. She said I should allow them inadequate facilities such as beds or space for managing to sleep and that I’m not in any labour. So I had women referred for urgent care due to severe maternal to go and so it was when I started pushing that the hypertension. Unavailability of hospital beds for admit- people [other patients] on the ward called out to ting mothers with hypertensive emergencies in most the nurses “she is giving birth ooo” and when they health facilities was frequently mentioned. However, came I had given birth” (IDI, 24 years, married) urgent institutional arrangements were made in some In the process of provision of maternal care some cases to provide space for admission of  the affected women experienced physical abuse which included mothers following some avoidable institutional delays. being hit by health providers. Reasons cited for such “When we came in the evening, we were told there mistreatment include patients’ refusal to obey instruc- was no bed. So they came to look for a place to put tions and lack of patience on the health workers’ part. a bed. So they cleared the place where they had put “When they [health workers] have to wake you up certain things and then put me there. They said for you to take your medication, they hit you very because of my case I had to lie down. I shouldn’t be hard as if you were their little sister before they standing so they made a bed for me to lie down and will tell you to take your medication instead of then they checked my BP frequently” (IDI, 28 years, tapping you gently. That was my problem” (FGD, married) 37 years, married) Situations where pregnant women on admission had Sometimes the attitudes of some of the health work- no beds and slept on the floor were also mentioned. Such ers put the patients off and made them wish they had situations occurred frequently when the hospitals were an alternative health facility to seek treatment. Major- overwhelmed with high patient loads. A typical example ity of the mothers felt uncomfortable and worried when of these experiences encountered personally by some of health professionals who are taking care of them are the hypertensive mothers is indicated below. unfriendly and disinterested in their welfare. “Please one good experience I encountered when I “Some nurses are not all that friendly; if you are was transferred after delivery to the ward was that, talking to them as if they are listening, sometimes there were no beds for the first half and I was given the way they talk to you makes you feel uncom- a mattress which I laid on till evening. In the evening fortable, so I think at least they should be a little one midwife came and asked why a BP patient was A du‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 9 of 14 lying on the floor. There was a bed then, so she car- receive the care the doctors are ready to give us. ried me unto the bed like a baby. The woman [mid- Because if you have high blood pressure and you wife] did very well. So, this is one good experience don’t have money, you are still thinking how will the which I had” (FGD, 32 years, co-habiting) hypertension will go?” (IDI, 43 years, married). In some instances of “no bed syndrome”, some hyper- tensive pregnant women are managed in chairs until beds b. Insecurity about the proficiency of the medical team become available. The following quote describes a typi- Some women with maternal hypertension had the cal experience by one hypertensive pregnant woman who impression that some of the medical practitioners were was nursed in a plastic chair when she presented with not adequately competent to offer optimal treatment to severe hypertension and required hospital admission and them on certain occasions. There were instances of argu- immediate treatment ments among the doctors about the most appropriate “When I arrived here, I was told there was no bed clinical decision in the presence of the patients and this so I should look for a plastic seat and sit on. So I sat created a feeling of insecurity, uncertainty and fear due in the seat while they took care of me. I was injected to perceived impression of inexperienced medical per- and all that sitting in the chair” (FGD, 31  years, sonnel. These feelings of insecurity were compounded by married) lack of communication and interaction with the affected patients who only looked up to God for miracle. Some mothers narrated how they were scared by the actions or a. High cost of laboratory tests and antihypertensive clinical decision of some doctors. medications “My problem over here is that it was like trial and The cost of healthcare was a prominent theme that error. When this person comes [referring to the doc- emerged from almost all the respondents. It became clear tor] he will come and write his report, “severe pre- that the most important underlying challenge associated eclampsia”. When this person [referring to another with the care for women with maternal hypertension was doctor] also comes, he writes mild pre-eclampsia financial constraint. An important concern mentioned by and then leaves. What I have being yearning for my majority of the women was the high cost of hospital stay. whole life [referring to a baby], you have students In addition, the cost of medications (antihypertensive coming in and out. When this one comes, he comes drugs) were high for which they implored the govern- to write then when the doctors come, they don’t read ment and other organizations to support. the report. This one comes to write “mild” and then “The drugs are very expensive. There are some drugs the other one comes to write “severe”. So when the which are not covered by health insurance. You will time came for me to go to theatre they should have have to buy it yourself. You can buy drugs to the tune found out whether it [the baby] will come on or not, of 400, 500, 600 and sometimes 1.2 cedis [with the but they were arguing among themselves that I was sum mentioned here ranging from 70 to 125 USD]. para zero or para “o” or something so they had to go Some are even more than that. So you will buy it and take the baby out for me. So this is the problem I yourself. Health insurance doesn’t cover. It covers had” (FGD, 42 years, married). very little, the ones that are not expensive like 35 or “When I came they [doctors] did not explain things 5 cedis” (IDI, 33 years, married) to me and when they checked they asked me to go home and come the following week but if it had not Financial constraint was cited as the single most impor- been for the head of the hospital I could have gone tant challenge encountered by women with hypertension, home and something could have happened to me” especially in paying for their laboratory tests and medi- (FGD, 29 years, single) cations. The participants made recommendations to the government to either reduce the cost of the medications or supply the relevant drugs to them at no cost. c. Delays in receiving care at health facilities “So the government should make sure that the labs Majority of the mothers with maternal hypertension [laboratory tests] done for pregnant women with recounted their experiences of significant delays at the hypertensive disorders of pregnancy should be made health facilities before receiving the needed care. This free because without the labs the doctors cannot do was reported by participants from all the health facilities their work well” (IDI, 33 years, married) included in the study. Further enquiry indicates that the “The government should reduce the cost and help actual provision of care they received at the facilities are those of us who don’t have money so that we can commendable despite prior delays in accessing the care. Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 10 of 14 “I leave home very early because I’m coming from ment should see to it for us” (FGD, 41  years, mar- afar. I get here by 6 am and start heading back home ried) at 5 pm. We suffer a lot. We are cared for alright but some people who arrive later go ahead of us because they know someone who works here. We sit in the e. National health insurance associated challenges queue for long because we don’t know anyone who There was a general perception that the National Health works here. So we really suffer a lot” (FGD, 31 years, Insurance (NHIS) has major limitations and does not married). cover the cost of maternal care completely. Most women had extreme difficulty in procuring all the prescribed Some women who were referred on account of severe medications and laboratory tests. These sentiments were hypertension had to obtain folders before they were pro- expressed by almost all the hypertensive mothers with vided the needed care. The challenge of going through mixed reports on whether the NHIS covers the drugs and the long registration process without the initial triage laboratory tests fully or partly. or treatment results in significant delay in receiving the needed urgent care, especially for emergency cases. Such “The NHIS doesn’t cover the BP drugs so they should long processes of acquiring folders (in-hospital registra- improve the insurance so that it covers the drugs tion) could result in increased adverse pregnancy out- because not everyone can afford it. When I came, comes for undiagnosed hypertensive emergency due to I have spent almost 600 Ghana cedis here and not delay in initiating anti-hypertensive treatment on time. everyone can afford it” (IDI, 29 years, single)“With the labs it was not expensive because the “When I got here, I was asked to go and make a card. health insurance covers some and the rest you will After that I was given a nurse who checked my BP so have to pay for it. And the drugs too, the insurance upon checking my BP, they realized it was an emer- covers some of them so the ones it does not cover you gency so they saw that the BP had gone up so they have to buy them either at the hospital when they gave me to a doctor” (IDI, 33 years, married) have some or outside”. (IDI, 31 years, single) “We got here at 3 something and they asked us to go and get a folder. My husband kept long with the get- Based on the gross limitations associated with the ting of the folder. So I was attended to after the folder NHIS as enumerated by the women including its inabil- was brought and they checked my Bp and then they ity to pay for the cost of most medications and labora- sent me to a room. I was given injections instantly” tory tests, several requests were made to the government. (FGD, 34 years, Married) These appeals mainly related to increasing the coverage of the NHIS to defray the hospital bill for women with maternal hypertension. “They should increase the coverage of the insurance. d. Shortage of health professionals Majority of the women thought the number of health We are told with insurance, delivery is free but this professionals (nurses and doctors) were inadequate to is not so we still pay. Even for the labs and drugs we take care of the high patient load. Most women appre- still pay. So far, I have spent almost 500 cedis” (IDI, ciated implicitly that the actual number of health pro- 33 years, married) fessionals were not adequate. However, they  (health workers) were mostly supported by students who were learning on the job. Some patients attributed poor pro- f. Home care management fessional output by the health professionals to the high Some participants recommended the idea of managing patient load and the inadequate numbers to manage the some selected patients at home for less severe conditions high volumes of obstetric cases. as compared to the strict hospital confinement. Inferably, “I think sometimes there is pressure on them (doc- some women felt their condition were not severe enough tors) and some of the patients they do not abide by to require admission to the hospital and that the possibil- the instructions, and they don’t take their drugs and ity of home care and monitoring for less severe cases of come with worse conditions. So, I think a lot of doc- maternal hypertension should be explored by health pro- tors should be employed” (IDI, 26 years, married). fessionals. The reasons for advocating home management “The midwives are not many so if more of those who as compared to hospital care majorly related to reduced have completed school can be added. At the govern- healthcare cost and loss of women’s productive time. ment hospitals the patients are more than the nurses “I think when someone comes and the condition is that is why they don’t have time for us so the govern- not too serious the doctors should prescribe drugs A du‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 11 of 14 for the person and not necessarily admit the per- deaths or severe morbidity [35, 36]. Also, high costs of son as it takes some productive hours of work away laboratory tests and antihypertensive medications were from the person and being admitted here, the cost of considered a major challenge for women and continu- admission too is expensive and not all can pay” (IDI, ous support from the government was frequently solic- 29 years, single) ited. In this case, all-inclusive and effectively working “For me, I was not ok because I told them to allow NHIS is indispensable in improving the quality of care. me to go home so that I can come for review while Majority of the mothers lamented desperately on the searching for some money and they refused, and limitations of the existing NHIS. Originally, the NHIS in it was because of my siblings I left at home” (IDI, Ghana was deemed to cover 95% of all healthcare cost 25 years, single) (including maternal care services) with some specific exceptions [37]. However, the constant public outcry including reports of frustrations experienced by hyper- Discussion tensive mothers in this multi-center study calls for a criti- This multi-center qualitative study provides a unique cal review of patients’ benefit and coverage of the NHIS opportunity to understand the quality of maternal care in the country. from the perspectives of women treated for hyperten- Another important health system-related concern was sion during pregnancy and their lived experiences of the feeling of insecurity by some women about the profi- care at health facilities in Ghana. Women with HDP ciency of the medical teams. Some hypertensive mothers reported mixed (positive and negative) experiences of had the impression that some of the health workers were care. Major bottlenecks in the provision of high-quality not adequately competent. Unavailability of skilled per- care identified relate to health system challenges such sonnel to make correct diagnosis and implement appro- as lack of logistics, inefficient national health insurance priate healthcare plan constitutes substandard care with and unexplained delays at health facilities; health profes- increased risk of severe maternal near-miss and mortal- sionals-related factors including ineffective provider–cli- ity [38]. The challenge of substandard care for maternal ent communication, inappropriate attitude by the health hypertension is not limited to LMICs. For instance, in professionals, disrespectful treatment including verbal the Netherlands where maternal mortality ratio is among and physical abuse; and inadequate women’s knowledge the lowest worldwide, maternal hypertension is the lead- about hypertension in pregnancy. ing cause of maternal deaths with about 96% associated The finding of inadequate knowledge on the preec- with substandard care [39]. Similar concerns related to lampsia or maternal hypertension by the hypertensive the quality of maternal care have been reported in other mothers is consistent with other reports across the globe high-income countries including the confidential inquir- especially in LMICs [24–28]. In a related study in the ies into maternal deaths in the United Kingdom. The United Kingdom, Wotherspoon et  al. determined lim- issue of substandard care remains a major clinical chal- ited knowledge of preeclampsia by women most of whom lenge that warrants urgent attention globally [27]. were unaware of the potential risk of developing preec- In addition, a significant number of mothers reported lampsia [29]. In that study, majority of the women were personal experiences of disrespectful treatments from uninformed about the rationale for regular measure- some health professionals including neglect, verbal and ment of their blood pressures and urine samples. Relat- physical abuse. Such mistreatment of women during edly, majority of the mothers attributed the development provision of maternal care remains a global phenom- of hypertension to stressful situations they experience enon with worse implications in the LMICS [11, 40]. In during pregnancy especially from their  workplaces and Ghana, disrespectful maternity care occurring in various home environment. The notion of ‘stress-induced preec- forms has been reported with differing opinions about its lampsia’ was of paramount concern to the hypertensive rationale or acceptability in contemporary maternal care mothers and this emerging discovery requires further [12, 41–43]. Admittedly, mistreatment of women dur- research as similar findings have been reported [28]. ing provision of maternal care is a complex phenomenon Although the etiology of maternal hypertensive remains that requires the input of all stakeholders including the elusive recent studies have demonstrated causal associa- government, health institutions, health professionals and tions with chronic psychosocial stress [30–33]. society. More recently, a WHO multi-country study on Majority of the mothers with maternal hypertension mistreatment of women comprising both labour obser- recounted their experiences of significant delays at the vation and postpartum community survey reported that health facilities before receiving healthcare services as over 40% of women experienced some form of mistreat- reported by other studies [2, 34, 35]. These unnecessary ment [13]. The main public health concern about mis- and avoidable delays could result in preventable maternal treatment of women with hypertensive disorder relates Adu‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 12 of 14 to its potential to disincentivize prospective mothers and of experiences of care and major determinants of quality their families in seeking care at health facilities. Evidence- of care. Another important aspect of this study relates to based interventions of locally appropriate dimensions the timing of the interviews which occurred after hospi- are urgently required to minimize abusive treatment tal discharge which enabled participants to express the of women and improve respectful maternity care in the opinions freely without any fear of retribution from the country. healthcare providers. Also, all the IDIs and the FGDs Effective communication between health care pro- were undertaken by a trained researcher who is non- viders and women is strongly recommended by WHO healthcare professional, and this enhanced the wom- to enhance positive experience of care and minimize en’s willingness to discuss their views freely. Finally, we unnecessary anxiety [10]. In our study, inadequate inter- employed both IDIs and FGDs to ensure comprehensive active communication was a major theme that emerged understanding (method triangulation) [22] of the process from majority the hypertensive mothers, consistent involved in the provision of care and lived experiences of with similar reports from other studies [25, 44, 45]. In a hypertensive mothers. related study in the United States, various recommen- This study has some limitations. Although this was dations were provided to improve effective communica- a multi-center study, it was mainly conducted in the tion between patients and healthcare providers including southern zone of the country where coverage of mater- building trust, rapport and reflective listening [46]. Lack nal healthcare services is highest. Therefore, women’s of effective communication negatively impact on sat- experiences of care including challenges associated isfaction with care. In a study conducted in Germany, with provision of maternal care services reported in our approximately 70% of the hypertensive mothers reported study may be underestimated. Also, data collection for dissatisfaction with the medical information provided by the IDIs was mainly undertaken by only one author and their healthcare providers on maternal hypertension [47]. this may have influenced the triangulation of the findings This quantitative report by Leeners et  al. [47] comple- (investigator triangulation) with increased potential for ments the qualitative reports demonstrated in our study monotony. Investigator triangulation relates to the use of and calls for a paradigm shift in provider–client commu- more researchers in data collection or analysis resulting nication. Re-training and empowerment of healthcare in improved assurance of data variety and confirmation professionals, including improvement of their salaries, of the findings [22]. However, the findings of this study health facilities and personal circumstances are viable depict the gross overview of the quality of care associated measures to improve efficient provision of care and wom- with maternal hypertension in the country. en’s experiences. Intriguingly, the concept of home care management Conclusion and monitoring for less severe maternal hyperten- This multi-center qualitative study has highlighted sion was raised by some of the hypertensive mothers to hypertensive  women’s perspectives on the  quality of reduce the burden on health facilities, health care cost care and their lived experiences with the care for women and improve women’s productivity. In another study, Bar- with hypertensive disorders of pregnancy. A complex low et al. reported expression of similar recommendation array of elements affects the provision and experience by hypertensive mothers as they preferred to continue of care for women with maternal hypertension. This their bed rest and medications at home because they includes health system related factors such as lack of thought their condition were not severe [48]. In some logistics, substandard professional attitude and unex- high-income countries home management of women plained delays at health facilities. Patient related factors with non-severe maternal hypertension is permissible that negatively influence the provision of care comprise and recommended [49–51]. More recently, Perry et  al. inadequate awareness of maternal hypertension and its reported significant reduction in the number of hospital complications and financial challenges. The quality of visits among hypertensive pregnant women when man- care experienced by women with maternal hypertension aged on home-based blood pressure monitoring without was  negatively influenced by ineffective provider–client increasing adverse pregnancy outcomes [52]. communication, inappropriate attitude by the health pro- fessionals, disrespectful treatment. Strengths and limitations The quality of provision and experience of care The main strengths of this qualitative study include the for maternal hypertension in the country could be multi-center nature comprising five major hospitals in improved by integration of appropriate evidence-based Ghana and the rigorous methodology adopted. In this interventions at different levels such as health system, study, women of various age groups were sampled pur- healthcare cost coverage, regular refresher courses for posively which resulted in a comprehensive assessment health workers and patient-centered care interventions. A du‑Bonsaffoh et al. Reproductive Health (2023) 20:49 Page 13 of 14 The emphasis should be placed on multidimensional Author details 1 collaboration of all stakeholders in both governmen- Julius Global Health, Julius Center for Health Sciences and Primary Care, Uni‑ versity Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. tal and non-governmental organizations as well as the 2 Department of Obstetrics and Gynaecology, University of Ghana Medical entire society. Well-integrated maternal health edu- School, Korle‑Bu, P.O. Box 77, Accra, Ghana. 3 Holy Care Specialist Hospital, cation promotion should be integrated into the edu- Accra, Ghana. 4 Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana. 5 Department of Obstet‑ cational programs to create and maintain optimal rics and Gynaecology, Greater Accra Regional Hospital (Ridge), Accra, Ghana. awareness about the relevance of high-quality maternal 6 Institute for Health Research, University of Health and Allied Sciences, Ho, 7 health. Further studies of high methodological quality Ghana. Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands. with wider national coverage are recommended to bet- ter understand how quality and experience of care can Received: 6 August 2021 Accepted: 5 March 2023 be improved for women with maternal hypertension. Abbreviations References COREQ C onsolidated criteria for reporting qualitative research 1. 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The mistreatment of women dur‑ • rapid publication on acceptance ing childbirth in health facilities globally: a mixed‑methods systematic • support for research data, including large and complex data types review. PLoS Med. 2015;12:1–32. 41. Rominski SD, Lori J, Nakua E, et al. When the baby remains there for a • gold Open Access which fosters wider collaboration and increased citations long time, it is going to die so you have to hit her small for the baby to • maximum visibility for your research: over 100M website views per year come out: justification of disrespectful and abusive care during childbirth among midwifery students in Ghana. Health Policy Plan. 2017;32:215–24. At BMC, research is always in progress. 42. Crissman HP, Engmann CE, Adanu RM, et al. Shifting norms: pregnant women’s perspectives on skilled birth attendance and facility‑based Learn more biomedcentral.com/submissions delivery in rural Ghana. Afr J Reprod Health. 2013;17:15–26.