Barriers and insights for maternal and newborn health service delivery redesign in Pakistan: a qualitative study

Abstract Background Access to maternal and newborn health services in Khyber Pakhtunkhwa, Pakistan, is hindered by several barriers that impact the effectiveness of care. This study aimed to identify these barriers and gather community feedback on potential solutions for improving service delivery in the region through the implementation of Service Delivery Redesign. Methods A descriptive-exploratory qualitative study was conducted using purposive sampling to select participants from three districts in Khyber Pakhtunkhwa: Kohat, Battagram, and Shangla. A total of 210 participants, including mothers, fathers, and Community Health Workers, took part in 18 Focus Group Discussions. Each discussion lasted approximately two hours. Thematic analysis was used to identify barriers to accessing maternal and newborn health services and to gather recommendations from the community on how to improve service delivery. Results Key barriers to accessing maternal and newborn health services included limited availability of services, workforce shortages, disrespectful care, medicine shortages, and transportation challenges. Financial barriers, such as lack of knowledge about the Sehat Card and reliance on out-of-pocket payments, were also significant. Cultural factors, such as elder decision-making, patriarchal norms, and financial dependence, influenced healthcare-seeking behavior. Community stakeholders recommended improving infrastructure, supply chain management, respectful care, financial protection, and transportation. Conclusions The study found several connected barriers that affect how mothers and newborns use healthcare in Khyber Pakhtunkhwa. People in the community pointed out problems such as a lack of medicines, equipment, and basic healthcare services. They also mentioned that there are not enough healthcare workers, which makes it harder to get good care. Many participants were also worried about being treated with respect and dignity. They said that how healthcare providers act and communicate has a big impact on whether people seek care and trust health facilities. Decisions about maternal healthcare were shaped by complicated family and social factors. Fathers, mothers-in-law, and money all played important roles in determining when and where women sought care. Including fathers in this study provided useful new insights into how they influence maternal health decisions, an aspect that has often been overlooked in earlier research in Pakistan. Even with these challenges, people in the community said they strongly prefer giving birth in health facilities. They listed several areas that need improvement, including more medicines and supplies, more staff, easier access, and care that is more respectful and patient-focused. These results show that there is a need for broad strategies that tackle both problems in the health system and the social issues that affect healthcare use. Redesigning services based on what the community says is needed could help ensure everyone has fair access to high-quality maternal and newborn care in Khyber Pakhtunkhwa. To overcome these barriers, it is important to strengthen primary healthcare centers, train healthcare workers to focus on patients, improve transportation, raise public awareness, and improve the Sehat Card program. These steps could help improve the health of mothers and newborns and lower preventable illness and death in Khyber Pakhtunkhwa.