Mixed study on barriers of access to prevention, diagnosis and treatment of gestational malaria in pregnant women at risk from an endemic region of Colombia

Abstract

Background

Gestational malaria (GM) is a serious public health problem, control of GM requires guarantee universal access to prevention, diagnosis and treatment. In Colombia, no studies have been conducted on barriers to healthcare access for pregnant women exposed to GM. The objective of this study was to analyse the barriers to healthcare access for women at risk of GM in an endemic region of Colombia.

Methods

A mixed QUAN-QUAL study with 400 pregnant women; from this group, 28 were selected for the QUAL component, to which an interview with eight health workers was added. The barriers investigated were sociocultural, economic, institutional response capacity, knowledge of the actors, previous experiences and health financing. In the QUAN component, the frequency of the barriers and their associated factors were identified. In the QUAL component, a hermeneutic analysis was conducted to enhance the explanatory depth of the barriers, through open (description), axial (conceptual ordering) and selective (theorization) categorization.

Results

The most frequent barriers included delays in care from a physician (93%) or specialist (89%), and procedures with a Health-Promoting Entity (HPE) (84%); the least frequent barriers were the delivery of drugs (23%) and quality of care (23%). All pregnant women reported at least one barrier, 50% reported between 7 and 11 barriers, with the highest number of barriers among housewives, multigravida and poor pregnant women. The QUAL component included the intersection of GM with sociocultural and economic barriers, financial limitations of public health programmes, failure to fulfill responsibilities by health professionals, and a lack of knowledge regarding health rights among pregnant women.

Conclusion

Multiple access barriers were identified; the most affected subgroups were identified, and some sociocultural and economic explanations for this problem were explored in depth. It is important to expand the health action of GM control, and to improve the care of pregnant women and their quality of life.

Background

Malaria is a global public health problem. According to the World Malaria Report, 249 million cases were recorded in 85 endemic countries in 2022 [1]. This report does not detail cases of gestational malaria (GM), but a recent publication reported that 248 million pregnancies occur worldwide, of which 63% (157 million) come from 85 malaria-endemic countries and 49% (122 million) occur in areas with active transmission of the parasite [2]. In the Colombian case, according to the epidemiological bulletin [3], the country reported 104,949 cases in 2024, without specifying their frequency in pregnant women.

This is significant considering that GM increases the risk of anaemia, severe malaria, and maternal death; delays intrauterine growth, and can cause abortions, stillbirths, low birth weight, and other outcomes [4]. For example, in 2020, in countries with active transmission of Plasmodium, 1.4 million stillbirths and 49.6 million abortions were estimated to occur [2].

In response to this problem, the World Health Organization (WHO) strategies are based on three pillars: (i) achieving universal access to malaria prevention, diagnosis, and treatment; (ii) accelerating efforts to achieve elimination or malaria-free status; and (iii) transforming malaria surveillance as a basic intervention [5]. In specific cases of GM prevention, the WHO recommends intermittent preventive treatment with sulfadoxine-pyrimethamine, insecticide-treated mosquito nets, and effective case management [6].

The above highlights multiple challenges to preventing and mitigating the risks of morbidity and mortality for GM. These are more serious in Colombia, a country where the use of preventive treatment has not been approved, the situation of exposed pregnant women is unknown, and research focuses on preclinical issues or frequency of the event. In addition, the National Institute of Health (NIH) reports general figures and does not disaggregates data in pregnant population; control is focused on treatment, prevention and timely diagnosis, and the determinants of the disease are unknown, particularly those related to access to health services for pregnant women [7, 8].

Access to healthcare services is defined as the ability of a person or group of people to seek and obtain medical care; barriers to health care access (BHCA) correspond to any limitations that prevent access to healthcare [9]. The identification of these barriers is crucial to guarantee equity in access to quality services, improve the efficiency of the care system, and design public health interventions and policies; in pregnant women, it contributes to the reduction of complications, the promotion of antenatal care (ANC), the active participation of pregnant women in different actions related to their health, reducing socio-health inequalities, and ensuring that pregnant women receive adequate care regardless of their cultural or socioeconomic context [10].

In Colombia, there are no studies on BHCA in GM. In other Colombian populations, it has been reported that the main BHCA are the population’s perception that their problem is not serious (36.3%), the costs involved in attending health services (10.65%), the perception of poor quality of care (10.3%), the cost of transportation (7.3%), and not being affiliated with social security (7.2%) [11]. In Medellín city, main BHCA are users’ economic situation, geographic distance, and sociocultural characteristics of the population (educational level and community networks determine the demand and access to services), administrative obstacles, lack of infrastructure, lack of professional resources, and delays in authorizations [9]. Barriers to seeking care are also highlighted, where emphasis is placed on users’ difficulties in communicating and scheduling appointments to achieve continuity of care, since some procedures, diagnostic tests, medications, and appointments with specialists are not available when required [9]. A study with subsidized regime users living in a rural area highlighted the economic and administrative obstacles to achieving access to health, delays in medication acquisition, and incomplete dispensing of medication, leading to people incurring expenses or abandoning treatment [12].

There are few precedents in the world regarding BHCA for pregnant women. A study conducted in Winnipeg, Canada, highlighted transport problems, lack of family and health support, short time to medical consultations, negative behaviour and attitudes of health workers, shortage of health workers, and long distances and waiting times [13]. In three rural towns in northern Argentina, the main BHCA were geographical, economic, and administrative problems [14]. In Antioquia, Colombia, a qualitative study reported that the main BHCA for pregnant women were the lack of experience of health personnel, lack of availability of specialized personnel, distance from the hospital, and lack of diagnostic aids [15].

Specifically, in pregnant women from endemic regions, quantitative studies have reported major barriers for using insecticide-treated nets (ITNs), 40% did not perceive the need to use them, and 60% referred discomfort and high heat [16]. Other authors have reported the cost of preventive methods (especially ITNs) [17]. Barriers to intermittent preventive treatment (IPT) included medication stockouts, late attendance to ANC, lack of autonomy among pregnant women, lack of knowledge about GM prevention, affordability, health education, trust in health system, and monetary resources [18]. The following barriers have been reported in systematic reviews: adverse events of preventive treatment for GM [19]; to prevent malaria in HIV-positive pregnant women with mefloquine and other drugs, the main barriers are the increased risk of HIV transmission to the fetus and poor drug tolerability [20]. Qualitative evidence from community members reported poor knowledge about prevention, allergic reactions to chemicals used for ITNs, unaffordability of insecticide sprays, and inaccessibility to other methods [21].

Previous studies revealed that in Colombia BHCA for pregnant women exposed to malaria have not been investigated, that the barriers reported in other populations are heterogeneous in their typology and magnitude, and that the research performed covered only a part of these barriers because the studies used either qualitative or quantitative approaches. Therefore, this study was conducted with the objective of analysing BHCA in pregnant women at risk of GM in northwest Colombia by means of a mixed study.

Methods

Type of study

Sequential QUAN-QUAL mixed study. QUAN component was a cross-sectional study, and from its results, the QUAL component was structured based on Straus’s grounded theory. For the topic of this research, this method is pertinent because it combines inductive and deductive elements to generate theories with a versatile, systematic and structured analysis of open (description), axial (conceptual ordering) and selective (theorization) categorization. The theory is defined as concepts related that emerge from experiences of social actors, to generate new explanations for the disease adjusted to the specificity of each sociocultural context [22].

The QUAN component was implemented to recruit a large sample size and ensure sample representativeness, to show statistical trends on the magnitude or proportion of pregnant women affected by the main BHCA reported in previous studies in Colombia, and to identify the main associated factors or subgroups most affected by these BHCA. The QUAL component was used to delve deeper into the explanations for the presence of the BHCA quantified in the previous component, to identify other BHCA that emerged from the experiences of social actors, and to understand the social, economic, cultural and political determinants of the BHCA in pregnant women.

Mixed studies combine quantitative and qualitative methods to collect, analyse, and integrate data in a systematic, empirical, and critical manner. Overcome the limitations and enhance the strengths of both approaches to better understand of the phenomenon, and perform meta-interferences [23, 24]. Applied in public health, in mixed studies the topics of study can be assumed in a transdisciplinary way, address the complexity of factors that influence health, enrich traditional epidemiology; evaluate practices, programmes, interventions, and policies in public health; and improve the understanding of causal mechanisms [25,26,27,28]. In GM mixed studies promote the understand of the complexity and diversity of the factors that determine the disease [29].

Study location

The research was conducted in the department of Córdoba, the municipalities of Puerto Libertador and Tierralta, which are endemic for malaria and have poor health and socioeconomic conditions, characterized by deficiencies in waste collection, water, and sewage services; absence of continuous water supply, houses with deteriorated structures, and palm roofs. Regarding socioeconomic characteristics, agricultural and mining activities predominate, with several victims of displacement from rural to urban areas due to armed conflict. In terms of environmental conditions, these municipalities have a warm climate with heavy rainfall throughout the year, which favours the presence of stagnant water, floods, and humidity [30].

According to the epidemiological bulletin of NIH in 2024, Córdoba is a department in Colombia with the second highest number of cases of uncomplicated malaria and the third highest number of complicated malaria; the municipalities with the highest number of reported cases are Tierralta and Puerto Libertador; those municipalities are in a situation of malaria outbreak with a risk stratum five where Tierralta is the municipality with the most reported cases in the country so far this year [31].

Subjects of study

The cross-sectional research was conducted with 400 pregnant women who completed the socioeconomic survey and BHCA, they were selected by sampling was non-probabilistic when attended ANC. From this group, 28 pregnant women were selected for maximum variation (it allows to obtain a wide range of perspectives in the narratives of the interviewees, selected with varied characteristics, in this case, wide age range, various health affiliation regimes and different residential areas) and theoretical saturation (no additional topics emerge, all categories are identified and completed). An interview was also conducted with eight health workers of the ANC programmes, emergencies, promotion and prevention department, and malaria control. In both components the eligibility criteria were as follows: permanent residence in the municipality, attendance at the local hospital's ANC, not having a diagnosis of gynaecological or obstetric diseases or complications that prevented them from answering the survey or attending the interview, acceptance to participate voluntarily in the study and signing the informed consent or assent.

Data collection

The design of the measurement instruments began with the identification of the barriers described in previous studies in the Colombian population [2, 12, 15, 32,33,34,35,36] (Table 1). In the QUAN component, a face-validity of the survey was applied to characterize the population and evaluate the main BHCA. Face-validity of the survey included two criteria: i) applicability according to five experts with more than 10 years of experience in epidemiological studies on malaria, with knowledge of the study area (executed previous research in this region of Colombia) and with knowledge of the healthcare model for pregnant women in the Colombian health system. and ii) acceptability with 20 pregnant women of the study sample who endorsed the questions, the design of the survey, the clarity of the items, the simplicity of answering it and the absence of ambiguities. The diagnosis of GM was extracted from the medical chart of the pregnant women who had the result of a thick blood smear. The sociodemographic and economic description included the following variables: age group (14–19, 20–28 and 29–44 year old), level educational (primary, secondary, technical-professional), occupation (housewife, other), origin (rural, urban), number of pregnancies, poverty level according to Unsatisfied Basic Needs (this indicator includes housing built with inadequate materials for roofs, walls or floors, with overcrowding, inadequate sanitary services, economic dependence on the head of the household and school-age children who do not attend school).

Table 1 Barriers to healthcare described in previous studies

In the QUAL component, semi-structured interviews were conducted to investigate BHCA perceived by pregnant women and to describe the specific barriers to the prevention, diagnosis, and treatment of GM based on those identified in the QUAN component. These were complemented with interviews to health workers who lead malaria control or ANC initiatives (doctors, nurses and microscopists). The interviews were complemented by non-participant observation at local hospital and malaria diagnostic posts. One researcher (JACA) conducted the interviews and field immersion and filled out the field diary with reflective, theoretical, and methodological notes.

Information analysis

Nominal and ordinal variables were described using frequency analysis, whereas quantitative variables were described using summary measures, specifically median and interquartile ranges, given their non-normal distribution. The normality of the data was assessed using the Kolmogorov–Smirnov test. Based on these results, bivariate analysis was performed using the Mann–Whitney U test, the Kruskal–Wallis H test, and Spearman correlation. A linear regression model was performed to identify possible confounding variables, with the number of BHCA as the dependent variable. The analyses were performed using SPSS version 29.0.

In the qualitative component, all the discursive material was transcribed for subsequent hermeneutic analysis with pre-established categories BHCA and GM control, using open, axial and selective categorization. This analysis was performed by three researchers, for this purpose the following constructs were established: (i) category: name and group the testimonies that refer a particular characteristic or a common concept; (ii) properties: characteristics of a category that show its nuances and allow its specificity and meaning to be defined (attributes that delimit the content of each category); and (iii) dimensions: represents the location and variations range of a property.

Ethical considerations

The ethical principles of the Declaration of Helsinki and Resolution 8430 of Colombia were applied. The study was classified as minimal risk and was approved by the Ethics Committee of the SIU (University Research Headquarters), University of Antioquia. The participants provided informed consent (of legal age) or assent (under 18 years of age), which was obtained in writing and was also signed by a witness (external to the research group) and a member of the health team who explained its content. In cases where possible, parental consent was obtained; however, according to rulings C-246/17 and T-675–17 on Self-determination of minors, the Constitutional Court of the Republic of Colombia in 2017 determined that parental consent is not necessary in these cases given that at 14 years of age, it has been established that minors can have the maturity to begin to assume obligations and responsibilities in society, such as marriage, consent to sexual relations and the right to privacy in the family environment.

To mitigate possible impacts on the principles of justice, autonomy, beneficence and non-maleficence, generated by cultural, economic and other asymmetries among the community and research team, prior to the execution of the study an immersion in the field was conducted to identify leaders recognized and respected by the community, who coordinated all the field work and mediated relationships with the pregnant women, especially the most vulnerable (incl. young, low-school, low socioeconomic status).

Results

QUAN component

In the study group, the highest proportion were young pregnant women (45.5%), with a secondary educational level (79.5%), one-two pregnancies (53%) and poor according to the Unsatisfied Basic Needs (UBN) index (84.2%) (Table 2). The majority were affiliated with the subsidized health regime (97%), housewives (93%) and few were students (2%) or employees (5%). The main BHCA were delays in receiving medical care (93%), appointments with specialists (89%) and procedures with HPE (84%); the least frequent were the delivery of medications (23%) and the quality of care (23%). All pregnant women reported at least one BHCA, 50% reported between 7 and 11 BHCA, and 50% of the central data reported between 5 and 8 BHCA (Table 3).

Table 2 Socioeconomic characteristics of the study group

Table 3 Barriers to access to healthcare in the pregnant women studied

The prevalence of GM was 5.5% (n = 22) by thick blood smear performed during ANC. The BHCA number did not show statistically significant differences with the following variables: positive thick blood smear (p Mann–Whitney U = 0.534), health insurance plan (p Mann–Whitney U = 0.130), home overcrowding (p Mann–Whitney U = 0.503), living in a home without adequate sanitary services (p Mann–Whitney U = 0.212), age (p Spearman's Rho = 0.855), educational level (p Spearman's Rho = 0.948), number of abortions (p Spearman's Rho = 0.863), and number of UBN (p Spearman's Rho = 0.113) [data are not included in tables because all subgroups of these variables presented similar BHCA number].

The factors associated with BHCA number were occupation (higher in housewives), pregnancy (higher in multigravida), and poverty due to inadequate housing conditions (highest in those with this UBN) or economic dependence (highest in those without this UBN (Table 4).

Table 4 Factors associated with barriers to health care

QUAL component

Table 5 shows the main categories and subcategories of the QUAL component.

Table 5 Categories and subcategories of QUAL component

Sociocultural and economic barriers

The different actors refer to various problems, including the difficulty in arrive to health centers, mainly for pregnant women who live in rural areas and must travel long distances, often using different means of transportation, which increases the cost of travel, and it is an obstacle to entering the ANC, adequate diagnosis, prevention of GM and follow-up of pregnant women. Some testimonies have expanded on this problem:

“Our dispersed rural population is quite large, more than 60%. We have many villages and townships in very dispersed and remote areas, six or eight hours from the urban zone. We have communities that travel part of the path on foot or on horseback, another by water [boats / canoes] or motorcycle, another part by bus or car. We have quite dispersed communities that are three or four hours away by vehicle, such as a motorcycle. This made it difficult for many of our malaria cases, which are in dispersed rural areas to reach the urban zone and access the hospital. And considering the economic factor, the low economic affordability that many people have to travel to the hospital, then that impacts their poor health” (testimony of a physician, man, 35 years old).

In relation to economic problems, not only the costs of travel were mentioned but also the costs of care health, where some pregnant women do not have the necessary monetary resources to undergo the different tests, mainly the thick blood smear, since in some cases they must pay for them themselves, as evidenced in the following testimony:

“Pregnant women sometimes come here [to the malaria clinic] and ask me: look, girl, tell me how much a thick blood smear costs, I tell them ten thousand [approximately 3 US dollars]. They roll their eyes and continue without returning. Some do it, others don't, others don't even come or come even once in the entire pregnancy. Because doctors and bacteriologists send them here. But most of them don’t have money” (testimony of a microscopist, woman, 40 years old).

These costs of care can be increased by changes in HPE or points of care, which implies an extra cost for care providers and pregnant women, because they state that many times, they do not make the transfer in an adequate manner, or that it is a very long process for which one of the two parties must end up paying for the care. This situation was reflected in the following testimonies:

“That is a serious problem for the maternity program, and it is the issue of mobility. Today I am here, tomorrow I am going to another municipality, or I am moving to another place, and I do not make a transfer from HPE. I didn't perform portability, and I did not do any of that. We from the hospital cannot deny care, but we know that no one is going to pay us for that care, and that can affect the hospital's finances” (testimony of a nurse, man, 46 years old, promotion and prevention program coordinator).

“Until now I was behind with the controls, so I was from Emdisalud [an HPE], and now they transferred me to Mutualser [an HPE], but it appeared in another municipality. So they could not visit me here. For the baby's urgent exams, I had to pay for them out of pocket. It’s a very hard time for me because I still don’t have all the care here. I have to go to the Hospital in my municipality of residence, and others in Montería [capital city]. So far I haven't had all the exams because I don't have the money to go to Montería. So far, the HPE hasn't recognized anything for me. So since I don't have money, everything is difficult for me in my health, in my appointments, in the baby health" (testimony of a pregnant woman from a village, 24 years old).

Other problems related to the sociocultural sphere include the normalization of malaria by the affected population, which means that the affected population may not fully understand the magnitude of the disease, mainly in pregnant women. As a result, they do not take adequate preventive action, leading to self-medication when they experience symptoms associated with the disease. In some cases, the patient does not even consider medical attention necessary. The latter is also seen in indigenous communities, due to their culture and beliefs, they do not attend ANC or medically assisted births, because they prefer care from midwives, reducing the coverage of ANC.

“People have become accustomed to it: do you experiencing intermittent fever? That is malaria. That is normal for the community; they know that it can happen to them and that it can recur. So, in that normality they got used to not paying attention to it, they got used to that disease, and that is why it stopped being important for the community” (nurse testimony, woman, 32 years old, maternal emergencies).

“We have pregnant women who do not consult for antenatal care and are only seen during childbirth. Many pregnant women did not participate in the program. There are many indigenous reservations, and one of the biggest problems in ANC is the indigenous population. Due to cultural considerations, these indigenous communities do not attend ANC, and their births are conducted traditionally in their communities with midwives. In addition, the hospital does not have direct contact with midwives. The issue with indigenous communities is that pregnant women generally arrive here with the gestational product, seeking to legalize the entire issue of the child’s civil registry, and receive the live birth registry” (testimony of a nurse, woman, 52 years old, ANC coordinator).

Underfunding and evasion of responsibilities by health system actors

A major problem is the lack of funding for the Social Development Secretariat, which is responsible for managing different areas, including health, to ensure social equity. This makes it difficult to redistribute public money in different areas, and ensure that it is sufficient to meet the needs of the population. This directly affects the health budget; in addition, there is only one official in charge of managing the multiple functions of the Social Development Secretariat.

“The Social Development Secretariat is an entity, a department that is in charge of education, health, sports, culture and vulnerable populations. It is much things for a single official”… “Regarding vulnerable populations, these are the populations: indigenous people, displaced population, elderly people, abandoned children. Everything must be done with scarce money” (testimony of an employee of a municipal social development secretariat, man, 50 years old).

Another problem is the evasion of responsibilities by different actors, where none of the parties wants to assume the responsibilities associated with health care, delegating their functions to other actors, thus evidencing a lack of commitment, which ultimately affects the quality of care.

“We all know that in this model of healthcare in Colombia, there is medical auditing, and medical auditing consists of taking money from each other [HSPI vs. HPE]. So, thinking about glosses and those issues affects care” (testimony of a doctor, man, 29 years old).

“They take the blame, the health department says that it is the hospital's responsibility, and the hospital says that they are not responsible for that” (testimony of a medical coordinator, man, 42 years old).

Deficient prevention and control programmes for gestational malaria

Despite being an endemic malaria area, prevention and control programmes by health or Social Development Departments, hospitals, and other providers are limited; for this reason, pregnant women are unaware of their malaria risks. They do not know about the transmission, prevention, implications, and risks of pregnancy; pregnancy has become normalized within the population, evidencing a huge deficit in public health programmes. This is evident in the following testimonies:

“They should hire more people in the villages. They should also give speeches and raise awareness among the public because it depends on that. For example, there are people who tell you to lie: who told you that mosquitoes give malaria? If mosquitoes gave me malaria, everyone in my village would have it. You get malaria because you get wet with rainwater, or you get it because you bathe in a ravine, or you are weak” (testimony of a pregnant woman, 20 years old, rural area).

“In general, I don't know anything about malaria, and during my checkup, they haven't told me anything about malaria. I know that if I have a fever and a lot of pain and chills, I come here to the clinic and pay 10,000 for a thick blood smear, and it comes out positive, I go to the hospital pharmacy. Otherwise, I don’t hear anything about malaria in this town, and in the area, there is almost nothing like that [referring to actions to control, prevent or treat malaria]” (testimony of a pregnant woman, 18 years old, urban area).

“In rural areas, if people do not hear about malaria from the hospital or the HSPI, they are not likely to think about it. In fact, I could assure you that in the communities of our municipality, there is no health work done, much less in malaria" (nurse testimony, woman, 32 years old, ANC).

Deficiencies in diagnosis and response capacity

The low response capacity of healthcare providers was perceived as a major problem, mainly related to the adequate and timely diagnosis of GM. Despite being an endemic area, major deficiencies regarding personnel of diagnosis, both in quantity and competence, delayed the access to timely treatment.

“I feel that the bacteriologist does not see malaria samples well; they do not perform a good count of parasitemia. I feel that we have many problems for diagnosing malaria in the urban zone, and we practically have nothing for the rural zone” (testimony of a physician, woman, 35 years old).

“Everyone here pays for the thick blood smear. The pregnant women experiencing the right through their HPE to have the thick blood smear done, so why is it not done? Moreover, bacteriologists do not have time because they have too much work to perform eight, nine, ten thick blood smears on pregnant women for a day. All the patients pay out of their own pocket, except the pregnant women who join the University projects, they do not have to pay, otherwise they all have to pay 10,000 COP (testimony of a microscopist, woman, 33 years old).

Added to this, the reduction in the number of microscopists currently hired by the hospitals has led to a deficit regarding diagnosis of GM, especially in these endemic municipalities, where there is no longer or only one microscopist. This indicates a deficit in the capacity of health providers, which has led to microscopists continuing to provide work charging for the thick blood smear. However, the economic difficulties previously expressed by pregnant women means that many cannot access this service.

“Previously when the Government hired us, there were practically microscopists in all districts. There were no cases in the same district but in nearby villages, that is, enough to cover the entire territory. However, since 2008 the Government said: this is no longer our responsibility; it is up to each hospital hire its microscopists. Although I know that in other municipalities the hospital has its microscopists in the most endemic areas, for example I know that in other municipalities, the hospital pays the microscopists” (testimony of a microscopist, woman, 35 years old).

“We have many difficulties in our municipality. For example, here we have patients from Savia Salud [a HPE], but Savia Salud does not have a headquarters in our municipality, so who does we charge for this care. This is where this difficulty comes in. We should discuss the financial issue with representatives of the Government, the HPE, and the HSPI to resolve it. For example, we have microscopists that are volunteers, at the expense of what people contribute to sample collection. However, the microscopists continue to collaborate and have been working on their information responses day after day” (testimony of a coordinator, man, 55 years old).

Lack of knowledge among actors

The absence of malaria control and prevention programmes has led to a lack of knowledge on GM in pregnant women; they unknown their responsibilities to ensure a safe pregnancy and the care of their bodies. In addition, many physicians come to these rural areas to provide mandatory social services, but despite their training, they do not have sufficient strategies to properly monitor pregnant women.

“Until about five years ago, malaria testing was not required for pregnant women. Today, it is requested, but not all of them do it because they forget, because they do not know how to do it from the hospital, and because they do not have the money. Now, there is another problem, many rural doctors come here and they forget to do the GM screening, or they only write in the medical chart that they requested the test but do not bother to check if they did or why they did not do it” (testimony of a doctor man, 45 years old).

“There are many limitations in ANC, but the most important is the lack of knowledge among pregnant women. It is very sad, but it is the truth. You see that the staff in the Local Hospital travels a lot to the villages and makes brigades to identify pregnant women, here there is always a nurse or a doctor who can do the entry to ANC; but unfortunately, there are still many mothers who do not give it the importance it has, not all the controls are done, even women have arrived at birth without a single control. Therefore, there is a lack of knowledge. It happens, like with COVID-19, that people knowingly do not get vaccinated” (testimony of a doctor, woman, 39 years old, ANC)

Given the obvious lack of knowledge on the part of the actors, there is also a poor response capacity in HSPI and HPE; thus, it is difficult to solve problems in providing healthcare. This can be seen in the following testimony:

“Many arrive at the ANC without an ultrasound and say: no doctor, they were supposed to call me, and they didn’t call me. They don't receive psychological or gynecological care. But the doctor is left without knowing if the problem is with the HPE that did not authorize, with the HSPI that has delayed the agenda, or with the patient who did not bring what was needed to receive care” (testimony of a nurse, woman, 32 years old, ANC).

Discussion

In both, QUAN and QUAL components, common BHCA were identified, the paperwork with the HPE, economic issues, and transportation to hospital. Regarding the paperwork with the HPE, the QUAN component was one of the most frequently reported BHCA, affecting 83.5% of pregnant women. In the QUAL component, it was possible to specify that the difficulties were mainly related to authorizations, changes in HPE, portability, and other factors related to changes in residence. This increases the costs of healthcare, that must be assumed by pregnant women, their families, or service providers; which agrees with previous reports in which the procedures with HSPI or HPE are referred to as the most frequent BHCA and are related to an increase in health care costs [9, 12, 32, 33]; these economic aspects also have been documented for specific GM actions such as access to ITN and IPT [17, 18].

This is supported by qualitative evidence from other studies with health workers, managers, technical and administrative staff, users and community leaders, who reported that administrative procedures are not only related to delays and over costs of healthcare, but also lead to non-attendance by users [37], which is serious for the pregnant population where non-attendance ANC implies a great risk of multiple morbid events in the woman, fetus, and newborn. In this regard, it is necessary for the HPE to expand its coverage of contracting services with public or private institutions located in areas where its users reside, thereby avoiding prolonged and costly transfers.

On the other hand, economic BHCA were presented, which in the QUAN component refer to a lack of resources to visit the hospital, which could include aspects such as travel costs, test payment, and co-payments. This was a BHCA reported by 59.8% of those surveyed; in the QUAL component, this perception was expanded to include aspects such as the cost of thick blood smears, the cost of travel, and economic losses due to not receiving timely care given that when timely diagnosis and treatment are not carried out, malaria can become complicated, leading to hospitalizations that increase expenses due to unproductive days for the pregnant woman and her family. This is consistent with the scientific literature for GM [17, 18], and it is one of the most frequently BHCA; for example, a study conducted in Tumaco, a malaria-endemic area in Colombia, reported high health costs attributed to transportation, mainly in dispersed rural areas, since microscopists do not reach them and users must make long and complicated trips, which in turn imply paying for several means of transportation and days off work, which reduces household income while increasing their out-of-pocket health expenses [37]. In addition, another study conducted in Medellín found the following BHCA: cost of services, including copayments, services, medications, and transportation [9]. These economic BHCA not only limit access to healthcare services but also aggravate malaria transmission by delaying timely diagnosis and treatment. To mitigate these effects, health authorities should provide transportation subsidies and free essential tests, such as blood tests, for vulnerable populations and those far from urban zones. Furthermore, it would be advisable to implement policies that facilitate the mobilization of health teams to rural areas and guarantee equity in access to health services [9].

Likewise, another BHCA reported in both components was transportation. In the QUAN component, travel times longer than one hour affected 43% of respondents. However, in the QUAL component, it is evident that these trips can last up to eight hours to access an urban zone. In addition to the fact that travel times are not only long but also require the use of various means of transport, high health costs, discomfort, and risks to maternal and fetal health. A study on febrile malaria patients in El Bagre, Antioquia, suggested that users who live in such remote areas should consider that their hours of attention coincide with their transport schedules. Added to this is the BHCA of the aforementioned paperwork, since it also implies long wait times to access services that include medical appointments, examinations, and treatment, which mostly affects the population furthest from the hospital [38]. In addition, the shortage of rural transportation routes leads to non-attendance at medical appointments because pregnant women arrive late or, in many cases, prefer not to travel to the hospital because they know that they will not be able to attend the medical appointment on time, which affects their medical follow-up [39]. These findings highlight the need to promote home care services in vulnerable and remote populations. It is also necessary to simplify the processes with strategies such as automatic renewal of orders for appointments or examinations in cases where the HPE was late in assigning the service, without the need for the patient to travel just to generate a new order, in addition to promoting virtual and telephone communication to inform about the availability of medications and give priority to vulnerable patients, all of which are accompanied by clear and simple instructions so that they can be understood by patients.

In the QUAN component, a high frequency of delays in receiving medical care (61%), appointments with specialists (89%), long waiting times for care (93%), and delays in authorizing appointments with specialists (88%) and laboratory tests (63%) were also noted. All these BHCA demonstrate a deficit regarding provision of services, which is consistent with a previous study in which a significant BHCA was reported in the capacity of the system to respond to user needs, primarily regarding portfolio of services, their availability, and schedule [9]. All these BHCA are part of the offer and involve service administrators (HPE) and the service providers (HSPI). The HPE presents BHCA mainly related to delays and long waiting times, whereas the HSPI has barriers regarding timely assignment of appointments, the offer of services, waiting times, and the capacity to respond to demand, whether regarding human resources, supplies, or infrastructure [9].

A systematic review of BHCA related to ANC found that long waiting times were a determining factor because they generate frustration and demotivation when seeking care [35]. These BHCA represent an obstacle to timely care for pregnant women, can lead to complications during pregnancy, and experiencing negative consequences on the health of the infant [40].

Another BHCA to highlight is the difficulties associated with medication delivery, which was reported by 23% of pregnant women. This finding coincides with a study conducted in a rural zone of Antioquia, where access to medications was reported as the most significant BHCA, because access involves long lines that do not guarantee full access. The availability of these medications is limited in rural areas; thus, users must travel several times to obtain complete formulas, which increases the cost; for this reason, many patients choose to buy or give up treatment [12]. Another study conducted in Pereira on individuals with disabilities reported difficulties in medication delivery associated with authorization, long waiting times, costs, distances, and time to medication claim [33]. This situation has also been described in GM [18]. These complications regarding delivery of medications increase different risks of morbidity for the health of pregnant women because the lack of timely access to these treatments can lead to complications during pregnancy, mainly in diseases such as malaria [41].

The last BHCA reported in the QUAN component were poor quality of care provided by clinic staff (27.8%) and HPE (22.8%). This BHCA is determinant in the assessment of services provided by pregnant women. In a study conducted on 17 pregnant women with maternal external morbidity from Medellín, poor quality of care was found, mainly related to the inexperience of health workers, and the lack of empathy at the time of care [15]. Insensitive and depersonalized care gives patients a feeling of insecurity, which reduces their credibility with the healthcare system and health workers [42]. Therefore, it is essential to make institutional efforts to humanize health services by increasing the duration of medical appointments so that they are not performed in a rushed and depersonalized manner, in addition to promoting sensitivity and friendly treatment by professionals regarding routine care of mothers, which would facilitate communication and adherence to health care [42,43,44].

Regarding the QUAL component, BHCA related to the culture and beliefs of pregnant women were found, mainly in indigenous communities that practice traditional medicine, excluding ANC, examinations, and treatments offered at hospitals. Other studies have identified this type of BHCA for indigenous peoples, where the main obstacle is the lack of knowledge of health workers about the perception of health-disease process in these communities, that triggers a lack of understanding in health team as well as exclusion and inequality in access for indigenous peoples [45]. For the access and use of GM preventive methods, these types of sociocultural BHCA have also been found, highlighting the following: discomfort with ITN, distrust in health system, lack of autonomy, distrust in the use of medications and vector control with chemicals due to their adverse effects on health [16, 18,19,20,21].

In addition, a study conducted Guapi, Colombia showed the normalization of malaria by the population in these endemic areas. This has consequences ranging from the lack of prevention to practices such as the evasion of care and self-medication, which can have health consequences, especially in pregnant women, because the lack of adequate care and treatment can lead to pregnancy-related complications [46, 47]. To address this BHCA, it is essential that health policies have an intercultural approach that includes both training health worker on indigenous traditions and awareness programmes for these communities to promote access to traditional medical care, so that mistrust is reduced and access to ANC, prevention, and treatment of diseases such as GM can be improved [48].

Another BHCA is deficits in financing and evasion of accountability. This deficit is evident in general in the Colombian healthcare system, in which state regulation and financing have been reduced, affecting the response capacity of healthcare providers, while the segmentation and decentralization of functions and responsibilities facilitates the evasion of responsibility by some actors in the system [49]. Therefore, policies must be implemented that promote an increase in the government’s budget for healthcare, allocate resources fairly to rural and endemic areas, guarantee continuity in care, and grant incentives to healthcare providers that provide adequate levels of care. Strengthening supervisory systems is essential to ensure proper use of resources and compliance with care protocols, with effective sanctions for institutions that do not fulfill their duties, to reduce structural failures and improve the quality of services [50].

There is a BHCA centred on the deficit in malaria prevention and control, since prevention policies have not been able to mitigate the spread of the disease, and the deficit in health promotion is evident in the testimonies of pregnant women and health workers. These findings highlight the lack of education on malaria transmission and prevention, which has led to a normalization of the problem in affected communities, an erroneous perception about the causes of malaria, and the absence of effective public health programmes. This indicates an urgent need to strengthen epidemiological surveillance, implement more robust awareness campaigns, and promote changes in social behaviour. This perception is consistent with a systematic review on malaria control in public health management, that highlights the need to increase efforts for malaria surveillance, control and promotion to reduce the number of cases, since the deficiency in these programmes contributes to the lack of significant decreases in the prevalence of malaria. In addition, health policies must include promotion strategies that motivate communities to actively participate in disease prevention and control even in the context of social crises and limited economic resources [51].

Likewise, the QUAL component highlights a deficit in timely MG diagnosis due to limitations, such as the shortage of trained microscopists and staff workload, that makes it difficult to correctly perform thick blood smears. The lack of human resources in hospitals, especially in rural zones, worsens the situation, and the charge for this service in some areas intensifies the previously described economic problems. Other studies show that this limitation could be due to the lack of training and experience of the staff, while other authors reaffirm that it is vital to ensure the continued hiring of this staff, who are a fundamental human resource in the early diagnosis and timely treatment of malaria, mainly in rural and difficult-to-access areas [46, 52]. This situation reflects a structural deficit in the health system, where the lack of coordination between providers and insurers, together with the reduction in the number of hired staff, compromises access to an adequate and timely diagnosis, which could lead to the development of complications of GM.

Finally, the lack of knowledge on the part of the actors was also an important aspect to highlight in the QUAL component. This widespread lack of knowledge about GM among pregnant women, coupled with the lack of effective care programmes, represents a serious obstacle in endemic rural areas. This lack of knowledge also extends to the administrative procedures of the HPE and HSPI, that delay treatments and diagnosis, negatively affecting medical care. These problems are exacerbated when patients do not receive the necessary guidance on the importance of the tests or encounter economic BHCA, indicating the urgent need to improve health education and the response capacity of health services in these regions [40, 42].

To mitigate these BHCA, it is essential for both the HPE and HSPI to implement strategies to improve the efficiency of the system, primarily in terms of the authorization of services and their assignment. To do this, the health budget must be increased and policies implemented to increase human resources and infrastructure to meet the high demand and reduce times, which could improve the adherence of pregnant women to ANC. Likewise, it is necessary for health authorities to improve the distribution of medicines, mainly in rural areas, by increasing distribution points or implementing home deliveries for the most vulnerable population and ensuring access and adherence to treatment. These actions, together with awareness campaigns and inter-institutional collaboration, could effectively reduce the prevalence of GM.

The limitations of the study include the impossibility of apply a probability sampling because there was no sampling frame for pregnant women; the statistical associations are exploratory; in the QUAL component it was not possible to include health workers from other hospitals with greater healthcare complexity where other BHCA could be detected.

The main practical recommendations are the following: (i) at the individual level, health education, communication or training programmes should be improved to overcome barriers such as the normalization of malaria, low perception of risk, self-medication, low attendance at health centers in some communities, low knowledge among pregnant woman and health workers; (ii) at the institutional level, the quantity and quality of resources for the prevention, diagnosis and treatment of GM must be increased, active epidemiological surveillance actions must be implemented, primary health care teams must be formed to travel to areas of greatest endemicity, and more humanized healthcare must be promoted; (iii) at the community level, to implement educational actions and budget allocation to manage vector control actions, early diagnosis and timely treatment by community leaders; (iv) at the structural and public policy level, it is necessary to increase the budget for the malaria control programme, articulate health actions with policies to improve the economic situation of poor and vulnerable families; and (v) strategies to articulate the previous levels must be applied, it is crucial Primary Health Care activities focusing on Integrated Health Service Networks and Community-Oriented Primary Care to optimize the healthcare response in vulnerable regions, to empower the population in managing their health, enabling the design of health education strategies tailored to local needs and community characteristics, and significantly reduce BHCA.

Conclusion

A high frequency of BHCA for pregnant women exposed to GM was found, the subgroups most affected by this problem were identified, and some sociocultural and economic explanations for this problem were explored in depth. This is important for expanding the health action axes of malaria control programmes and improving the care of pregnant women and their quality of life.