Barriers to seeking consultation at public service and medical facilities among pregnant and postpartum women in Japan: a cross-sectional study

Introduction

Universal health coverage, defined as “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship (World Health Organization, 2024),” is key to achieving Sustainable Development Goals 3: “Ensure healthy lives and promote well-being for all at all ages” (United Nations, 2015). Women and children are particularly vulnerable regarding access and utilization of essential healthcare. Approximately 47,000 mothers and 423,000 newborns in low- and middle-income countries died due to a lack of healthcare utilization (Kruk et al., 2018). Although most maternal and newborn deaths occur within the first month after childbirth in these countries (Lawn et al., 2014; Say et al., 2014), depression and anxiety are common morbidities during pregnancy and the postpartum period globally (National Institute for Health and Care Excellence, 2014; Vogel et al., 2024), which can impede mother-to-child interactions, maternal care, and child development (Slomian et al., 2019). Therefore, ensuring women’s access to healthcare services for family, parenting, and child health issues is important from pregnancy through the early and late postpartum periods.

Poor access to healthcare services for women is not always caused by healthcare system failures but often stems from women’s low capability or motivation to seek care. A review study reported major reasons for not seeking health care services: women tend to accept problems as part of normal motherhood, fear negative judgment, and face societal norms that often normalize maternal health issues (Rouhi et al., 2019). Studies conducted in low-, middle-, and high-income countries have reported various barriers and disparities in women’s access to healthcare services, including age, ethnicity, healthcare costs, recognition of danger signs, transportation arrangement, and accessibility to a health facility (Lassi et al., 2019; Mi et al., 2022; Wilcox, Levi & Garrett, 2016). While the concept of access to healthcare services remains complex, a previous study proposed a framework with five dimensions (approachability, acceptability, availability and accommodation, affordability, and appropriateness) and five abilities that enable a person to access healthcare (the ability to perceive, seek, reach, pay, and engage) (Levesque, Harris & Russell, 2013).

Japan has an established healthcare system offering public health and medical services to women and their children at low costs. Women receive maternity care from pregnancy through delivery and up to 1 month postpartum at medical facilities, with expenses subsidized by the local government. Children receive home-visit health checks and regular checkups at pediatric clinics or public health facilities until 3 years of age (Ministry of Health Labour and Welfare, 1998). They also receive medical services under health insurance, supplemented by local government subsidies (Children and Families Agency Government of Japan, 2023) and various childcare support services provided by the local government (Children and Families Agency Government of Japan, 2022). While maternal and infant mortality rates are low, maternal mental health remains a critical public health issue. For example, a meta-analysis reported the period prevalence of prenatal depression at 14.0% in the second trimester and 16.3% in the third trimester. The period prevalence of postpartum depression was 15.1% in the first month, 11.6% at 1–3 months, 11.5% at 3–6 months, and 11.5% at 6–12 months after birth (Tokumitsu et al., 2020). During the COVID-19 outbreak, maternal depression was observed in 30.3% of pregnant women and 24.2% of postpartum women (Chen et al., 2023), with mother-to-infant bonding difficulties at 26.1% (Chen et al., 2024). This suggests that women may encounter family and parenting issues, leading to subsequent mental health problems. However, access to public services or medical facilities for consultation has not been thoroughly investigated.

Therefore, this study aimed to (1) identify the characteristics of women associated with refraining from seeking consultation at public service or medical facilities and (2) examine reasons why women refrain from seeking consultation at these facilities.

Materials & Methods

Results

Table 1 presents the basic characteristics of the 7,326 women included in the analysis. Among these, 11.9% were experiencing their first pregnancy, 41.9% had one child and were in the postpartum period, 7.2% had one child and were pregnant, and 35.8% had two or more children and were in the postpartum period, and 3.4% had two or more children and were pregnant at the time of the survey. The top three current concerns of women were parenting, financial issues, and jobs, at 60.4%, 54.3%, and 50.5%, respectively. Regarding study outcomes, 8.6% refrained from seeking consultation at public service facilities, whereas 5.1% refrained from seeking consultation at medical facilities.

Women’s characteristics associated with refraining from seeking consultation at public service facilities were those who had one child and were in the postpartum period (aOR 2.07, 95% CI [1.51–2.86]) and those who had two or more children and were in the postpartum period (aOR 1.50, 95% CI [1.08–2.10]) relative to first pregnancy with no child, low health literacy (aOR 1.20, 95% CI [1.01–1.41]), having a non-supportive partner (aOR 1.71, 95% CI [1.34–2.18]), current depression or psychiatric disease (aOR 1.82, 95% CI [1.22–2.72]) and current disability (aOR 2.13, 95% CI [1.19–3.81]) (Table 2). Women’s characteristics associated with refraining from seeking consultation at medical facilities included educational attainment of high school or lower (aOR 1.38, 95% CI [1.07–1.78]), those who had one child and were in the postpartum period (aOR 1.57, 95% CI [1.07–2.30]) relative to first pregnancy with no child, low health literacy (aOR 1.42, 95% CI [1.14–1.76]), having a non-supportive partner (aOR 1.71, 95% CI [1.27–2.31]), and current disability (aOR 2.34, 95% CI [1.16–4.71]).

Among women who refrained from seeking consultation at public service facilities (n = 627), the top five reasons were “difficulties in taking the child to the consultation” (35.1%), “uncertainty about the seriousness of the problem” (31.7%), “not knowing where to seek help” (28.6%), “time constraints” (27.1%), and “skepticism about the problem’s solvability through consultation” (25.7%) (Fig. 1).

Among women who refrained from seeking consultation at medical facilities (n = 375), the top two reasons were the same as for public service facilities, “difficulties in taking the child to the consultation” (21.9%), “uncertainty about the seriousness of the problem” (20.5%), followed by “skepticism about the problem’s solvability through consultation” (19.5%), “hesitancy or reluctance” (19.2%), and “not knowing where to seek help” (17.3%) (Fig. 2).

Discussion

In summary, 8.6% had refrained from seeking consultation at public service facilities, and 5.1% had refrained from seeking consultation at medical facilities. Four common factors associated with refraining from both facilities were identified: low health literacy, having a child and being in the postpartum period at the time of the survey, lack of partner support, and current disability. The primary reasons for refraining from seeking consultation were “difficulty in taking the children to the consultation” and “uncertainty about the seriousness of the problem,” with a higher percentage at public service facilities than at medical facilities.

Low health literacy was associated with refraining from consulting at public service and medical facilities. Low educational attainment, an established determinant of health literacy (World Health Organization, 2015), was also associated with refraining from consulting at medical facilities. In Lavesque’s framework of healthcare access, health literacy plays a crucial role in perceiving the need for care (Levesque, Harris & Russell, 2013). Health literacy serves as the foundation for individuals to gather, understand, and use information effectively and access care resources (Ogasawara & Hashimoto, 2020). Women with low health literacy may have an insufficient ability to translate their perceived need to seek help. Notably, “uncertainty about the seriousness of the problem,” “not knowing where to seek help,” or “hesitancy or reluctance” were highly ranked reasons why women refrained from visiting these facilities for consultation, which may indicate low health literacy. Therefore, public service and medical facilities should offer prenatal education on the importance of seeking help, provide information on where and what kinds of issues women can consult about, and create facility environments that women can visit without hesitancy or reluctance.

Women who had at least one child and were in the postpartum period at the time of the survey were less likely to seek consultation at both public service and medical facilities than women in their first pregnancy. The perceived difficulty of bringing their child(ren) to consultation emerged as the primary reason women refrained from seeking consultation at public service and medical facilities, highlighting childcare responsibility as a barrier to accessing services (Bina, 2020). Online medical consultation became widely available in Japan in April 2020 (Ministry of Health Labour and Welfare, 2020), which improved access to medical services. Conversely, public service facilities are fewer in number than medical facilities, and their consultation services are generally available only on weekdays. Online consultation services provided by public health facilities may help more women seek consultation when they perceive the need. Furthermore, among women with at least one child, those with one child were more likely to refrain from consultation than those with multiple children. This result may represent a difference in parenting experience and knowledge of maternal or child health problems between women with one and those with more children. Similar results have been reported previously (Brembilla et al., 2018).

A lack of partner support was also associated with refraining from consulting at public service or medical facilities. Levesque’s framework for access to healthcare highlights that social support plays a critical role in seeking and reaching healthcare (Levesque, Harris & Russell, 2013). Male partners are frequently identified as the primary decision-makers in seeking treatment for women’s distress (Fonseca & Canavarro, 2017) and are instrumental in encouraging them to seek help (Fonseca & Canavarro, 2017; Rouhi et al., 2019). Consequently, women who lack support from their partners may have difficulty accessing public health and medical services. Particularly for women who refrained from consultation due to the challenges of taking their children together, partner support as a caretaker of their children may mitigate this barrier to seeking consultation.

Finally, women with disabilities are more likely to refrain from both public service and medical facility visits for consultations. Additionally, women with depression or psychiatric disease were more likely to refrain from seeking consultation at public service facilities. Disabilities and mental health issues are common characteristics of vulnerable populations (Grabovschi, Loignon & Fortin, 2013; Midboe et al., 2020). The impact of disability on access to consultations may vary by type of disability or mental illness. However, this study did not distinguish between mental disability, developmental disability, visual impairment, hearing impairment, and physical disability owing to the small number of women who reported having each disability. Further investigations to assess disability-specific barriers to accessing consultations would be worthwhile.

Our study had some limitations. First, this study used an online survey that involved registered panels pooled by an Internet survey agency. The study sample was limited to those with internet access and registered panelists. Further, 9.0% of participants were excluded from the analysis due to providing irrelevant or contradictory responses. Second, women who were the most vulnerable in accessing consultation might not have participated in this study owing to lack of internet access, low literacy, being occupied with parenting, or poor physical or mental health conditions. For these reasons, the study sample may not represent the general population, affecting the generalizability of the study findings. Third, we did not assess the specific details of family or parenting issues that women wanted to consult about but refrained from seeking consultation. The absence of this data may limit the interpretation and implications of our findings. Fourth, we might have missed some critical barriers or reasons for refraining from seeking consultation, as we assessed them using a quantitative approach. A qualitative study exploring barriers and reasons not assessed in this study will be worthwhile. Despite these limitations, our study findings provided critical insight into what medical or public service facilities should consider and how they should improve services to help women overcome barriers to seeking consultations.

Conclusions

This study revealed that women were less likely to seek support for family and childcare issues, especially under conditions of low health literacy, having a child(ren), lack of partner support, current disability, depression, psychiatric disease, and lower educational attainment. Healthcare workers at public service and medical facilities, central to the community safety net, should provide prenatal education on seeking consultation and pay special attention to these vulnerable women. Furthermore, online consultation systems and facility environments that reduce women’s perceived barriers to seeking consultation may encourage their proactive seeking of help.

Supplemental Information