Navigating challenges in access to antenatal and intrapartum care: Afghan refugee women’s experiences amidst the COVID-19 pandemic in Pakistan

Background: Balochistan, Pakistan’s most economically and health system-deprived province, hosts a significant portion of the Afghan refugee population. The province’s already fragile healthcare infrastructure faces additional strain due to the refugees. Objective: This study aimed to investigate the barriers to antenatal and intrapartum care seeking among Afghan refugee women in Balochistan during the Coronavirus disease 2019 (COVID-19) pandemic. Design: This study employed a cross-sectional survey approach to assess antenatal and intrapartum care-seeking behavior among Afghan refugee women residing in Balochistan, Pakistan. The study focused on refugee women living in Kharotabad Union Council in Quetta city to understand their barriers to accessing maternal healthcare services. Methods: The survey focused on antenatal and childbirth care-seeking behaviors among married women of reproductive age (MWRA) with at least one child aged 12–23 months born during the first four waves of COVID-19 in Pakistan. Results: Of 480 MWRAs, only 36.9% sought antenatal care (ANC); only 13.1% received at least four ANC visits. Furthermore, only 38.8% of MWRA had skilled birth attendance. Only 32.9% of MWRAs received at least one ANC and had skilled birth attendance (i.e., comprehensive care). Accessing comprehensive care was associated with maternal age less than 25 years (adjusted odds ratio (OR): 0.40; 95% confidence interval (CI): 0.21, 0.78), Tajik ethnicity (adjusted OR: 0.40; 95% CI: 0.23, 0.70) and large family size (adjusted OR: 0.58; 95% CI: 0.37, 0.93). Predictors of poor access were concern related to documentation of the refugee women they faced (adjusted OR: 1.52; 95% CI: 1.00, 2.34), women with no one at household to accompany them at health facility (adjusted OR: 1.75; 95% CI: 1.13, 2.70), myths and misconceptions related to available care (adjusted OR: 1.89; 95% CI: 1.18, 3.02), and the transport availability (adjusted OR: 1.76; 95% CI: 1.12, 2.77). Concerns related to COVID-19 had no association. Conclusion: The study highlights the barriers to maternal, neonatal and child health service utilization among Afghan refugee women in Balochistan. Tailoring healthcare services to consider age, ethnicity, cultural dynamics, and system constraints is crucial for improving access.