Factors Influencing Maternal Healthcare Service Utilization Decisions among Homeless Women: A Qualitative Study

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Akuffo, Salome Amissah-Essel, Philomina Y. Anti Kwakye, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8671982/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Homeless women experience significant barriers to access maternal healthcare services. Understanding the factors that shape healthcare-seeking decisions of homeless women is essential for developing responsive services. This study examined factors influencing maternal healthcare service utilization decisions among homeless women in Sekondi-Takoradi Metropolis in Ghana. Methods: This qualitative study employed interpretative phenomenological analysis. Using purposive sampling method, 38 homeless women aged 18-42 years who were pregnant or within the postpartum period were recruited from various locations in Sekondi-Takoradi Metropolis between August and November 2023 for the study. Semi-structured face-to-face interviews were conducted using the Fante language, audio-recorded, transcribed verbatim, and analysed thematically. The study adhered to COREQ guidelines. Results: Four major themes emerged regarding motivations to seek care: pregnancy, illness severity, routine check-ups, and no motivation. When asked about the impact of living conditions on healthcare-seeking desires, 25 participants reported substantial negative effects related to financial constraints, physical exhaustion, and lack of time, while 13 reported no impact. Regarding provider preferences, participants chose doctors, nurses, midwives, pharmacists, while some expressed no preference. Homeless women valued professional qualifications and respectful treatment over provider type. Conclusions and global health implications: Maternal healthcare utilization decisions among homeless women are shaped by their immediate health needs, economic constraints, living conditions, and interpersonal experiences with healthcare providers. Pregnancy emerged as a primary motivator for formal care-seeking, while daily survival challenges often supersede preventive health behaviours. Healthcare systems need to adapt service delivery models to address the vulnerabilities of homeless pregnant women through flexible scheduling, reduced financial barriers, and sensitized provider interactions. These adaptations can improve maternal health outcomes and reduce disparities experienced by homeless women in urban low-resource contexts. homeless women maternal healthcare utilization pregnancy healthcare access Ghana interpretative phenomenology Figures Figure 1 Introduction Maternal healthcare utilization remains a public health concern in many low-and middle-income countries (LMICs). Despite global efforts to improve maternal health outcomes through the Sustainable Development Goals (SDGs), disparities persist among vulnerable populations 1 Homeless women represent an exceptionally marginalized group facing multiple barriers to accessing maternal healthcare services. 2 , 3 In Ghana, where the national maternal mortality ratio stands at 310 deaths per 100,000 live births, homeless pregnant women experience disproportionately worse outcomes. 1 , 4 Recent estimates from African countries suggest that homelessness affects tens of millions of people across the continent, including about 24.4 million people in Nigeria, 12 million in Egypt, 200,000 in South Africa, and roughly 100,000 roofless people in Ghana. 5 Homelessness among women of reproductive age has increased in urban areas across West Africa. In Sekondi-Takoradi Metropolis, Ghana's third-largest city, approximately 6,258 homeless women reside within the metropolitan area. 2 These women engage in street hawking, manual labour, load-carrying (Kayayi), begging, transactional sex, and cleaning work for surviveal. Their daily realities of economic insecurity, lack of shelter, and social marginalization intersect with pregnancy and postpartum care needs, creating complex health-seeking behaviours that health systems struggle to address. 3 , 4 Understanding factors influencing homeless women's decisions to seek maternal healthcare services is essential for designing accessible, acceptable, and effective interventions. Existing research from high-income countries documented that homeless pregnant women face structural barriers, including lack of transportation, inability to afford care, unstable housing, and experience stigma and discrimination from healthcare providers. 4 , 6 , 7 However, limited evidence exists from African context where healthcare systems, cultural norms, and social support structures differ substantially from the Western settings. 6,8 In Ghana, the National Health Insurance Scheme theoretically provides free maternal healthcare services 8 , but homeless women continue to underutilize antenatal care, skilled delivery services, and postpartum care. 8 , 9 Previous research in Ghana examined barriers to maternal healthcare among rural women and women from low socioeconomic backgrounds but has not specifically explored the decision-making processes of homeless women. 8 The intersectionality of homelessness, gender, poverty, and pregnancy creates unique challenges that require specific investigation. 9 This study aimed to examine factors influencing homeless mothers' decisions to utilize maternal healthcare services in Sekondi-Takoradi Metropolis in Ghana. Specifically, we explored what motivates homeless women to seek medical treatment, how their living situations impact their desire for care, and their preferences regarding healthcare providers. Understanding these factors from the women's perspectives could inform development of targeted interventions and service delivery models that better meet the needs of this highly marginalized population. Methods and Materials Design This qualitative study employed interpretative phenomenological analysis (IPA) to explore the lived experiences concerning decision-making of homeless mothers regarding their maternal healthcare utilization. IPA was selected because it allows us to examine how these women make sense of their significant life experiences. 10,11 This approach enabled in-depth exploration of this complex, but subjective factors that shape healthcare-seeking behaviours among these homeless women. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Setting and context The study was conducted in Sekondi-Takoradi Metropolis, Western Region, Ghana, between August 2023 and November 2023. The metropolis covers 191.7 km² with a population of approximately 1,035,000 residents. 2 As a major urban and commercial centre hosting Ghana's largest seaport, the city attracts rural-urban migrants seeking economic opportunities. However, limited affordable housing and lack of employment opportunities have contributed to a growing homeless population. Homeless women in the metropolis typically lack permanent residence, even in harsh weather conditions and rely on informal work for survival. The metropolis has several public health facilities, including the Effia-Nkwanta Regional Hospital, polyclinics, health centres, and private hospitals, all theoretically accessible under the National Health Insurance Scheme. 12,13 Participants The study population comprised homeless women aged 18 years and above who were currently pregnant or within six weeks postpartum and residing in Sekondi-Takoradi Metropolis. These homeless women included women without a permanent home or fixed place of residence, who sleep in public spaces, markets, lorry stations, abandoned buildings, or temporary shelters. Participants were recruited using purposive, convenient, and snowball sampling techniques . 14,15 An assemblyman (local government official) familiar with the area helped identify the locations where the homeless women congregate. The researchers visited these locations during evening hours (6:30-8:30 pm) when the homeless women returned to their sleeping areas, making identification more reliable. Initial participants who met inclusion criteria and consented to participate were asked to refer other homeless women who might be interested in the study, facilitating snowball sampling. 15 Sample size was determined by data saturation, the point at which no new information or themes emerged from the data. To be included in the study, the woman must be pregnant or within six weeks of postpartum at the time of data collection, must be 18 years or older, be homeless, be willing to take part in the study, have stable mental health to give consent. However, they were excluded if they were ill and could give consent. Instrument and procedures An interview guide containing open-ended questions was used for data collection in this study. This guide explored motivations for seeking healthcare, the impact of living conditions on healthcare desires, preferences for types of healthcare providers, and decision-making processes regarding maternal health service use. The interview guide was developed based on literature review 16,17 and was validated by two experts in qualitative research and maternal health before fieldwork commenced. Probing questions were used to elicit detailed descriptions and to clarify participants’ responses. Data were collected through semi-structured face-to-face interviews conducted using the Fante language, the predominant local language in the study area (Supplementary File 1). The first author, who is fluent in Fante, conducted all the interviews to ensure consistency and cultural sensitivity of the data. Each interview lasted between 45 and 90 minutes. Interviews were conducted in private, quiet locations chosen by the participants to ensure confidentiality and comfort, including secluded areas in markets, parks, or near participants' sleeping locations when other women or people were absent. All interviews were audio-recorded with participants' consent. Field notes were also taken during the interviews, while non-verbal cues, contextual observations, and initial analytical impressions were equally captured. Participants were assigned pseudonym or codes (PHN 1 to PHN 38) to protect their identity. Ethical considerations Ethical approval was obtained from the Institutional Review Board of the University of Cape Coast (UCCIRB/CES/2023/165). Permission was also secured from the Sekondi-Takoradi Metropolitan Assembly and the Social Welfare Department. Community leaders in the study areas were verbally informed about the research and their cooperation was secured. Informed consent was obtained verbally from all participants before the interviews. The interviewer explained the study purpose, procedures, possible risks and benefits, confidentiality measures, and the estimated time commitment in the Fante language to each of the women. Participants were informed that participation was entirely voluntary and that they could withdraw at any time without consequences. Confidentiality was maintained through the use of pseudonym codes rather than participants' names. Audio recordings and transcripts were stored securely in password-protected files accessible only to first and last authors. Participants were pre-informed that discussing their experiences might evoke emotional discomfort, sadness, or distress, so, a qualified psychologist was available during data collection to provide immediate support to any participant experiencing psychological distress as a result of the interview. This study was conducted in accordance with the Declaration of Helsinki for studying human and animal subjects. Data Analysis Audio recordings were transcribed verbatim in Fante and then translated to English by language experts. A bilingual research assistant back-translated 20% of the transcripts to verify translation accuracy. Any discrepancies were discussed and resolved through consensus among the researchers and a homeless woman who attained secondary education. Data analysis followed the IPA framework 10,11 , involving multiple readings of the transcripts to gain familiarity with the data, while noting initial observations. Line-by-line coding identified meaningful units and preliminary themes. Similar codes were grouped into broader categories, and relationships between categories were examined. Themes were reviewed iteratively, refined, and organised into a coherent structure that captured participants' decision-making processes. The lead researcher conducted primary coding, with a second researcher independently coding 25% of transcripts. The research team met regularly to discuss emerging themes, resolve disagreements through discussion, and ensure analytical rigour 18 Since none of the researchers ever experienced homelessness, we invited and engaged a homeless woman having secondary education and an experienced social welfare worker to assess and validate the data and the associated interpretations. Results A total of 38 homeless pregnant women and postpartum mother participated in the study. The age of the women ranged from 18 to 42 years. Most of the women had limited formal education, with the majority having completed primary school or no formal schooling. They engaged in various informal economic activities, including street vending, load-carrying (Kayaye), domestic work, and some engaged in transactional sex for survival (See Table 1). Insert Table 1: Participant Characteristics Motivations for seeking medical treatment When participants were asked what motivated them to seek medical treatment, responses revealed four distinct themes: pregnancy, illness severity, routine check-ups, and having no motivation (See Table 2). Insert Table 2: Table 2: Motivations for Seeking Healthcare and Impact of Living Situation Pregnancy: Eight participants identified pregnancy as their primary reason for engaging with healthcare services, recognizing it as a condition requiring professional medical attention and monitoring. One participant explained: " Nobody pushes me. Like I can't say I am staying home while I am pregnant with no medicine and with nothing. It is right that I go to the hospital to be looked after and take medicine " (PHN 22). Another woman elaborated on the importance of professional monitoring of her pregnancy: " It's not right not go to the hospital while you're pregnant because you don't know what is happening to the baby, because sometime]es they do scan to know the position of the baby whether good or bad. And the medicine given will improve the baby's wellbeing and you the mother as well. (PHN 8). For these women, pregnancy represented a distinct health state that necessitates formal healthcare engagement, even when they typically avoided or could not access healthcare for other health concerns. One participant revealed instrumental engagement with healthcare during late pregnancy: " I did not go to the hospital, until it got to eight months, I went to take a card otherwise during labour they will not take care of me, but even if they do [the card] it will come with cost of which my family cannot afford " (PHN 2). Illness severity as a trigger: Twenty participants indicated that they seek healthcare only when illness becomes severe or unbearable. Routine ailments or minor discomforts were typically managed through self-care or traditional remedies, with formal healthcare reserved for serious conditions. One participant stated: " If I am sick and I do not take infusion, I won't be fine. I must take an infusion. It is the sickness that drives me. Yes, when it gets serious " (PHN 3). Another explained: " Sometimes, you can treat the illness with medications but there will be no change, this signals the need to hasten and take your child to the hospital for treatment " (PHN 9). This pattern reflects a reactive rather than preventive approach to healthcare, where women engage with health services primarily because symptoms become disabling or when informal treatments prove ineffective. One participant also described the diagnostic value of hospital care: " At times when you are home, you are sick, you don't know what exactly is worrying you. Some people are sick, they stay at home, but doesn't know exactly what is worrying them. But if you go to the hospital, they will test you and see exactly what is happening to you, that your head aches " (PHN 21). Routine check-ups and preventive care: Seven participants expressed awareness of the importance of preventive healthcare and routine check-ups, though their ability to consistently access such care varied. One participant explained: " I am a little stubborn. I like going out and selling things at my workplace and hawking in the afternoon. Sometimes I can feel my health declining, so I go to check what is happening. At times, I go to those who check around and they brief me on what is happening in my body " (PHN 4). Another expressed a forward-thinking health philosophy: " As a human being, you need to go for healthcare before something even happens to you " (PHN 5). Regarding antenatal check-ups specifically, one participant acknowledged the necessity: " Ooh, it is necessary. You must go and take the scan because maybe the child is not lying well, or there is a fault somewhere. You know that the child is in your womb, but you don't have any knowledge about it " (PHN 20). No motivation to seek care: Three participants indicated that nothing motivates them to seek medical care. These women did not elaborate extensively, but their responses suggested either previous negative experiences, perceived futility, or resignation regarding healthcare access. One expressed: " No oo nothing pushes me" (PHN 13). Another simply retorted: "Nothing pushes me to seek medical care " (PHN 36). Impact of living situation on desire for medical treatment When asked how their living situation impacts their desire for medical treatment, participants' responses revealed varied. Twenty-five participants reported that their living conditions substantially affected (limited) their ability and desire to seek healthcare, while 13 stated their living situation did not affect them (See Table 2). Primarily, living conditions affect these women’s healthcare seeking behaviours through financial constraints. Economic barriers emerged as the most prominent theme. One participant explained the financial impossibility of seeking care: " Yes, but I don't go to the hospital, but I buy drugs for body pains and hot ointment for my arms and legs and sides of my neck. I also take medicine to make my bones stronger, since there is no money, the little I get, I just use it when the need arises. Money is hard to come by in our situation " (PHN 2). Another participant described the toll of daily survival: " It gives me tiredness. It makes me tired. It gives sicknesses. You have to go around in the sun. All because of the money issues. By the time you come, you are not well. We are tired. We are sick and we cannot afford hospital bills all the time " (PHN 31). The interaction between financial constraints and healthcare access was starkly expressed by one participant: " If I get it, I will go, but where is the money? I don't have it. Even if I should bring some money, it will not be enough, and if they should give you any drugs, whichever way, they will collect their money before I leave there. Even if I say I don't have money, they will not consider it unless you meet someone considerable and thinks about humans, then he can consider you to go, and I will do everything, someone too " (PHN 13). Healthcare provider preferences When asked about their preferences regarding healthcare providers, participants identified four main providers: preference for doctors, preference for nurses or midwives, no particular preference, and preference for pharmacists (See Table 3). Insert Table 3: Preference for Healthcare Preference for doctors: Fourteen participants expressed preference for doctors, primarily based on perceived superior knowledge, experience, and qualifications. One participant explained: " I will choose the doctor because they are knowledgeable, not like some pharmacist, even though some pharmacists are also good, but they are usually on pension. (PHN 1). Another participant elaborated on doctors' experience: " I just need someone who can treat us well to recover from our sickness. For me, I want the doctor in particular to attend to me ……... As for the doctor, he has experience, he has completed all the academic stages, but these young nurses don't know much like the doctor who has a degree in it. So far, I prefer a doctor to those nurses " (PHN 6). Preference for nurses/midwives: Twelve participants expressed their preference for nurses or midwives. Gender concordance emerged as a reason, with participants appreciating care from female providers. " Nurse, because it is a woman " (PHN 3). Efficiency was another consideration: " Yes, I prefer to be treated by the nurse quickly so I can go " (PHN 9). Some participants recognized that nurses may have substantial practical experience: " That will depend on the person you will go and meet. If it is a woman or a man, all of them can attend to me. At times, the nurse even knows more than the doctor " (PHN 29). The interpersonal qualities of providers also matter. One participant described a preferred midwife: " There's this lady there, her this thing is fine, her treatment is nice. She's a lady and midwife. Yh. (laughs)" (PHN 8). Another valued gentle physical examination: " You see, she (a female nurse) speaks well with you, and when she's examining your stomach, even her palms. You see some people have hard palms, so you feel pain when they touch you, but hers is soft and fine, so you won't feel any pain. For these young nurses, they do it. 'kakyakakya' "- anyhow (PHN 27). No particular preference: Eleven participants stated they had no preference regarding provider type, prioritizing competence and respectful treatment over professional category. One stated: " No, I don't. I don't mind who takes care of me. They are there because they are qualified so, whether they are young or old. The person should be able to take care of you and show you respect. They are there because of us " (PHN 4). Another offered a nuanced perspective on provider competence: " It is everyone and how they went for their training. How can he treat the person? If you meet some nurses, they are able to attend to a person better than the doctor who attended to her. For me, every human being is a human being to me. If I come and if the doctor attends to me, fine. If a nurse attends to me, fine " (PHN 36). Gender preferences existed beyond professional category, with some participants reporting better experiences with male providers, contrary to the general preference for the female providers. One participant recounted a negative experience: " If it is a doctor or nurse that attends to me, I prefer a male. The men are better than the women. The woman they will flex on your ooh. They will tell you that when they were going to their school, you didn't go with them. Last time I met one at a certain hospital I nearly beat her " (PHN 37). These accounts illustrate how experiences of gender, disrespect and discrimination from healthcare providers shaped subsequent provider preferences among pregnant and postpartum homeless women. Preference for pharmacists: Only one participant expressed preference for pharmacists, primarily for expedited service: she said: " I want the pharmacist to attend to me early because after I submit the papers (prescriptions), I don't know what will happen before they give me oxygen and the others " (PHN 2). We designed the results are into a framework – Homeless Women Healthcare Service Utilisation Model. The model (Figure 1) depicts that in the resource-limited economy, homeless pregnant or postpartum women consider a number of factors in seeking healthcare. Accordingly, there is motivation that stems from having a pregnancy or carrying a pregnancy, the severity of any illness the woman may be suffering, and seeking preventive care, including checkup. Meanwhile, the living situations (i.e. economic) of these homeless women and their preferences for healthcare providers affect how they seek care during these critical periods of their lives. Interestingly, while some have no preference, many others prefer doctors, nurses/midwives and pharmacist, either male or female, when considering seeking care. Tus, it is critical that these and many other factors and their interrelations are considered in planning interventions, including maternal and child health care services for these highly vulnerable women group in developing countries. Discussion The findings from this study are that healthcare-seeking behaviour among homeless women is shaped by immediate health needs (pregnancy), economic constraints, living conditions, provider characteristics, and interpersonal experiences within the healthcare system. Pregnancy emerged as a distinct motivator for engaging with formal healthcare services by homeless women who are pregnant or during postpartum. Some of these women identified pregnancy as a reason to seek medical care, separate from other health concerns. This pattern suggests that these homeless women recognize pregnancy as a unique physiological state requiring specialized medical attention and monitoring. For instance, the desire to know the baby's (fetus) position, monitor fetal development, prevent anaemia, and ensure safe delivery drove healthcare engagement even among these women who typically avoided formal health services. This finding aligns with research from Ethiopia showing that pregnant homeless women perceive antenatal care as essential despite facing multiple access barriers. 6 Instrumental nature of engagement with healthcare is noteworthy. One participant's account of attending healthcare only at eight months to obtain a delivery card further underscores the quest for skills delivery. However, this reactive engagement undermines the preventive and monitoring benefits of early and continuous antenatal care for pregnancy. Similar patterns are documented in Ghana among marginalized populations who engage with maternal health services primarily to avoid penalties or additional costs during delivery rather than for comprehensive pregnancy monitoring and care. 8 . These women need continuous health education to understand and appreciate early and continuous for pregnancy. The predominance of illness severity as a trigger for healthcare-seeking among these homeless women also reflects a reactive rather than preventive health orientation. Homeless women in this study typically sought formal healthcare when symptoms became unbearable or when self-care measures failed. The challenge is that such delay in care seeking could compromise health and safety of the fetus and that of the mother. This pattern is consistent with research among homeless populations in even high-income countries, where crisis-driven healthcare utilization results from multiple structural and financial barriers that prevent early intervention. 4,19 The economic precarity of homelessness means that healthcare competes with immediate survival needs such as food, shelter, and income generation. Under these circumstances, preventive healthcare becomes a luxury that only a few can afford. 3,9 The relatively small number of participants (n=7) who expressed commitment to routine check-ups and preventive care suggests awareness of health maintenance principles but limited capacity to implement such consistently. This gap between health knowledge and health behaviour reflects structural constraints of homelessness rather than individual deficits in health literacy. Research from other African contexts demonstrate that health knowledge does not automatically translate into health behaviour when structural barriers remain unaddressed. 20,21 For instance, financial constraints emerged as a barrier affecting healthcare desire and utilization. Many participants described how lack of money directly prevented them from healthcare access despite perceived need. Even though Ghana's National Health Insurance Scheme theoretically provides free maternal healthcare, 8 participants reported being required to pay for drugs, supplies, and services. This finding exposes the gap between health policy and implementation, undermining universal health care and the quest to achieve SDG 3. Similar discrepancies are documented across Africa, where supposedly free maternal healthcare services involve numerous out-of-pocket costs that effectively exclude the poorest women. 8,22 Provider characteristics and interpersonal experiences within healthcare settings shape subsequent healthcare decisions 22 . While some of these homeless women expressed preferences for doctors, nurses, or midwives, others prioritized competence and respectful treatment over professional category. The value placed on “ gentle physical examination ”, “ clear communication ”, and “ respectful interaction ” reflect the interpersonal dimension of healthcare quality that may matter as much as or more than technical competence, particularly for socially marginalized women who often experience stigma and discrimination in society 23,24 , including healthcare workers. Reports of disrespectful treatment from healthcare providers, for example, are particularly concerning to some of these highly vulnerable homeless women. For instance, a homeless woman’s description of being treated rudely by a laboratory technician that nearly resulted to physical confrontation illustrates how negative interpersonal experiences can deter future healthcare engagement. Previous research demonstrates that disrespectful, abusive, or neglectful treatment during childbirth and maternal healthcare are widespread in many low-resource settings and disproportionately affects women from marginalized groups. 25,26 For homeless women who already face multiple stigmas related to poverty, housing status, and sometimes sex work, experience of disrespect from providers may be particularly damaging 23 , compounding their care seeking actions. The finding also revealed that some of these homeless women preferred male providers, a situation that contradicts general expectations about gender concordance in maternal healthcare. This unexpected preference was explained by negative experiences with female providers who were perceived as condescending or dismissive. This suggests that gender concordance alone does not guarantee quality care, but the interpersonal attitudes and professional conduct of providers equally matter. 27 The finding that living conditions substantially affect healthcare desire for 25 participants, but reportedly did not affect 13 participants warrants careful interpretation. The 13 homeless women who stated that their living situation did not impact their healthcare desire may represent either exceptional resilience, normalization of hardship, or reluctance to acknowledge vulnerability. Alternatively, these responses may reflect social desirability bias or a desire to project self-sufficiency despite difficult circumstances. Qualitative research with marginalized populations often encounters such response patterns, and researchers must interpret them within the broader context of participants' circumstances. 28 Implications for practice and research This study has several implications for maternal health service delivery for homeless the population of homeless pregnant and postpartum women developing countries. First, the recognition that pregnancy motivates healthcare engagement presents an opportunity for targeted outreach for education. Mobile antenatal clinics, flexible scheduling, and integration of antenatal services with other services that homeless women access could increase early and continuous care. Second, the substantial impact of financial barriers despite free maternal healthcare policy indicates the need to address hidden costs, including drugs, supplies, transportation, and opportunity costs. Voucher systems, drug subsidies, and integration of healthcare with income-generating activities merit exploration. Third, provider training on respect-to-care for marginalized populations is essential. From global health perspective, this study contributes to understanding healthcare-seeking behaviours among a very marginalized populations in low-resource urban settings 9,29 The intersection of homelessness, poverty, gender, and maternal health creates unique challenges that require context-specific solutions. Experiences from Sekondi-Takoradi may inform interventions in other West African cities experiencing rapid urbanization, growing informal settlement, and inadequate housing, which are creating homelessness. The study demonstrates that providing nominally free healthcare is insufficient without addressing structural barriers, hidden costs, and interpersonal quality to provision of care. Future research should examine the effectiveness of mobile maternal health services for homeless women, explore male partners' roles in homeless women's maternal healthcare decisions, document the experiences of healthcare providers serving homeless populations, and quantify maternal and neonatal outcomes among homeless women. Longitudinal studies would provide deeper understanding of care continuity challenges and opportunities among this group of women. Limitations The use of purposive and snowball sampling mean that results may not represent all homeless women in the metropolis or in the country. Women who agreed to participate may differ from those who declined. Data were collected at a single time point, capturing experiences at that moment, but not in a longitudinal pattern. Participants may have demonstrated social desirability bias, reporting what they believed researchers wanted to hear rather than their actual experiences and beliefs. Despite these limitations, the study provides valuable understanding of maternal health issues of a very vulnerable population that is often invisible in health research and policy. Conclusions Maternal healthcare utilization decisions among homeless women in Sekondi-Takoradi Metropolis are shaped by pregnancy recognition, illness severity, economic constraints, living conditions, and interpersonal experiences with healthcare providers. Pregnancy emerged as a primary motivator for formal care-seeking, while daily survival challenges often supersede preventive health behaviours. Financial barriers remain despite free maternal healthcare policy, reflecting implementation gaps and hidden costs to seeking care among these very vulnerable women. Provider attitudes and interpersonal treatment quality significantly influence their healthcare-seeking decisions. Ghana risks attaining the targets in SDG 3 unless provision of healthcare services cover the very vulnerable women in the country. So, we prosed a framework (Fig. 1 ): Homeless Women Healthcare Service Utilization Framework, as important guideline to studying healthcare seeking behaviours or factors that influence healthcare seeking actions of homeless women who are pregnant or within the postpartum period. Declarations Conflicts of Interest: The authors declare no competing interests. Financial Disclosure: Nothing to declare. Funding/Support: There was no external funding for this study. Ethics Approval: Ethical approval was granted by the Institutional Review Board of the University of Cape Coast (UCCIRB/CES/2023/165). Permission was also granted by the Sekondi-Takoradi Metropolitan Assembly and the Social Welfare Department. This was conducted in accordance with the Declaration of Helsinki for studying human and animal subjects. Declaration of Patient Consent: Informed consent was obtained verbally from all the participants after explaining to them study purpose, procedures, risks, benefits of the study and their right to withdraw. All participants consented to audio recording of interviews. Author Contributions: Conceptualization, FOA, EWA and SAE, Method, FOA, EWA and SAE, Data collection, FOA, Data management and analysis, FOA, EWA and SAE, initial draft, FOA, EWA and PYAK, Final review EWA and SAE. All authors review and approved the finial manuscript for publication. Acknowledgments: The authors acknowledge the homeless women who participated in this study and shared their experiences. We thank the Sekondi-Takoradi Metropolitan Assembly, Social Welfare Department, and community leaders for facilitating access to study participants. References World Health Organization. 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Public Health Nurs . 2017;34(3):240-252. doi:10.1111/phn.12314 Gebreyesus T, Kassa A, Mihret MS. Barriers to antenatal care seeking among homeless pregnant women in urban Ethiopia: A phenomenological study. BMC Pregnancy Childbirth . 2019;19(1):469. doi:10.1186/s12884-019-2612-5 Ganle JK, Parker M, Fitzpatrick R, Otupiri E. A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition. BMC Pregnancy Childbirth . 2014;14:425. doi:10.1186/s12884-014-0425-8 Robinson CA, Atkinson SJ, Dierker LC, others. Health and social experiences of pregnant and parenting individuals experiencing homelessness: A mixed-methods study. Int J Equity Health . 2025;24(1):3. doi:10.1186/s12939-024-02325-6 Kopanitsa G, Kobrinskaya A, Danilov A. Digital health interventions for homeless people: A systematic review. Int J Med Inf . 2023;171:104985. doi:10.1016/j.ijmedinf.2023.104985 Galvin E HJ Stack E, O’Donovan D. Barriers and facilitators affecting homeless individuals’ access to healthcare services: A narrative synthesis. Health Soc Care Community . Published online 2024. doi:10.1155/2024/9941966 Sekondi-Takoradi Metropolitan Assembly. Health services. Published online 2023. https://stma.gov.gh National Health Insurance Authority. Accredited health facilities. Published online 2023. Kneck A, Mattsson E, Ohlsson U, Klang B. Being homeless and needing care: Older adult women’s experiences. Nurs Open . 2021;8(5):2381-2391. doi:10.1002/nop2.857 Sutherland R, Sinfield M, Rhodes N, others. Trauma-informed care: Accounts of healthcare delivery by women experiencing homelessness in Scotland. Health Expect . 2022;25(6):2828-2838. doi:10.1111/hex.13607 Creswell JW CV. Designing and conducting mixed methods research. 2nd Ed . Published online 2011. Marshall C, Rossman GB. Designing Qualitative Research . 6th ed. SAGE Publications; 2014. Li M, Urada LA. Homelessness in Los Angeles: Voices from the margins. J Public Health Manag Pract . 2020;26(Suppl 2):S51-S53. doi:10.1097/PHH.0000000000001131 Carroll A WA. Maternal healthcare experiences of women experiencing homelessness: A scoping review. Midwifery . Published online 2024. doi:10.1016/j.midw.2023.103881 Terefe YT, Abebe Y, Teka H. Utilization of healthcare services among homeless pregnant and lactating women in Addis Ababa, Ethiopia. PLoS One . 2022;17(3):e0265062. doi:10.1371/journal.pone.0265062 Davis EW, Lupo PJ, Taylor BD, others. Maternal housing instability and birth outcomes: A population-based study. Paediatr Perinat Epidemiol . 2019;33(6):404-411. doi:10.1111/ppe.12583 Dawson-Rose C, Cuca YP, Webel AR, others. Building trust and relationships between patients and providers: An essential complement to health literacy in HIV care. J Assoc Nurses AIDS Care . 2020;27(5):574-584. doi:10.1016/j.jana.2016.03.001 Campbell S et al Greenwood M, Prior S, Shearer T, Walkem K, Young S. Purposive sampling: complex or simple? Research case examples. J Res Nurs 2020 258 652-661 . Published online 2020. Smith JA, Osborn M. Interpretative phenomenological analysis. In: Smith JA, ed. Qualitative Psychology: A Practical Guide to Research Methods . 3rd ed. SAGE Publications; 2015:25-52. Starks H, Trinidad SB. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qual Health Res . 2007;17(10):1372-1380. doi:10.1177/1049732307307031 Saunders B, Sim J, Kingstone T, others. Saturation in qualitative research: Exploring its conceptualization and operationalization. Qual Quant . 2018;52(4):1893-1907. doi:10.1007/s11135-017-0574-8 Stuttaford M, Hundt GL, Vostanis P. Homelessness and access to mental health services in South Africa. Vulnerable Child Youth Stud . 2009;4(2):102-109. doi:10.1080/17450120902730373 Creswell JW. Qualitative Inquiry and Research Design: Choosing among Five Approaches . 3rd ed. SAGE Publications; 2012. Kruk ME, Kujawski S, Mbaruku G, others. Disrespectful and abusive treatment during facility delivery in Tanzania: A facility and community survey. Health Policy Plan . 2018;33(1):e26-e33. doi:10.1093/heapol/czu079 Tables Table 1: Participant Characteristics Characteristic n (%) Age (years) 18-42 Education Level No formal education 16 (42.1%) Primary school 15 (39.5%) Junior High School 7 (18.4%) Pregnancy Status Currently pregnant 22 (57.9%) Within 6 weeks postpartum 16 (42.1%) Primary Income Source Street vending/hawking 18 (47.4%) Load carrying (Kayayi) 8 (21.1%) Domestic work 5 (13.2%) Begging 4 (10.5%) Other informal work 3 (7.9%) Table 2: Motivations for Seeking Healthcare and Impact of Living Situation Theme Sub-theme n Representative Quote What Motivates Healthcare-Seeking Pregnancy 8 "It's not right to not go to the hospital while you're pregnant because you don't know what is happening to the baby" (PHN 8) Illness severity 20 "It is the sickness that drives me. Yes, when it gets serious" (PHN 3) Routine check-ups 7 "As a human being, you need to go for healthcare before something even happens to you" (PHN 5) No motivation 3 "No oo nothing pushes me" (PHN 13) Impact of Living Situation Does not affect 13 "It's okay with my health, nothing bothers me" (PHN 22) Substantially affects 25 "If I get it, I will go, but where is the money? I don't have it" (PHN 13) Table 3: Preference for Healthcare Provider Type n (%) Primary Reasons Doctor 14 (36.8%) Superior knowledge, experience, qualifications Nurse 9 (23.7%) Gender concordance (female), efficiency Midwife 3 (7.9%) Specialization, gentle examination No preference 11 (28.9%) Prioritize competence and respect over provider type Pharmacist 1 (2.6%) Quick service Additional Declarations No competing interests reported. Supplementary Files SupplementaryFIle.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Apr, 2026 Reviews received at journal 03 Mar, 2026 Reviews received at journal 03 Mar, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor assigned by journal 30 Jan, 2026 Submission checks completed at journal 28 Jan, 2026 First submitted to journal 28 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Akuffo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDACCQiVAMSMD4AEDx8pWpgNQFrYSNHCBmYT1MI/u/nwhx81Nnn80s3HKr/m2MmwMTA/fHQDnyV3jqVJ9hxLK5accyzttuy2ZKDD2IyNc/BoMZDIMWNmYDucuOFGjtltyW3MQC08bNL4teR//szw73Di/hv534olt9UToyWHQZqxDWiLRA4b48dthwlrkbiRZibZ25eWOONGmrE047bjPGzMBPzCPyP58Ycf32wS+2ckP/z4c1u1PT9788PH+LSgAGYeMEmschBg/EGK6lEwCkbBKBgxAACLxEX3+9+R2QAAAABJRU5ErkJggg==","orcid":"","institution":"University of Cape Coast","correspondingAuthor":true,"prefix":"","firstName":"Francisca","middleName":"O.","lastName":"Akuffo","suffix":""},{"id":585923254,"identity":"e734246b-816e-4c65-bdde-216ce8e07320","order_by":1,"name":"Salome Amissah-Essel","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Salome","middleName":"","lastName":"Amissah-Essel","suffix":""},{"id":585923255,"identity":"ae63379d-70c1-4509-9e3a-e642ad5f4c35","order_by":2,"name":"Philomina Y. Anti Kwakye","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Philomina","middleName":"Y. Anti","lastName":"Kwakye","suffix":""},{"id":585923258,"identity":"0de48c7c-20d7-46c7-9cfd-0239d8394318","order_by":3,"name":"Edward W. Ansah","email":"","orcid":"","institution":"University of Cape Coast","correspondingAuthor":false,"prefix":"","firstName":"Edward","middleName":"W.","lastName":"Ansah","suffix":""}],"badges":[],"createdAt":"2026-01-22 16:40:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8671982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8671982/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102238512,"identity":"bc299721-fee8-4570-b7d5-f2bbc3d93eb1","added_by":"auto","created_at":"2026-02-09 16:40:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68333,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHomeless Women Healthcare Service Utilization Model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8671982/v1/b02129838caf16ec7a37bfbf.png"},{"id":102238553,"identity":"37c7bde3-1ddb-48cc-a317-ab1490935100","added_by":"auto","created_at":"2026-02-09 16:41:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1045469,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8671982/v1/f00f3b71-ea89-41dd-8736-494994b31af2.pdf"},{"id":102238511,"identity":"8cd8039d-fce6-424e-b257-d80621eb808c","added_by":"auto","created_at":"2026-02-09 16:40:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34996,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFIle.docx","url":"https://assets-eu.researchsquare.com/files/rs-8671982/v1/fdb58f5317fa413f286b126f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Influencing Maternal Healthcare Service Utilization Decisions among Homeless Women: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMaternal healthcare utilization remains a public health concern in many low-and middle-income countries (LMICs). Despite global efforts to improve maternal health outcomes through the Sustainable Development Goals (SDGs), disparities persist among vulnerable populations\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Homeless women represent an exceptionally marginalized group facing multiple barriers to accessing maternal healthcare services.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In Ghana, where the national maternal mortality ratio stands at 310 deaths per 100,000 live births, homeless pregnant women experience disproportionately worse outcomes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRecent estimates from African countries suggest that homelessness affects tens of millions of people across the continent, including about 24.4\u0026nbsp;million people in Nigeria, 12\u0026nbsp;million in Egypt, 200,000 in South Africa, and roughly 100,000 roofless people in Ghana.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Homelessness among women of reproductive age has increased in urban areas across West Africa. In Sekondi-Takoradi Metropolis, Ghana's third-largest city, approximately 6,258 homeless women reside within the metropolitan area.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e These women engage in street hawking, manual labour, load-carrying (Kayayi), begging, transactional sex, and cleaning work for surviveal. Their daily realities of economic insecurity, lack of shelter, and social marginalization intersect with pregnancy and postpartum care needs, creating complex health-seeking behaviours that health systems struggle to address.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnderstanding factors influencing homeless women's decisions to seek maternal healthcare services is essential for designing accessible, acceptable, and effective interventions. Existing research from high-income countries documented that homeless pregnant women face structural barriers, including lack of transportation, inability to afford care, unstable housing, and experience stigma and discrimination from healthcare providers.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, limited evidence exists from African context where healthcare systems, cultural norms, and social support structures differ substantially from the Western settings. \u003csup\u003e6,8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn Ghana, the National Health Insurance Scheme theoretically provides free maternal healthcare services\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, but homeless women continue to underutilize antenatal care, skilled delivery services, and postpartum care.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Previous research in Ghana examined barriers to maternal healthcare among rural women and women from low socioeconomic backgrounds but has not specifically explored the decision-making processes of homeless women.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The intersectionality of homelessness, gender, poverty, and pregnancy creates unique challenges that require specific investigation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study aimed to examine factors influencing homeless mothers' decisions to utilize maternal healthcare services in Sekondi-Takoradi Metropolis in Ghana. Specifically, we explored what motivates homeless women to seek medical treatment, how their living situations impact their desire for care, and their preferences regarding healthcare providers. Understanding these factors from the women's perspectives could inform development of targeted interventions and service delivery models that better meet the needs of this highly marginalized population.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study employed interpretative phenomenological analysis (IPA) to explore the lived experiences concerning decision-making of homeless mothers regarding their maternal healthcare utilization. IPA was selected because it allows us to examine how these women make sense of their significant life experiences.\u003csup\u003e10,11\u003c/sup\u003e This approach enabled in-depth exploration of this complex, but subjective factors that shape healthcare-seeking behaviours among these homeless women. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Sekondi-Takoradi Metropolis, Western Region, Ghana, between August 2023 and November 2023. The metropolis covers 191.7 km\u0026sup2; with a population of approximately 1,035,000 residents.\u003csup\u003e2\u003c/sup\u003e As a major urban and commercial centre hosting Ghana\u0026apos;s largest seaport, the city attracts rural-urban migrants seeking economic opportunities. However, limited affordable housing and lack of employment opportunities have contributed to a growing homeless population. Homeless women in the metropolis typically lack permanent residence, even in harsh weather conditions and rely on informal work for survival. The metropolis has several public health facilities, including the Effia-Nkwanta Regional Hospital, polyclinics, health centres, and private hospitals, all theoretically accessible under the National Health Insurance Scheme.\u003csup\u003e12,13\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population comprised homeless women aged 18 years and above who were currently pregnant or within six weeks postpartum and residing in Sekondi-Takoradi Metropolis. These homeless women included women without a permanent home or fixed place of residence, who sleep in public spaces, markets, lorry stations, abandoned buildings, or temporary shelters.\u003c/p\u003e\n\u003cp\u003eParticipants were recruited using purposive, convenient, and snowball sampling techniques\u003csup\u003e.\u003c/sup\u003e\u003csup\u003e14,15\u003c/sup\u003e An assemblyman (local government official) familiar with the area helped identify the locations where the homeless women congregate. The researchers visited these locations during evening hours (6:30-8:30 pm) when the homeless women returned to their sleeping areas, making identification more reliable. Initial participants who met inclusion criteria and consented to participate were asked to refer other homeless women who might be interested in the study, facilitating snowball sampling.\u003csup\u003e15\u003c/sup\u003e Sample size was determined by data saturation, the point at which no new information or themes emerged from the data.\u003c/p\u003e\n\u003cp\u003eTo be included in the study, the woman must be pregnant or within six weeks of postpartum at the time of data collection, must be 18 years or older, be homeless, be willing to take part in the study, have stable mental health to give consent. However, they were excluded if they were ill and could give consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrument and procedures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn interview guide containing open-ended questions was used for data collection in this study. This guide explored motivations for seeking healthcare, the impact of living conditions on healthcare desires, preferences for types of healthcare providers, and decision-making processes regarding maternal health service use. The interview guide was developed based on literature review\u0026nbsp;\u003csup\u003e16,17\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand was validated by two experts in qualitative research and maternal health before fieldwork commenced. Probing questions were used to elicit detailed descriptions and to clarify participants\u0026rsquo; responses.\u003c/p\u003e\n\u003cp\u003eData were collected through semi-structured face-to-face interviews conducted using the Fante language, the predominant local language in the study area (Supplementary File 1). The first author, who is fluent in Fante, conducted all the interviews to ensure consistency and cultural sensitivity of the data. Each interview lasted between 45 and 90 minutes. Interviews were conducted in private, quiet locations chosen by the participants to ensure confidentiality and comfort, including secluded areas in markets, parks, or near participants\u0026apos; sleeping locations when other women or people were absent.\u003c/p\u003e\n\u003cp\u003eAll interviews were audio-recorded with participants\u0026apos; consent. Field notes were also taken during the interviews, while non-verbal cues, contextual observations, and initial analytical impressions were equally captured. Participants were assigned pseudonym or codes (PHN 1 to PHN 38) to protect their identity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board of the University of Cape Coast (UCCIRB/CES/2023/165). Permission was also secured from the Sekondi-Takoradi Metropolitan Assembly and the Social Welfare Department. Community leaders in the study areas were verbally informed about the research and their cooperation was secured. Informed consent was obtained verbally from all participants before the interviews. The interviewer explained the study purpose, procedures, possible risks and benefits, confidentiality measures, and the estimated time commitment in the Fante language to each of the women. Participants were informed that participation was entirely voluntary and that they could withdraw at any time without consequences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConfidentiality was maintained through the use of pseudonym codes rather than participants\u0026apos; names. Audio recordings and transcripts were stored securely in password-protected files accessible only to first and last authors. Participants were pre-informed that discussing their experiences might evoke emotional discomfort, sadness, or distress, so, a qualified psychologist was available during data collection to provide immediate support to any participant experiencing psychological distress as a result of the interview. This study was conducted in accordance with the Declaration of Helsinki for studying human and animal subjects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAudio recordings were transcribed verbatim in Fante and then translated to English by language experts. A bilingual research assistant back-translated 20% of the transcripts to verify translation accuracy. Any discrepancies were discussed and resolved through consensus among the researchers and a homeless woman who attained secondary education.\u003c/p\u003e\n\u003cp\u003eData analysis followed the IPA framework\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e10,11\u003c/sup\u003e, involving multiple readings of the transcripts to gain familiarity with the data, while noting initial observations. Line-by-line coding identified meaningful units and preliminary themes. Similar codes were grouped into broader categories, and relationships between categories were examined. Themes were reviewed iteratively, refined, and organised into a coherent structure that captured participants\u0026apos; decision-making processes. The lead researcher conducted primary coding, with a second researcher independently coding 25% of transcripts. The research team met regularly to discuss emerging themes, resolve disagreements through discussion, and ensure analytical rigour\u003csup\u003e18\u003c/sup\u003e Since none of the researchers ever experienced homelessness, we invited and engaged a homeless woman having secondary education and an experienced social welfare worker to assess and validate the data and the associated interpretations. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 38 homeless pregnant women and postpartum mother participated in the study. The age of the women ranged from 18 to 42 years. Most of the women had limited formal education, with the majority having completed primary school or no formal schooling. They engaged in various informal economic activities, including street vending, load-carrying (Kayaye), domestic work, and some engaged in transactional sex for survival (See Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Table 1: Participant Characteristics\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMotivations for seeking medical treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen participants were asked what motivated them to seek medical treatment, responses revealed four distinct themes: pregnancy, illness severity, routine check-ups, and having no motivation (See Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Table 2: Table 2: Motivations for Seeking Healthcare and Impact of Living Situation\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy:\u003c/strong\u003e Eight participants identified pregnancy as their primary reason for engaging with healthcare services, recognizing it as a condition requiring professional medical attention and monitoring. One participant explained:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eNobody pushes me. Like I can\u0026apos;t say I am staying home while I am pregnant with no medicine and with nothing. It is right that I go to the hospital to be looked after and take medicine\u003c/em\u003e\u0026quot; (PHN 22).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother woman elaborated on the importance of professional monitoring of her pregnancy:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIt\u0026apos;s not right not go to the hospital while you\u0026apos;re pregnant because you don\u0026apos;t know what is happening to the baby, because sometime]es they do scan to know the position of the baby whether good or bad. And the medicine given will improve the baby\u0026apos;s wellbeing and you the mother as well.\u0026nbsp;\u003c/em\u003e(PHN 8).\u003c/p\u003e\n\u003cp\u003eFor these women, pregnancy represented a distinct health state that necessitates formal healthcare engagement, even when they typically avoided or could not access healthcare for other health concerns. One participant revealed instrumental engagement with healthcare during late pregnancy:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI did not go to the hospital, until it got to eight months, I went to take a card otherwise during labour they will not take care of me, but even if they do\u0026nbsp;\u003c/em\u003e[the card] \u003cem\u003eit will come with cost of which my family cannot afford\u003c/em\u003e\u0026quot; (PHN 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIllness severity as a trigger:\u0026nbsp;\u003c/strong\u003eTwenty participants indicated that they seek healthcare only when illness becomes severe or unbearable. Routine ailments or minor discomforts were typically managed through self-care or traditional remedies, with formal healthcare reserved for serious conditions. One participant stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIf I am sick and I do not take infusion, I won\u0026apos;t be fine. I must take an infusion. It is the sickness that drives me. Yes, when it gets serious\u003c/em\u003e\u0026quot; (PHN 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother explained:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eSometimes, you can treat the illness with medications but there will be no change, this signals the need to hasten and take your child to the hospital for treatment\u003c/em\u003e\u0026quot; (PHN 9).\u003c/p\u003e\n\u003cp\u003eThis pattern reflects a reactive rather than preventive approach to healthcare, where women engage with health services primarily because symptoms become disabling or when informal treatments prove ineffective. One participant also described the diagnostic value of hospital care:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAt times when you are home, you are sick, you don\u0026apos;t know what exactly is worrying you. Some people are sick, they stay at home, but doesn\u0026apos;t know exactly what is worrying them. But if you go to the hospital, they will test you and see exactly what is happening to you, that your head aches\u003c/em\u003e\u0026quot; (PHN 21).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoutine check-ups and preventive care:\u0026nbsp;\u003c/strong\u003eSeven participants expressed awareness of the importance of preventive healthcare and routine check-ups, though their ability to consistently access such care varied. One participant explained:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI am a little stubborn. I like going out and selling things at my workplace and hawking in the afternoon. Sometimes I can feel my health declining, so I go to check what is happening. At times, I go to those who check around and they brief me on what is happening in my body\u003c/em\u003e\u0026quot; (PHN 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother expressed a forward-thinking health philosophy:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eAs a human being, you need to go for healthcare before something even happens to you\u003c/em\u003e\u0026quot; (PHN 5).\u003c/p\u003e\n\u003cp\u003eRegarding antenatal check-ups specifically, one participant acknowledged the necessity:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eOoh, it is necessary. You must go and take the scan because maybe the child is not lying well, or there is a fault somewhere. You know that the child is in your womb, but you don\u0026apos;t have any knowledge about it\u003c/em\u003e\u0026quot; (PHN 20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNo motivation to seek care:\u0026nbsp;\u003c/strong\u003eThree participants indicated that nothing motivates them to seek medical care. These women did not elaborate extensively, but their responses suggested either previous negative experiences, perceived futility, or resignation regarding healthcare access. One expressed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eNo oo nothing pushes me\u0026quot;\u0026nbsp;\u003c/em\u003e(PHN 13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother simply retorted: \u003cem\u003e\u0026quot;Nothing pushes me to seek medical care\u003c/em\u003e\u0026quot; (PHN 36).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of living situation on desire for medical treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked how their living situation impacts their desire for medical treatment, participants\u0026apos; responses revealed varied. Twenty-five participants reported that their living conditions substantially affected (limited) their ability and desire to seek healthcare, while 13 stated their living situation did not affect them (See Table 2).\u003c/p\u003e\n\u003cp\u003ePrimarily, living conditions affect these women\u0026rsquo;s healthcare seeking behaviours through financial constraints. Economic barriers emerged as the most prominent theme. One participant explained the financial impossibility of seeking care:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eYes, but I don\u0026apos;t go to the hospital, but I buy drugs for body pains and hot ointment for my arms and legs and sides of my neck. I also take medicine to make my bones stronger, since there is no money, the little I get, I just use it when the need arises. Money is hard to come by in our situation\u003c/em\u003e\u0026quot; (PHN 2).\u003c/p\u003e\n\u003cp\u003eAnother participant described the toll of daily survival:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIt gives me tiredness. It makes me tired. It gives sicknesses. You have to go around in the sun. All because of the money issues. By the time you come, you are not well. We are tired. We are sick and we cannot afford hospital bills all the time\u003c/em\u003e\u0026quot; (PHN 31).\u003c/p\u003e\n\u003cp\u003eThe interaction between financial constraints and healthcare access was starkly expressed by one participant:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIf I get it, I will go, but where is the money? I don\u0026apos;t have it. Even if I should bring some money, it will not be enough, and if they should give you any drugs, whichever way, they will collect their money before I leave there. Even if I say I don\u0026apos;t have money, they will not consider it unless you meet someone considerable and thinks about humans, then he can consider you to go, and I will do everything, someone too\u003c/em\u003e\u0026quot; (PHN 13).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare provider preferences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked about their preferences regarding healthcare providers, participants identified four main providers: preference for doctors, preference for nurses or midwives, no particular preference, and preference for pharmacists (See Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Table 3: Preference for Healthcare \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreference for doctors:\u0026nbsp;\u003c/strong\u003eFourteen participants expressed preference for doctors, primarily based on perceived superior knowledge, experience, and qualifications. One participant explained:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI will choose the doctor because they are knowledgeable, not like some pharmacist, even though some pharmacists are also good, but they are usually on pension.\u003c/em\u003e (PHN 1).\u003c/p\u003e\n\u003cp\u003eAnother participant elaborated on doctors\u0026apos; experience:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003e\u0026nbsp;I just need someone who can treat us well to recover from our sickness. For me, I want the doctor in particular to attend to me \u0026hellip;\u0026hellip;... As for the doctor, he has experience, he has completed all the academic stages, but these young nurses don\u0026apos;t know much like the doctor who has a degree in it. So far, I prefer a doctor to those nurses\u003c/em\u003e\u0026quot; (PHN 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreference for nurses/midwives:\u0026nbsp;\u003c/strong\u003eTwelve participants expressed their preference for nurses or midwives. Gender concordance emerged as a reason, with participants appreciating care from female providers. \u0026quot;\u003cem\u003eNurse, because it is a woman\u003c/em\u003e\u0026quot; (PHN 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEfficiency was another consideration: \u0026quot;\u003cem\u003eYes, I prefer to be treated by the nurse quickly so I can go\u003c/em\u003e\u0026quot; (PHN 9).\u003c/p\u003e\n\u003cp\u003eSome participants recognized that nurses may have substantial practical experience:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThat will depend on the person you will go and meet. If it is a woman or a man, all of them can attend to me. At times, the nurse even knows more than the doctor\u003c/em\u003e\u0026quot; (PHN 29).\u003c/p\u003e\n\u003cp\u003eThe interpersonal qualities of providers also matter. One participant described a preferred midwife:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThere\u0026apos;s this lady there, her this thing is fine, her treatment is nice. She\u0026apos;s a lady and midwife. Yh. (laughs)\u0026quot;\u003c/em\u003e (PHN 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother valued gentle physical examination:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eYou see, she (a female nurse) speaks well with you, and when she\u0026apos;s examining your stomach, even her palms. You see some people have hard palms, so you feel pain when they touch you, but hers is soft and fine, so you won\u0026apos;t feel any pain. For these young nurses, they do it. \u0026apos;kakyakakya\u0026apos;\u003c/em\u003e\u0026quot;- anyhow (PHN 27).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNo particular preference:\u0026nbsp;\u003c/strong\u003eEleven participants stated they had no preference regarding provider type, prioritizing competence and respectful treatment over professional category. One stated:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eNo, I don\u0026apos;t. I don\u0026apos;t mind who takes care of me. They are there because they are qualified so, whether they are young or old. The person should be able to take care of you and show you respect. They are there because of us\u003c/em\u003e\u0026quot; (PHN 4).\u003c/p\u003e\n\u003cp\u003eAnother offered a nuanced perspective on provider competence:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIt is everyone and how they went for their training. How can he treat the person? If you meet some nurses, they are able to attend to a person better than the doctor who attended to her. For me, every human being is a human being to me. If I come and if the doctor attends to me, fine. If a nurse attends to me, fine\u003c/em\u003e\u0026quot; (PHN 36).\u003c/p\u003e\n\u003cp\u003eGender preferences existed beyond professional category, with some participants reporting better experiences with male providers, contrary to the general preference for the female providers. One participant recounted a negative experience:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eIf it is a doctor or nurse that attends to me, I prefer a male. The men are better than the women. The woman they will flex on your ooh. They will tell you that when they were going to their school, you didn\u0026apos;t go with them. Last time I met one at a certain hospital I nearly beat her\u003c/em\u003e\u0026quot; (PHN 37).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese accounts illustrate how experiences of gender, disrespect and discrimination from healthcare providers shaped subsequent provider preferences among pregnant and postpartum homeless women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreference for pharmacists:\u0026nbsp;\u003c/strong\u003eOnly one participant expressed preference for pharmacists, primarily for expedited service: she said:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI want the pharmacist to attend to me early because after I submit the papers (prescriptions), I don\u0026apos;t know what will happen before they give me oxygen and the others\u003c/em\u003e\u0026quot; (PHN 2).\u003c/p\u003e\n\u003cp\u003eWe designed the results are into a framework \u0026ndash; Homeless Women Healthcare Service Utilisation Model. The model (Figure 1) depicts that in the resource-limited economy, homeless pregnant or postpartum women consider a number of factors in seeking healthcare. Accordingly, there is motivation that stems from having a pregnancy or carrying a pregnancy, the severity of any illness the woman may be suffering, and seeking preventive care, including checkup. Meanwhile, the living situations (i.e. economic) of these homeless women and their preferences for healthcare providers affect how they seek care during these critical periods of their lives. Interestingly, while some have no preference, many others prefer doctors, nurses/midwives and pharmacist, either male or female, when considering seeking care. Tus, it is critical that these and many other factors and their interrelations are considered in planning interventions, including maternal and child health care services for these highly vulnerable women group in developing countries.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from this study are that healthcare-seeking behaviour among homeless women is shaped by immediate health needs (pregnancy), economic constraints, living conditions, provider characteristics, and interpersonal experiences within the healthcare system. Pregnancy emerged as a distinct motivator for engaging with formal healthcare services by homeless women who are pregnant or during postpartum. Some of these women identified pregnancy as a reason to seek medical care, separate from other health concerns. This pattern suggests that these homeless women recognize pregnancy as a unique physiological state requiring specialized medical attention and monitoring. For instance, the desire to know the baby\u0026apos;s (fetus) position, monitor fetal development, prevent anaemia, and ensure safe delivery drove healthcare engagement even among these women who typically avoided formal health services. This finding aligns with research from Ethiopia showing that pregnant homeless women perceive antenatal care as essential despite facing multiple access barriers.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eInstrumental nature of engagement with healthcare is noteworthy. One participant\u0026apos;s account of attending healthcare only at eight months to obtain a delivery card further underscores the quest for skills delivery. However, this reactive engagement undermines the preventive and monitoring benefits of early and continuous antenatal care for pregnancy. Similar patterns are documented in Ghana among marginalized populations who engage with maternal health services primarily to avoid penalties or additional costs during delivery rather than for comprehensive pregnancy monitoring and care.\u003csup\u003e8\u003c/sup\u003e. These women need continuous health education to understand and appreciate early and continuous for pregnancy.\u003c/p\u003e\n\u003cp\u003eThe predominance of illness severity as a trigger for healthcare-seeking among these homeless women also reflects a reactive rather than preventive health orientation. Homeless women in this study typically sought formal healthcare when symptoms became unbearable or when self-care measures failed. The challenge is that such delay in care seeking could compromise health and safety of the fetus and that of the mother. This pattern is consistent with research among homeless populations in even high-income countries, where crisis-driven healthcare utilization results from multiple structural and financial barriers that prevent early intervention.\u003csup\u003e4,19\u003c/sup\u003e The economic precarity of homelessness means that healthcare competes with immediate survival needs such as food, shelter, and income generation. Under these circumstances, preventive healthcare becomes a luxury that only a few can afford.\u003csup\u003e3,9\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe relatively small number of participants (n=7) who expressed commitment to routine check-ups and preventive care suggests awareness of health maintenance principles but limited capacity to implement such consistently. This gap between health knowledge and health behaviour reflects structural constraints of homelessness rather than individual deficits in health literacy. Research from other African contexts demonstrate that health knowledge does not automatically translate into health behaviour when structural barriers remain unaddressed.\u003csup\u003e20,21\u003c/sup\u003e For instance, financial constraints emerged as a barrier affecting healthcare desire and utilization. Many participants described how lack of money directly prevented them from healthcare access despite perceived need. Even though Ghana\u0026apos;s National Health Insurance Scheme theoretically provides free maternal healthcare,\u003csup\u003e8\u003c/sup\u003e participants reported being required to pay for drugs, supplies, and services. This finding exposes the gap between health policy and implementation, undermining universal health care and the quest to achieve SDG 3. Similar discrepancies are documented across Africa, where supposedly free maternal healthcare services involve numerous out-of-pocket costs that effectively exclude the poorest women.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e8,22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eProvider characteristics and interpersonal experiences within healthcare settings shape subsequent healthcare decisions\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e22\u003c/sup\u003e. While some of these homeless women expressed preferences for doctors, nurses, or midwives, others prioritized competence and respectful treatment over professional category. The value placed on \u0026ldquo;\u003cem\u003egentle physical examination\u003c/em\u003e\u0026rdquo;, \u0026ldquo;\u003cem\u003eclear communication\u003c/em\u003e\u0026rdquo;, and \u0026ldquo;\u003cem\u003erespectful interaction\u003c/em\u003e\u0026rdquo; reflect the interpersonal dimension of healthcare quality that may matter as much as or more than technical competence, particularly for socially marginalized women who often experience stigma and discrimination in society\u003csup\u003e23,24\u003c/sup\u003e, including healthcare workers. Reports of disrespectful treatment from healthcare providers, for example, are particularly concerning to some of these highly vulnerable homeless women. For instance, a homeless woman\u0026rsquo;s description of being treated rudely by a laboratory technician that nearly resulted to physical confrontation illustrates how negative interpersonal experiences can deter future healthcare engagement. Previous research demonstrates that disrespectful, abusive, or neglectful treatment during childbirth and maternal healthcare are widespread in many low-resource settings and disproportionately affects women from marginalized groups.\u003csup\u003e25,26\u003c/sup\u003e For homeless women who already face multiple stigmas related to poverty, housing status, and sometimes sex work, experience of disrespect from providers may be particularly damaging\u003csup\u003e23\u003c/sup\u003e, compounding their care seeking actions.\u003c/p\u003e\n\u003cp\u003eThe finding also revealed that some of these homeless women preferred male providers, a situation that contradicts general expectations about gender concordance in maternal healthcare. This unexpected preference was explained by negative experiences with female providers who were perceived as condescending or dismissive. This suggests that gender concordance alone does not guarantee quality care, but the interpersonal attitudes and professional conduct of providers equally matter.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe finding that living conditions substantially affect healthcare desire for 25 participants, but reportedly did not affect 13 participants warrants careful interpretation. The 13 homeless women who stated that their living situation did not impact their healthcare desire may represent either exceptional resilience, normalization of hardship, or reluctance to acknowledge vulnerability. Alternatively, these responses may reflect social desirability bias or a desire to project self-sufficiency despite difficult circumstances. Qualitative research with marginalized populations often encounters such response patterns, and researchers must interpret them within the broader context of participants\u0026apos; circumstances.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for practice and research\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several implications for maternal health service delivery for homeless the population of homeless pregnant and postpartum women developing countries. First, the recognition that pregnancy motivates healthcare engagement presents an opportunity for targeted outreach for education. Mobile antenatal clinics, flexible scheduling, and integration of antenatal services with other services that homeless women access could increase early and continuous care. Second, the substantial impact of financial barriers despite free maternal healthcare policy indicates the need to address hidden costs, including drugs, supplies, transportation, and opportunity costs. Voucher systems, drug subsidies, and integration of healthcare with income-generating activities merit exploration. Third, provider training on respect-to-care for marginalized populations is essential.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom global health perspective, this study contributes to understanding healthcare-seeking behaviours among a very marginalized populations in low-resource urban settings\u003csup\u003e9,29\u003c/sup\u003e The intersection of homelessness, poverty, gender, and maternal health creates unique challenges that require context-specific solutions. Experiences from Sekondi-Takoradi may inform interventions in other West African cities experiencing rapid urbanization, growing informal settlement, and inadequate housing, which are creating homelessness. The study demonstrates that providing nominally free healthcare is insufficient without addressing structural barriers, hidden costs, and interpersonal quality to provision of care.\u003c/p\u003e\n\u003cp\u003eFuture research should examine the effectiveness of mobile maternal health services for homeless women, explore male partners\u0026apos; roles in homeless women\u0026apos;s maternal healthcare decisions, document the experiences of healthcare providers serving homeless populations, and quantify maternal and neonatal outcomes among homeless women. Longitudinal studies would provide deeper understanding of care continuity challenges and opportunities among this group of women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of purposive and snowball sampling mean that results may not represent all homeless women in the metropolis or in the country. Women who agreed to participate may differ from those who declined. Data were collected at a single time point, capturing experiences at that moment, but not in a longitudinal pattern. Participants may have demonstrated social desirability bias, reporting what they believed researchers wanted to hear rather than their actual experiences and beliefs. Despite these limitations, the study provides valuable understanding of maternal health issues of a very vulnerable population that is often invisible in health research and policy.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMaternal healthcare utilization decisions among homeless women in Sekondi-Takoradi Metropolis are shaped by pregnancy recognition, illness severity, economic constraints, living conditions, and interpersonal experiences with healthcare providers. Pregnancy emerged as a primary motivator for formal care-seeking, while daily survival challenges often supersede preventive health behaviours. Financial barriers remain despite free maternal healthcare policy, reflecting implementation gaps and hidden costs to seeking care among these very vulnerable women. Provider attitudes and interpersonal treatment quality significantly influence their healthcare-seeking decisions. Ghana risks attaining the targets in SDG 3 unless provision of healthcare services cover the very vulnerable women in the country. So, we prosed a framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): Homeless Women Healthcare Service Utilization Framework, as important guideline to studying healthcare seeking behaviours or factors that influence healthcare seeking actions of homeless women who are pregnant or within the postpartum period.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Disclosure:\u003c/strong\u003e Nothing to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support:\u003c/strong\u003e There was no external funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e Ethical approval was granted by the Institutional Review Board of the University of Cape Coast (UCCIRB/CES/2023/165). Permission was also granted by the Sekondi-Takoradi Metropolitan Assembly and the Social Welfare Department. This was conducted in accordance with the Declaration of Helsinki for studying human and animal subjects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Patient Consent:\u003c/strong\u003e Informed consent was obtained verbally from all the participants after explaining to them study purpose, procedures, risks, benefits of the study and their right to withdraw. All participants consented to audio recording of interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFOA, EWA and SAE, Method, FOA, EWA and SAE, Data collection, FOA, Data management and analysis, FOA, EWA and SAE, initial draft, FOA, EWA and PYAK, Final review EWA and SAE. All authors review and approved the finial manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors acknowledge the homeless women who participated in this study and shared their experiences. We thank the Sekondi-Takoradi Metropolitan Assembly, Social Welfare Department, and community leaders for facilitating access to study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eTrends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division\u003c/em\u003e. World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eGhana Statistical Service. \u003cem\u003e2021 Population and Housing Census: General Report\u003c/em\u003e. GSS; 2022.\u003c/li\u003e\n\u003cli\u003eEsen UI. Understanding healthcare seeking behaviours of homeless women. \u003cem\u003eJ Soc Distress Homeless\u003c/em\u003e. 2017;26(2):133-140. doi:10.1080/10530789.2017.1305140\u003c/li\u003e\n\u003cli\u003eMcGeough C CB Walsh A. Barriers and facilitators perceived by women while homeless and pregnant in accessing antenatal and or postnatal healthcare: A qualitative evidence synthesis. \u003cem\u003eHealth Soc Care Community\u003c/em\u003e. 2020;28(5):1380-1393. doi:10.1111/hsc.13000\u003c/li\u003e\n\u003cli\u003eAsibey BO MB Conroy E. Health problems and healthcare service utilisation amongst homeless adults in Africa: a scoping review. \u003cem\u003eBMC Public Health\u003c/em\u003e. Published online 2020. doi:10.1186/s12889-020-08648-y\u003c/li\u003e\n\u003cli\u003eJohnson AK RS Haffejee F. Homeless pregnant women\u0026rsquo;s access to and use of health services: A systematic review. \u003cem\u003ePublic Health Nurs\u003c/em\u003e. 2017;34(3):240-252. doi:10.1111/phn.12314\u003c/li\u003e\n\u003cli\u003eGebreyesus T, Kassa A, Mihret MS. Barriers to antenatal care seeking among homeless pregnant women in urban Ethiopia: A phenomenological study. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2019;19(1):469. doi:10.1186/s12884-019-2612-5\u003c/li\u003e\n\u003cli\u003eGanle JK, Parker M, Fitzpatrick R, Otupiri E. A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2014;14:425. doi:10.1186/s12884-014-0425-8\u003c/li\u003e\n\u003cli\u003eRobinson CA, Atkinson SJ, Dierker LC, others. Health and social experiences of pregnant and parenting individuals experiencing homelessness: A mixed-methods study. \u003cem\u003eInt J Equity Health\u003c/em\u003e. 2025;24(1):3. doi:10.1186/s12939-024-02325-6\u003c/li\u003e\n\u003cli\u003eKopanitsa G, Kobrinskaya A, Danilov A. Digital health interventions for homeless people: A systematic review. \u003cem\u003eInt J Med Inf\u003c/em\u003e. 2023;171:104985. doi:10.1016/j.ijmedinf.2023.104985\u003c/li\u003e\n\u003cli\u003eGalvin E HJ Stack E, O\u0026rsquo;Donovan D. Barriers and facilitators affecting homeless individuals\u0026rsquo; access to healthcare services: A narrative synthesis. \u003cem\u003eHealth Soc Care Community\u003c/em\u003e. Published online 2024. doi:10.1155/2024/9941966\u003c/li\u003e\n\u003cli\u003eSekondi-Takoradi Metropolitan Assembly. Health services. Published online 2023. https://stma.gov.gh\u003c/li\u003e\n\u003cli\u003eNational Health Insurance Authority. Accredited health facilities. Published online 2023.\u003c/li\u003e\n\u003cli\u003eKneck A, Mattsson E, Ohlsson U, Klang B. Being homeless and needing care: Older adult women\u0026rsquo;s experiences. \u003cem\u003eNurs Open\u003c/em\u003e. 2021;8(5):2381-2391. doi:10.1002/nop2.857\u003c/li\u003e\n\u003cli\u003eSutherland R, Sinfield M, Rhodes N, others. Trauma-informed care: Accounts of healthcare delivery by women experiencing homelessness in Scotland. \u003cem\u003eHealth Expect\u003c/em\u003e. 2022;25(6):2828-2838. doi:10.1111/hex.13607\u003c/li\u003e\n\u003cli\u003eCreswell JW CV. Designing and conducting mixed methods research. \u003cem\u003e2nd Ed\u003c/em\u003e. Published online 2011.\u003c/li\u003e\n\u003cli\u003eMarshall C, Rossman GB. \u003cem\u003eDesigning Qualitative Research\u003c/em\u003e. 6th ed. SAGE Publications; 2014.\u003c/li\u003e\n\u003cli\u003eLi M, Urada LA. Homelessness in Los Angeles: Voices from the margins. \u003cem\u003eJ Public Health Manag Pract\u003c/em\u003e. 2020;26(Suppl 2):S51-S53. doi:10.1097/PHH.0000000000001131\u003c/li\u003e\n\u003cli\u003eCarroll A WA. Maternal healthcare experiences of women experiencing homelessness: A scoping review. \u003cem\u003eMidwifery\u003c/em\u003e. Published online 2024. doi:10.1016/j.midw.2023.103881\u003c/li\u003e\n\u003cli\u003eTerefe YT, Abebe Y, Teka H. Utilization of healthcare services among homeless pregnant and lactating women in Addis Ababa, Ethiopia. \u003cem\u003ePLoS One\u003c/em\u003e. 2022;17(3):e0265062. doi:10.1371/journal.pone.0265062\u003c/li\u003e\n\u003cli\u003eDavis EW, Lupo PJ, Taylor BD, others. Maternal housing instability and birth outcomes: A population-based study. \u003cem\u003ePaediatr Perinat Epidemiol\u003c/em\u003e. 2019;33(6):404-411. doi:10.1111/ppe.12583\u003c/li\u003e\n\u003cli\u003eDawson-Rose C, Cuca YP, Webel AR, others. Building trust and relationships between patients and providers: An essential complement to health literacy in HIV care. \u003cem\u003eJ Assoc Nurses AIDS Care\u003c/em\u003e. 2020;27(5):574-584. doi:10.1016/j.jana.2016.03.001\u003c/li\u003e\n\u003cli\u003eCampbell S et al Greenwood M, Prior S, Shearer T, Walkem K, Young S. Purposive sampling: complex or simple? Research case examples. \u003cem\u003eJ Res Nurs 2020 258 652-661\u003c/em\u003e. Published online 2020.\u003c/li\u003e\n\u003cli\u003eSmith JA, Osborn M. Interpretative phenomenological analysis. In: Smith JA, ed. \u003cem\u003eQualitative Psychology: A Practical Guide to Research Methods\u003c/em\u003e. 3rd ed. SAGE Publications; 2015:25-52.\u003c/li\u003e\n\u003cli\u003eStarks H, Trinidad SB. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. \u003cem\u003eQual Health Res\u003c/em\u003e. 2007;17(10):1372-1380. doi:10.1177/1049732307307031\u003c/li\u003e\n\u003cli\u003eSaunders B, Sim J, Kingstone T, others. Saturation in qualitative research: Exploring its conceptualization and operationalization. \u003cem\u003eQual Quant\u003c/em\u003e. 2018;52(4):1893-1907. doi:10.1007/s11135-017-0574-8\u003c/li\u003e\n\u003cli\u003eStuttaford M, Hundt GL, Vostanis P. Homelessness and access to mental health services in South Africa. \u003cem\u003eVulnerable Child Youth Stud\u003c/em\u003e. 2009;4(2):102-109. doi:10.1080/17450120902730373\u003c/li\u003e\n\u003cli\u003eCreswell JW. \u003cem\u003eQualitative Inquiry and Research Design: Choosing among Five Approaches\u003c/em\u003e. 3rd ed. SAGE Publications; 2012.\u003c/li\u003e\n\u003cli\u003eKruk ME, Kujawski S, Mbaruku G, others. Disrespectful and abusive treatment during facility delivery in Tanzania: A facility and community survey. \u003cem\u003eHealth Policy Plan\u003c/em\u003e. 2018;33(1):e26-e33. doi:10.1093/heapol/czu079\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Participant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e18-42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e16 (42.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e15 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e7 (18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePregnancy Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eCurrently pregnant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e22 (57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eWithin 6 weeks postpartum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e16 (42.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Income Source\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eStreet vending/hawking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e18 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eLoad carrying (Kayayi)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e8 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eDomestic work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e5 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBegging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e4 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eOther informal work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 187px;\"\u003e\n \u003cp\u003e3 (7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Motivations for Seeking Healthcare and Impact of Living Situation\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"640\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative Quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat Motivates Healthcare-Seeking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003ePregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;It\u0026apos;s not right to not go to the hospital while you\u0026apos;re pregnant because you don\u0026apos;t know what is happening to the baby\u0026quot; (PHN 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eIllness severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;It is the sickness that drives me. Yes, when it gets serious\u0026quot; (PHN 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eRoutine check-ups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;As a human being, you need to go for healthcare before something even happens to you\u0026quot; (PHN 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNo motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;No oo nothing pushes me\u0026quot; (PHN 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact of Living Situation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eDoes not affect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;It\u0026apos;s okay with my health, nothing bothers me\u0026quot; (PHN 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eSubstantially affects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 366px;\"\u003e\n \u003cp\u003e\u0026quot;If I get it, I will go, but where is the money? I don\u0026apos;t have it\u0026quot; (PHN 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Preference for Healthcare \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"647\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvider Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Reasons\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eDoctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e14 (36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003eSuperior knowledge, experience, qualifications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003eGender concordance (female), efficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (7.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003eSpecialization, gentle examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eNo preference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e11 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003ePrioritize competence and respect over provider type\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 426px;\"\u003e\n \u003cp\u003eQuick service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"homeless women, maternal healthcare utilization, pregnancy, healthcare access, Ghana, interpretative phenomenology","lastPublishedDoi":"10.21203/rs.3.rs-8671982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8671982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e \u003cem\u003eHomeless women experience significant barriers to access maternal healthcare services. Understanding the factors that shape healthcare-seeking decisions of homeless women is essential for developing responsive services. This study examined factors influencing maternal healthcare service utilization decisions among homeless women in Sekondi-Takoradi Metropolis in Ghana.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e This qualitative study employed interpretative phenomenological analysis. Using purposive sampling method, 38 homeless women aged 18-42 years who were pregnant or within the postpartum period were recruited from various locations in Sekondi-Takoradi Metropolis between August and November 2023 for the study. Semi-structured face-to-face interviews were conducted using the Fante language, audio-recorded, transcribed verbatim, and analysed thematically. The study adhered to COREQ guidelines.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e Four major themes emerged regarding motivations to seek care: pregnancy, illness severity, routine check-ups, and no motivation. When asked about the impact of living conditions on healthcare-seeking desires, 25 participants reported substantial negative effects related to financial constraints, physical exhaustion, and lack of time, while 13 reported no impact. Regarding provider preferences, participants chose doctors, nurses, midwives, pharmacists, while some expressed no preference. Homeless women valued professional qualifications and respectful treatment over provider type.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions and global health implications:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e Maternal healthcare utilization decisions among homeless women are shaped by their immediate health needs, economic constraints, living conditions, and interpersonal experiences with healthcare providers. Pregnancy emerged as a primary motivator for formal care-seeking, while daily survival challenges often supersede preventive health behaviours. Healthcare systems need to adapt service delivery models to address the vulnerabilities of homeless pregnant women through flexible scheduling, reduced financial barriers, and sensitized provider interactions. These adaptations can improve maternal health outcomes and reduce disparities experienced by homeless women in urban low-resource contexts.\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"Factors Influencing Maternal Healthcare Service Utilization Decisions among Homeless Women: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 16:40:00","doi":"10.21203/rs.3.rs-8671982/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-06T18:01:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T16:58:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T12:32:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273963233569056225289235125197985733274","date":"2026-02-12T15:53:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4504192128620168763872409342203441596","date":"2026-02-12T14:41:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15205096976220541621196290483065422988","date":"2026-02-11T14:10:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336805106986380529177782841518870409112","date":"2026-02-11T08:50:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T19:00:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T17:08:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-28T17:20:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-28T17:11:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c55470da-40db-4112-9a4f-5127849e621e","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:40:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 16:40:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8671982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8671982","identity":"rs-8671982","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}