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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Pregnancy Childbirth . 2026 Mar 3;26:391. doi: 10.1186/s12884-026-08834-7 Search in PMC Search in PubMed View in NLM Catalog Add to search Poverty during pregnancy as a health inequality: pregnant women’s experiences in accessing primary health services Bilge Türkoğlu Bilge Türkoğlu 1 Health Sciences Faculty, Department of Social Work, Ondokuz Mayıs University, Samsun, Turkey Find articles by Bilge Türkoğlu 1, ✉ , Serap Öztürk Altınayak Serap Öztürk Altınayak 2 Health Sciences Faculty, Department of Midwifery, Ondokuz Mayıs University, Samsun, Turkey Find articles by Serap Öztürk Altınayak 2 , Kübranur Görmüş Kübranur Görmüş 3 Graduate School of Health Sciences, Social Work Department, Ankara University, Ankara, Turkey Find articles by Kübranur Görmüş 3 Author information Article notes Copyright and License information 1 Health Sciences Faculty, Department of Social Work, Ondokuz Mayıs University, Samsun, Turkey 2 Health Sciences Faculty, Department of Midwifery, Ondokuz Mayıs University, Samsun, Turkey 3 Graduate School of Health Sciences, Social Work Department, Ankara University, Ankara, Turkey ✉ Corresponding author. Received 2025 Nov 21; Accepted 2026 Feb 13; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13067725 PMID: 41776441 Abstract Background Comprehensive healthcare services -encompassing medical, nutritional, and psychosocial support provided by primary healthcare professionals- are crucial for safeguarding maternal and fetal health. High-quality healthcare provided during the preconception and pregnancy phases positively influences the postpartum process. However, due to economic constraints, not all pregnant women have equal access to primary healthcare services, leading to challenging conditions throughout their pregnancies. Methods This study aimed to explore the experiences of pregnant women living below the poverty line in accessing primary healthcare services. Adopting a phenomenological qualitative design and using purposive sampling, 19 pregnant women living under the poverty threshold in Turkey were recruited, and in-depth telephone interviews were conducted. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed. Results The data were analyzed through thematic analysis. Four main themes emerged: personal and cultural differences, income disparity, healthcare service delivery, and regional disparities. Participants highlighted barriers such as transportation costs, inability to afford prescribed medications, and negative interactions with healthcare staff in public institutions. Conclusions The findings suggest that to improve the adequacy, quality, and inclusiveness of primary healthcare services in Turkey, socioeconomic and regional inequalities must be minimized, and service delivery models should be diversified to meet the needs of vulnerable populations. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-026-08834-7. Keywords: Poverty, Pregnancy, Access to primary health care, Health inequality, Maternal health Background Maternal and fetal health are among the key indicators used to assess the effectiveness of a country’s healthcare system [ 1 , 2 ]. Despite rapid and significant advancements in access to healthcare services globally and in Turkey in recent years, maternal and infant mortality rates have yet to reach the targets set by the Sustainable Development Goals and national strategic health plans. This situation indicates that the quality of healthcare services remains inadequate and that inequalities are still widespread [ 3 ]. Reducing these rates requires not only improving the quality of healthcare services but also ensuring accessibility for all. Moreover, it is essential to guarantee that all individuals, including those in lower socioeconomic groups, benefit from these services through an equitable approach that prioritizes resource allocation based on specific needs rather than mere equality [ 4 – 6 ]. In this regard, access to health services structured with such a perspective—from the preconception period through pregnancy and the postpartum phase—should be considered both a vital social policy and a fundamental human right. Global health initiatives since the 1980 s have prioritized improving maternal health [ 7 ]. In the Millennium Development Goals (MDGs) adopted in 2000, improving maternal health and reducing child mortality were among the core targets [ 8 ]. Numerous studies have emphasized that adverse health conditions and low socioeconomic status disproportionately affect women and infants [ 9 , 10 ], resulting in systematic disparities in health outcomes [ 11 , 12 ]. These disparities are particularly concerning in low-income and developing countries as well as in rural areas of developed countries [ 13 , 14 ]. Moreover, given that pregnancy and childbirth are considered critical turning points in a person’s lifelong health trajectory, poverty experienced during this period is likely to have intergenerational and multifaceted negative consequences [ 15 – 17 ]. Poverty—defined not only by low income but also by limited access to quality healthcare, low educational attainment, and diminished power—is a complex phenomenon reflecting multiple dimensions of inequality [ 3 ]. It is estimated that approximately 1.5 billion people worldwide live below the absolute poverty line, with women comprising more than half of this population [ 18 , 19 ]. This presents serious concerns for pregnant women navigating the complex processes of pregnancy, childbirth, and the postpartum period. Indeed, maternal health outcomes vary significantly across socioeconomic groups, with a strong correlation between poverty and maternal mortality in low-income and developing countries [ 20 ]. Pregnant women in poverty are often exposed to multiple risk factors, including biological, social, environmental, and psychological challenges [ 21 ]. Additional vulnerabilities such as single motherhood, adolescent pregnancy, overcrowded or unsanitary living conditions, unemployment, HIV/AIDS, and malnutrition are also prevalent [ 22 , 23 ]. Consequently, their infants are more likely to face developmental disadvantages [ 24 , 25 ]. It is noteworthy that many complications threatening women’s health—such as infections, severe hemorrhage, hypertension, high-risk pregnancies, and unsafe abortions—are preventable. This highlights the critical importance of access to quality healthcare throughout the preconception, pregnancy, and postpartum stages [ 26 , 27 ]. Despite the importance of the topic, a review of the literature reveals a limited number of studies focusing specifically on pregnant women living in poverty [ 1 , 21 , 23 – 25 , 28 – 32 ]. These studies emphasize how demographic, socioeconomic, cultural, and geographical differences create barriers to healthcare access [ 11 , 33 ]. Penchansky and Thomas [ 34 ] identify five dimensions of healthcare access: availability, accessibility, accommodation, affordability, and acceptability. Others have grouped the barriers into sociocultural values, women’s autonomy, economic status, physical accessibility, type of health services, and illness categories [ 35 , 36 ]. Equally important is access to health-related information. Javanmardi et al. [ 37 ] draw attention to the challenges pregnant women face in obtaining accurate and timely information - particularly due to competing responsibilities at home and outside, limited education and employment, confusion between accurate and misleading information, lack of effective interaction with healthcare providers, and anxiety when dealing with pregnancy-related problems. The World Health Organization [ 27 ] lists key barriers to maternal healthcare as poverty, geographic distance to facilities, lack of information, insufficient or poor-quality services, and cultural beliefs and practices. Thus, access to healthcare emerges as a critical determinant not only for preventing diseases and early deaths but also for promoting health equity and awareness [ 11 , 38 , 39 ]. Given the link between poverty and negative maternal outcomes, reducing the barriers poor women face in accessing healthcare must be prioritized. According to the ‘Trends in maternal mortality 2000 to 2020’ report [ 40 ] published in 2023, global maternal mortality declined by approximately 34% during this period. However, over 800 women still die each day due to pregnancy or childbirth-related complications and infectious diseases [ 27 , 40 , 41 ]. Regional data show that Sub-Saharan Africa and South Asia account for 86% of global maternal deaths, with maternal mortality rates of 542 per 100,000 live births in Sub-Saharan Africa, compared to 12 in Europe and North America and 73 in Latin America and the Caribbean. In Turkey, significant progress has been made, with the maternal mortality ratio declining from 56 per 100,000 live births in 2000 to 15 in 2023 [ 40 ]. The Sustainable Development Goals (SDGs) established by the United Nations offer a framework for reducing global inequalities and injustices. In this context, SDG1 (No Poverty), SDG5 (Gender Equality), and SDG10 (Reduced Inequalities) are especially relevant [ 42 ]. SDG1 emphasizes access to essential goods and services and the effective implementation of social protection systems, particularly for vulnerable groups—making it a key goal in addressing the challenges faced by pregnant women living in poverty. Relatedly, SDG5 and SDG10 support gender-sensitive policy-making and equitable resource allocation, aiming to eliminate discrimination, ensure legal protection, and implement financial and social measures that promote equality [ 42 , 43 ]. In Turkey, notable improvements have been made in maternal and child health in recent years. Nevertheless, access to quality healthcare remains uneven, with disparities shaped by factors such as poverty. According to the 2023 Income and Living Conditions Survey by the Turkish Statistical Institute, poverty rates are 13.9% (based on 50% of median income), 21.7% (based on 60%), and 29.7% (based on 70%). Households composed of multiple members without a nuclear family have the lowest poverty rates [ 44 ]. According to the 2023 report by the Confederation of Turkish Trade Unions, the poverty threshold for a family of four reached 44,573.30 TRY (approx. $1,857 USD based on the 2023 average exchange rate), and the hunger threshold 13,683.99 TRY (approx. $570 USD). By February 2024, these figures rose to 52,955 TRY and 16,257 TRY, respectively [ 45 ]. These figures illustrate the severe implications of poverty during pregnancy, particularly in a context of hyperinflation, which affects pregnant women and children first and foremost. This study creates a unique opportunity to observe maternal health behaviors not just in chronic poverty, but specifically within the context of a deepening economic crisis and hyperinflation, distinguishing it from traditional poverty studies. Given this background, it becomes necessary to investigate the challenges and lived experiences of pregnant women living below the poverty line regarding their access to primary healthcare services. Therefore, the present study aims to explore the healthcare access experiences of pregnant women living in poverty. It focuses on understanding their specific needs and the barriers they face during the process. The findings are discussed within the framework of SDG1, SDG5, and SDG10, and corresponding recommendations are provided. To this end, the overarching aim of this study is to explore the multifaceted challenges faced by pregnant women living in poverty. Specially, the study seeks to answer the following research questions in the context of SDG1, SDG5, and SDG10: RQ1. What are the healthcare access experiences of pregnant women living below the poverty line? RQ2. What are the needs of pregnant women living in poverty during the healthcare access process? RQ3. What challenges do pregnant women living in poverty face in accessing healthcare services? Methods Research design This study adopts a descriptive phenomenological design grounded in Husserl’s philosophy [ 46 ]. This approach was chosen to describe the universal essence of the “lived experiences” of pregnant women living in poverty regarding healthcare access, without the interference of pre-existing theories or interpretations. To ensure the findings emerged directly from the participants, the researchers employed bracketing, consciously setting aside their own assumptions, knowledge, and biases throughout the data collection and analysis process. The aim is to understand the specific difficulties these women face in accessing healthcare and to assess their needs within the framework of the Sustainable Development Goals (SDG1, SDG5, and SDG10). Qualitative research is particularly well-suited to investigating the non-measurable essence of situations or phenomena through meanings, definitions, characteristics, and symbolic interpretations [ 47 ]. In this context, descritive phenomenology was chosen to derive a scientific and collective understanding of how poverty affects access to healthcare from the lived experiences of pregnant women [ 48 , 49 ]. The reporting of this study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. The research team consists of three female academics specializing in social work and midwifery. Our shared professional background in health and social sciences facilitated rapport building with the participants. However, acknowledging that our professional knowledge could influence interpretation, we maintained reflexivity throughout the study. This involved regular peer debriefing sessions and the use of reflective journals to document and examine our own emotional responses and preconceptions, ensuring they did not overshadow the participants’ voices. Study group The study employed criterion sampling, a purposive sampling technique in which participants are selected based on pre-established criteria relevant to the research objective [ 50 , 51 ]. This approach enables the selection of individuals with high potential to provide rich data and allows for an in-depth investigation of the phenomenon [ 52 ]. The inclusion criteria for participant selection were as follows: Aged 18 years or older, Currently experiencing a healthy pregnancy, Having an income below the poverty threshold, Willing to participate in an audio and/or video interview via a digital device. Note on technology access Although living below the poverty threshold, mobile phone ownership is widespread in Turkey as a primary means of communication. Participants often owned older models or shared devices within the household, enabling access to digital interviews. Participants under 18 years of age were excluded due to legal and ethical constraints in Turkey requiring parental consent, which could compromise the privacy of pregnant adolescents. Additionally, the study focused on women with ‘healthy pregnancies’ to specifically examine barriers to accessing routine primary healthcare services. High-risk pregnancies often require specialized tertiary care and emergency interventions, which present different clinical and accessibility dynamics outside the scope of this study. The poverty threshold was defined using the monthly income data released by the Turkish Statistical Institute between September 2022 and April 2023. Collaboration with midwives working in primary healthcare centers facilitated the recruitment process. To minimize selection bias, midwives were instructed to invite all pregnant women meeting the income criteria during the study period, regardless of their communication skills or compliance with medical advice. Midwives provided potential participants with a standard information brochure during their routine visits. This document outlined the study’s aims and explicitly stated that participation was strictly voluntary and that declining to participate would have no negative impact on the healthcare services they received. Referred individuals received detailed information about the study’s purpose, content, confidentiality measures, and interview process. Following this preliminary conversation, individuals who agreed to participate were provided with an invitation letter and informed consent was obtained. Main interviews were then conducted at scheduled times. Data collection Data were collected using a semi-structured interview form developed by the researchers. The interview questions were informed by a review of literature and definitions related to primary healthcare. The initial draft was reviewed by two subject-matter experts and revised accordingly. Two pilot interviews were conducted to test the form; these were not included in the final analysis. The final version consisted of two sections: The first section included demographic questions (e.g., age, education level, employment status, gestational month, insurance coverage, and whether the pregnancy was planned). The second section addressed participants’ experiences related to family planning services, nutrition, economic conditions, the influence of family, environment and traditions on healthcare access, and the adequacy of health insurance. A total of 22 women were contacted through midwives for preliminary interviews. Of these, 21 agreed to participate. One woman declined due to family-related reasons, and two others withdrew during the interview. The study was concluded upon reaching data saturation. Francis et al. [ 53 ] recommend conducting 10 initial interviews and continuing until three consecutive interviews yield no new data. A similar strategy was followed in this study, and when no new themes emerged, the interviews were concluded. Ultimately, 19 pregnant women from various provinces in Turkey participated between September 2022 and April 2023. Interviews lasted an average of 35 min and were conducted via phone calls with audio recording only, as participants expressed discomfort with video communication. Choosing telephone interviews was a methodological preference to ensure participants felt safe and unjudged in their domestic environment, allowing them to express their financial and emotional distress more freely without the pressure of a face-to-face encounter. While telephone interviews provided anonymity and comfort for participants in their domestic environments, they presented challenges such as the inability to observe non-verbal cues. To mitigate this limitation, the researcher focused on active listening and paid close attention to vocal intonations and pauses. A supportive and non-judgmental conversational tone was maintained to encourage participants to express themselves freely. Psychological safety protocol Given the sensitive nature of poverty and health, a distress protocol was implemented. The interviewer was trained to recognize signs of emotional distress (e.g., crying, prolonged silence). If distress occurred, the interview was paused, and the participant was asked if they wished to stop. Participants expressing severe anxiety or need were referred to the hospital’s social work unit for further support. All interviews were audio-recorded with verbal consent and later transcribed verbatim in Turkish. The participants reside in different cities across Turkey. Their ages range from 22 to 39 years, with a mean age of 29.5. Regarding educational background, 2 participants are primary school graduates, 3 have completed secondary school, 7 are high school graduates, 3 hold associate degrees and 4 hold bachelor’s degrees. Twelve participants are unemployed housewives, 3 are on maternity leave due to pregnancy, and 4 are actively working. Data analysis Data collection began following ethical approval granted by the Ondokuz Mayis University Social and Human Sciences Research Ethics Committee on May 27, 2022. The transcribed interviews were analyzed using MAXQDA22 software, employing thematic analysis. This method identifies recurring patterns of meaning within a dataset and brings together both explicit and latent themes [ 54 ]. The data were analyzed using the six-step thematic analysis framework proposed by Braun and Clarke [ 55 ]. The process involved: Familiarization with the data through repeated reading; Generating initial codes; Searching for themes; in this phase, researchers looked beyond the semantic content to identify latent themes—underlying ideas, assumptions, and conceptualizations regarding poverty and gender roles. While the initial coding was inductive (data-driven), the final interpretation of themes was deductive, guided by the theoretical framework of the Sustainable Development Goals (SDG 1, SDG 5, and SDG 10). This lens allowed the researchers to interpret individual experiences as reflections of broader structural inequalities. Reviewing themes; Defining and naming themes; and. Producing the final report. All interviews were conducted by a single researcher experienced in qualitative methods. After transcription, participant identities were anonymized and coded numerically. In the initial phase, open coding was applied to each transcript, followed by the development of a comprehensive code list. These codes were then reviewed, and meaningful categories were grouped into themes and sub-themes. To ensure consistency, all interviews were conducted using the same semi-structured guide and the same recording device. Data analysis was carried out collaboratively by all three researchers, who worked in coordination throughout the process. Trustworthiness Trustworthiness was established using Lincoln and Guba’s [ 56 ] criteria: Credibility : Ensured through prolonged engagement with the data and researcher triangulation. Transferability : Supported by providing a ‘thick description’ of the participants and the study context. Dependability : Maintained by keeping a detailed audit trail of the research process. Confirmability : Achieved through the use of reflexivity and bracketing to minimize researcher bias. Results A total of 19 pregnant women participated in the study. Participants resided in various cities across Turkey and ranged in age from 22 to 39, with a mean age of 29.5 years. Educational backgrounds varied: 2 participants had completed primary school, 3 middle school, 7 high school, 3 associate degrees, 3 undergraduate degrees, and 1 held a master’s degree. Among the participants, 12 were homemakers and unemployed, 3 were on pregnancy-related leave, and 4 were actively employed (Table 1 ). Table 1. Descriptive characteristics of the participants Name Age Education level Employment status Gestational age (weeks) Pregnancy order (parity) K1 29 Primary school Housewives and not employed 30 w 4 K2 33 Bachelor’s degree Actively working 18 w 2 K3 32 Secondary school Housewives and not employed 36 w 3 K4 30 Secondary school Housewives and not employed 36 w 3 K5 34 High school Housewives and not employed 24 w 1 K6 37 Bachelor’s degree Housewives and not employed 20 w 2 K7 32 Bachelor’s degree On maternity leave 32 w 1 K8 27 High school Actively working 28 w 2 K9 22 High school Housewives and not employed 28 w 1 K10 39 Primary school Housewives and not employed 24 w 4 K11 23 High school Actively working 12 w 1 K12 26 Associate’s degree Housewives and not employed 20 w 2 K13 37 High school Housewives and not employed 20 w 3 K14 27 Bachelor’s degree Actively working 28 w 1 K15 25 Secondary school Housewives and not employed 8 w 2 K16 30 Associate’s degree On maternity leave 24 w 1 K17 24 High school Housewives and not employed 24 w 2 K18 30 High school On maternity leave 26 w 3 K19 25 Associate’s degree On maternity leave 32 w 1 Open in a new tab *Maternity leave refers to the statutory paid leave provided under Turkish Labor Law The analysis revealed four main themes that shaped the pregnancy experiences of women living in poverty: (1) personal and cultural differences, (2) income disparities, (3) healthcare service provision, and (4) regional inequalities. These themes and their associated subthemes were found to reflect the broader contexts of inequality, social stereotypes, accessibility, and systemic barriers, and were interpreted in relation to SDG 1 (No Poverty), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). Personal and cultural differences: “The more negative things you think, the worse it gets.” The analysis revealed that for women living in poverty, barriers to healthcare are not merely structural but are deeply internalized through lack of ‘health literacy’ and cultural norms. Participants often viewed healthcare not as a right, but as a luxury accessed only in emergencies. This culture of hesitation was exacerbated by previous traumatic experiences, such as miscarriages, which transformed the pregnancy journey from a hopeful process into a period of intense anxiety and vigilance. “I couldn’t attend. I mean, they said there were these kinds of things to join, but I couldn’t because I was busy taking care of the kids.” (P4). “It was my first pregnancy. I was very inexperienced and didn’t know anything. I mean, I didn’t even know I had to go to the health center… I didn’t get my vaccinations.” (P12). Some participants, however, reported attending a “pregnancy school”—a free educational program organized by the Ministry of Health—based on recommendations from healthcare professionals. These sessions helped them gain knowledge about nutrition, physical exercise, and infant care. “There were training sessions supported by the municipality. I attended twice. They included information on breastfeeding, baby care, postpartum experiences, and also some exercise guidance.” (P7). Previous miscarriage experiences Several participants reported previous pregnancy losses, including miscarriages, ectopic pregnancies, and infant death shortly after birth. These experiences had a significant emotional impact on their subsequent pregnancies, often leading to anxiety and heightened vigilance. “I usually have spotting between the 8th and 10th weeks in my pregnancies. It happened with my first son too, and I had to get an injection to prevent miscarriage. In my second pregnancy, it was during a holiday, and I was in the village. Even though we got to the hospital, the spotting didn’t stop, and unfortunately, the heartbeat was gone. I miscarried at 10 weeks.” (P18). “This is technically my third pregnancy. With the miscarriage, it’s actually my fourth. At first, it looked like an ectopic pregnancy… I was so anxious. I was going to check-ups nearly every week. After a miscarriage, you become really cautious—you constantly monitor every little movement.” (P8). “This should actually be my fifth, but none survived. They were born sick and premature. We were constantly in and out of hospitals. My first baby lived for four months, the second for eight, the third for six… Last year, I had a miscarriage at two months.” (P5). Negative thoughts and emotions during pregnancy One of the subthemes that emerged from the interviews was the experience of stress, fear, anxiety, and worry related to pregnancy. These emotions were often expressed negatively and appeared to be shaped by previous traumatic or difficult experiences associated with childbirth or health complications. “During my first delivery… I had difficulty breathing. I still haven’t gotten over that psychological state. I’m afraid the same might happen again. What if I don’t wake up from the anesthesia?” (P6). “One of my twins died. I think it was due to family problems and stress. I was in a crowded environment. How comfortable can you be in that situation?” (P9). “They told me there was a hole in the baby’s heart. I was so scared because I had never experienced anything like that before.” (P17). Several women also reported experiencing the devastating earthquakes centered in Kahramanmaraş on February 6, 2023, during their pregnancy, which they described as exacerbating their psychological distress. “During pregnancy, when you keep thinking negatively, it really affects you. I kept asking myself how I would manage everything, especially after the disaster. I had to leave the city and stay with my family for about ten days because I was in such a bad mental state.” (P9). “After the earthquake… I felt fear and anxiety. At first, I couldn’t even drink water. But since we were carrying a baby, we had no choice. We kept going with prayers.” (P18). Physician gender Many women noted a preference for female physicians, stating that they felt more comfortable with them. However, most also emphasized that medical expertise was ultimately more important than gender. “My doctor is male. There’s also a female doctor in the hospital, but we never thought much about gender. We go to whoever is more experienced. Health comes first.” (P13). “You don’t really have a choice. You just have to go. My current doctor is better, but if circumstances don’t allow, there’s nothing you can do.” (P3). “Some people in my environment question why I go to a male doctor. But I prioritize my health, not the doctor’s gender.” (P13). Cultural stereotypes around healthcare utilization Participants reported social pressure regarding the frequency of doctor visits and working during pregnancy. Some shared how family members discouraged frequent medical checkups or prenatal tests, which reflects the impact of deep-rooted cultural beliefs. “There are often ingrained beliefs about childrearing and pregnancy in families. For instance, my mother-in-law didn’t think I needed extra checkups after we found out the baby’s gender. There’s this belief that going to the doctor too often is unnecessary or even harmful.” (P7). Income disparities: “I only use medication when I absolutely have to, so it doesn’t run out too soon” Income disparity manifested not just as a lack of funds, but as a constant trade-off mechanism. Participants were frequently forced to choose between purchasing essential nutrition/medication and covering other household survival needs. The data suggests that poverty effectively strips women of their autonomy to manage their pregnancy health, forcing them to ration prescribed medications or skip ‘optional’ screenings, thereby turning recommended medical protocols into impossible financial burdens. “Well, I want to eat better and consume healthier things during my pregnancy, but sometimes it’s just not possible due to financial limitations.” (P5). Payment difficulties Participants stated that they struggled to pay for medications, consultations, and certain medical tests. Particularly, unexpected and urgent situations requiring visits to private hospitals posed significant financial burdens. “I only use my medication when absolutely necessary so it doesn’t run out quickly. If I took it continuously, a 2–3 day supply wouldn’t be enough for me. Taking medicine every three days is insufficient.” (P9). “Anything can happen during pregnancy. For example, if I experience a sudden dark discharge, I have to go to the hospital immediately. Such sudden expenses arise. You know that it’s difficult to get an appointment quickly at public hospitals due to overcrowding, so sometimes you have to go to a private hospital. But private hospital fees are already high.” (P7). Limitations of social insurance coverage Pregnant women explained that social insurance provides limited coverage for payments and often does not cover certain medications at all. Given the diverse needs during pregnancy, this creates inequalities in access to necessary services. Especially for unexpected conditions or tests requiring private healthcare, the financial burden becomes significant. “Taking medication every three days isn’t enough for me. I face serious difficulties. Also, since we are newly married, we have debts to pay off alongside child-related expenses, so it’s challenging.” (P9). “I think it’s insufficient. Pregnant women should not be charged for essential medications like vitamins or folic acid. We pay for all other medications, even painkillers, during illnesses. When I was pregnant with my eldest son about 16 years ago, pregnancy medications were free; now they are charged.” (P13). Working conditions during pregnancy Pregnant participants highlighted the difficulties of working while pregnant, including the challenges of continuing work until the last month and balancing the role of a working mother. Particularly, those engaged in physical labor noted risks to their own health and their babies. “Since I work in cleaning, it’s hard. You can’t bend or straighten up during certain months. I want to pick up trash, but I can’t. They say it affects the bones of children… there is also the risk of premature birth.” (P8). “I experienced a miscarriage risk and bleeding. I was on medical leave at home, then I had another bleeding episode. I was hospitalized. I have a herniated disc and can’t stand for long. My work requires standing. I couldn’t risk the baby, so I had to quit. I had planned to work until the baby was 7 or 8 months old.” (P16). “The reason I leave work late is financial — the later I leave, the more salary I get. I think more prenatal support should be provided.” (P19). Provision of health services: “Even getting an appointment is difficult” The structural inadequacies of the public healthcare system -overcrowding, short consultation times, and appointment scarcity- were perceived by participants as a form of institutional neglect. The sharp contrast drawn between public and private care highlights a dual-standard health system where ‘care with dignity’ is perceived as a commodity available only to those who can pay. Negative interactions with healthcare staff in public facilities further alienated these vulnerable women, creating a psychological barrier to seeking future care. “We don’t usually have problems with what public hospitals do, but even getting an appointment is hard unless you know someone. You have to go early in the morning and wait in line, your feet swell while waiting… The hospital is big, but there are only two birth control specialists, and they are not enough. There are people coming from villages and surrounding areas, but the number of doctors is too low.” (P13). “Doppler ultrasound is only available in one hospital, but I can’t get an appointment. I went to a private hospital for my first birth, but now, due to financial reasons, I can’t.” (P6). Public-private hospital divide Pregnant women expressed dissatisfaction with services at public hospitals, reporting that the facilities and availability (due to high patient load and limited medical staff) are inadequate to meet the needs of pregnant patients. “Detailed ultrasounds are done in private clinics, but it’s difficult for someone earning minimum wage.” (P13). “Public hospitals are overcrowded. They can’t give enough attention. I would prefer the good doctor I know there, but I have to go private because I can’t otherwise.” (P19). Health workers’ attitudes and behaviors Participants noted variability in attitudes and behaviors of health workers between hospitals and individuals. Generally, they felt that health workers in public hospitals were less attentive due to high workload and provided limited explanations, contrasting with private hospitals. Indifference and sometimes aggressive behavior discouraged women from seeking care. “When I went to the hospital for bleeding, the doctor in the emergency room was very rude. I was already scared, worried about losing the baby. The doctor said, ‘If you’re going to stay, stay; if not, go home. But don’t come back saying you lost the baby.’” (P16). “Some doctors are very kind, some are very rude. I prefer to go to those who are kind. My doctor is very good with patients, which comforts me psychologically.” (P5). Regional differences: “Since we live in the village, these services don’t exist” Geography acted as a compounding factor to poverty. For rural participants, the ‘distance decay’ effect was evident; the physical distance to health centers, combined with the cost of transportation, rendered free public health services effectively inaccessible. This theme underscores that ‘universal coverage’ on paper does not translate to ‘universal access’ in practice when physical and economic mobility is restricted Urban-rural living divide. Women living in rural areas reported limited awareness of certain services or found these services geographically inaccessible. Such limitations restrict access to healthcare. “I have never participated in anything like this before… Since we live in the village, these services don’t exist here.” (P1). “No, no. We are at the top of the plateau, in the village… I have never participated.” (P3). Transportation conditions Pregnant women needing to travel to different districts or cities for specific services faced additional challenges that hindered their use of health services. “The service isn’t available where I live (district). My doctor referred me to a place about one and a half to two hours away… These things really cause difficulties. Not everyone can afford to travel by car to another city or private hospitals.” (P13) “The service isn’t available where I live (district). My doctor referred me to a place about one and a half to two hours away… These things really cause difficulties. Not everyone can afford to travel by car to another city or private hospitals.” (P13). Discussion This study aimed to explore the experiences of pregnant women living below the poverty line in accessing basic health services. Four main themes emerged: personal and cultural differences, income disparities, healthcare service delivery, and regional inequalities. Key issues highlighted by participants included economic status, insufficient knowledge about family planning, challenges faced by working mothers, disparities between public and private healthcare institutions, transportation difficulties, inadequacies within healthcare facilities, attitudes and behaviors of healthcare providers, and previous negative pregnancy experiences. Conversely, family and spousal support, vaccinations during pregnancy, and routine prenatal monitoring were positively emphasized. These findings illustrate that poverty operates as a fundamental cause of health inequality, restricting access through multiple intersecting pathways -material deprivation, psychosocial stress, and structural exclusion -which we discuss below using the ‘5 As’ framework. Health services are critical during pregnancy, childbirth, and the postpartum period in terms of ensuring maternal and infant health. Proper pregnancy planning and regular antenatal checkups play a crucial role in mitigating potential risks [ 57 ]. In this context, “access” is a widely used but often ambiguously defined concept within the field of healthcare. Some scholars conceptualize access not only as entry into the healthcare system but also as the ability to utilize available services. As such, a comprehensive analysis of access requires considering multiple dimensions: availability, accessibility, accommodation, affordability, and acceptability [ 34 ]. These dimensions offer a valuable framework for understanding how poverty shapes pregnant women’s access to health services. The findings of this study are also discussed in light of the Sustainable Development Goals (SDGs), particularly Goals 1 (No Poverty), 5 (Gender Equality), and 10 (Reduced Inequalities Accordingly, the discussion interprets the study’s findings through the lens of the five aforementioned dimensions of access. Availability and the access of poor pregnant women to healthcare services Availability refers to the relationship between the volume and types of existing services and the volume and types of services required by individuals. This includes evaluating the adequacy of hospitals, physicians, clinics, and specialized services such as emergency care [ 34 ]. Participants emphasized the insufficiency of both healthcare professionals and hospital infrastructure. This aligns with a study conducted in Nigeria, where focus group discussions revealed four central barriers to maternal healthcare: (i) poor accessibility, (ii) inadequate supply of drugs and medical materials, insufficient number of doctors, and long waiting times leading to perceptions of poor quality, (iii) high costs and informal payments requested by staff, and (iv) lack of partner support and inadequate evaluation of complications [ 58 ]. These themes—transportation, economic hardship, healthcare quality, and cultural beliefs—resonate with the sub-themes of the current study. Commonalities such as the distance to hospitals, financial costs, and lack of sufficient infrastructure or information reflect shared challenges across contexts. Unlike findings from some literature, which highlight family obligations and lack of partner support as barriers to healthcare access, this study revealed that family and spousal support often served as key resources for pregnant women. While Western literature often frames poverty as a factor isolating women from support networks, our findings suggest that in the Turkish cultural context, strong family solidarity acts as a crucial buffer mechanism against the harsh effects of economic deprivation. Considering the perceived inadequacy of hospital resources, SDG 1 and SDG 10 are particularly pertinent. Developing policies that guarantee access to quality healthcare, especially for those living below the poverty line, is critical to overcoming these inequalities. The failure to receive care tailored to their needs from nearby facilities further entrenches the disadvantages faced by poor pregnant women. Hence, equitable investment in healthcare infrastructure across regions and cities is necessary. Accessibility Accessibility refers to the geographic relationship between individuals and health services, considering transportation options, distance, and related costs [ 34 ]. Participants frequently mentioned difficulties in reaching hospitals due to rural residence, lack of private vehicles, or referrals to distant cities for certain tests. These experiences echo findings from a systematic review, which identified transportation, cultural norms, family support, economic constraints, and quality of care as key barriers to maternal healthcare access [ 59 ]. Living in remote areas and fulfilling multiple domestic roles restrict women’s access to information and services, reflecting broader patterns of gender inequality. Therefore, in addition to SDGs 1 and 10, Goal 5 on gender equality becomes relevant. Efforts to improve pregnant women’s access to care should include strengthening rural infrastructure, increasing the number of well-equipped health facilities, establishing emergency home care services, and introducing dedicated hotlines. Deploying mobile health teams to underserved areas for periodic health education and support could also be beneficial. Accommodation Accommodation pertains to the extent to which the healthcare system is organized to accommodate patient needs, including appointment systems, office hours, and ease of use [ 34 ]. Participants reported significant difficulties with securing appointments and long wait times even when appointments had been made. Sezerol and Sakarya [ 60 ] similarly found that individuals faced challenges with public hospital scheduling, often turning to private clinics despite high costs. The variation in service delivery between hospitals indicates persistent structural inequalities within the healthcare system, closely related to SDG 10. Solutions might include expanding hospital units, increasing staffing levels, and reforming appointment systems to reduce patient wait times. Affordability Affordability addresses the relationship between the cost of services and individuals’ income levels, insurance coverage, and capacity to pay [ 34 ]. Interviews revealed recurring concerns about the high cost of services, inadequate insurance coverage, and the financial burden of medications and tests. Economic status was a dominant theme, as supported by previous research demonstrating that financial hardship is a key determinant of access to medical care throughout pregnancy [ 61 – 63 ]. For example, a U.S.-based study of women during the prenatal and postpartum periods (2013–2018) found that 24% of participants experienced unmet healthcare needs, and 60% reported an inability to afford care. Women with private insurance or lower income were more likely to forgo needed services compared to those with public insurance or higher income [ 64 ]. In this study, low income and lack of insurance were central barriers to entering the healthcare system. Addressing such inequities requires minimizing the public–private divide by standardizing service quality across institutions and fostering inter-ministerial cooperation—particularly between the Ministry of Health and the Ministry of Family and Social Services. Although Turkey has a universal health coverage system, the increasing out-of-pocket expenditures for specific tests, supplements, and private hospital visits (due to overcrowding in public ones) create a ‘hidden cost’ barrier that effectively excludes the poor from quality care. Acceptability Acceptability concerns the compatibility between patients’ and providers’ characteristics and expectations, including attitudes toward gender, age, education, facility location, and provider beliefs [ 34 ]. It also encompasses providers’ biases toward service recipients, particularly those from disadvantaged backgrounds. Participants highlighted their preferences regarding the gender of physicians and discomfort with frequent hospital visits, reflecting the significance of cultural values. These attitudes may deter women from seeking care and point to the intersection of cultural and gender norms. Existing literature further supports this. For instance, Yaya et al. [ 65 ] outline three levels of barriers to maternal healthcare: individual (e.g., socioeconomic status), relational (e.g., partner control over decision-making), and societal (e.g., patriarchal systems). Additionally, previous studies have emphasized structural and personal factors such as insufficient knowledge, negative prior experiences, and lack of autonomy [ 66 ]. While gender inequality was not identified as a distinct theme in this study, experiences such as employment discrimination during pregnancy and the disproportionate burden of family responsibilities point to its underlying influence. Participants also discussed disparities between public and private hospitals, noting that the former often involved overcrowded, inattentive, or impersonal care, whereas the latter offered more attentive and responsive service. These findings resonate with Bellerose, Rodriguez, and Vivier [ 67 ], who, in a systematic review, demonstrated that low-income pregnant women experience structural and interpersonal barriers in accessing care. Acceptability intersects with SDGs 1, 5, and 10. The confluence of socioeconomic disadvantage, cultural norms, and provider attitudes creates compounded challenges for women during pregnancy. Thus, addressing the biases and assumptions of healthcare workers is as essential as supporting pregnant women themselves. Without such efforts, neglect—whether conscious or not—may become a hidden but pervasive risk. Strengths and limitations This study has several strengths. First, it focuses on a vulnerable and hard-to-reach population—pregnant women living below the poverty line—providing in-depth insights into their lived experiences regarding healthcare access. Second, the study was conducted in Turkey, offering a perspective from a developing country that has implemented Universal Health Insurance but still grapples with persistent socioeconomic inequalities. This context provides valuable insights for other nations in similar transitional phases regarding health equity. However, there are some limitations. The interviews were conducted via telephone with audio recording only due to participant preference and privacy concerns. This prevented the observation of non-verbal cues and body language, which are valuable components of qualitative data. Additionally, although data saturation was reached, the study reflects the experiences of a specific group of women, and the findings may not be generalizable to all pregnant women living in poverty in different regions or cultural contexts. Furthermore, detailed data on total household income and the employment status of other family members were not exhaustively collected, which limits the ability to fully assess the participants’ broader financial support systems. Conclusions The quality of maternal healthcare services before, during, and after childbirth is essential for both maternal and child health outcomes [ 68 ]. For women to make informed decisions regarding their own and their babies’ health, they must have access to relevant information and the health literacy to interpret and apply it effectively [ 69 ]. Regarding the healthcare access experiences of pregnant women living in poverty (RQ1) , the findings revealed that access is deeply hindered by personal and systemic barriers. Participants experienced significant anxiety driven by previous pregnancy losses and a lack of knowledge about available services. Interactions with healthcare providers varied; while some found support, others faced dismissive or rude attitudes in public institutions, leading to feelings of exclusion and hesitation to seek further care. In terms of the needs of these women (RQ2) , the study highlights a critical need for comprehensive support that goes beyond medical check-ups. Participants require financial assistance for nutrition and medications, clear and accessible health information, and psychosocial support to manage pregnancy-related anxiety. There is also a distinct need for respectful, patient-centered care that acknowledges their socioeconomic vulnerabilities without judgment. Concerning the challenges faced (RQ3) , the primary obstacles are economic and structural. High costs of transportation, “hidden costs” of supplements and tests not fully covered by insurance, and the inability to afford private care when public services are overcrowded constitute major hurdles. Regional disparities further exacerbate these challenges, with rural women facing greater isolation and physical barriers to reaching healthcare facilities. To address these issues , policy interventions must be multifaceted. It is recommended to integrate social service units within primary health centers to provide targeted financial and social support alongside medical care. Increasing the coverage of the social security system to fully include essential pregnancy-related costs (such as vitamins and detailed ultrasounds) is vital. Future research should extend to other marginalized groups, including refugees and adolescents, to build a more inclusive framework for maternal health equity. In conclusion, a coordinated, intersectional strategy that integrates health and social services is vital to ensure that all pregnant women, regardless of income, geography, or background, receive equitable and respectful care throughout the maternity continuum. Supplementary Information Supplementary Material 1. (286.4KB, pdf) Acknowledgements Request for APC WaiverDear Editor, I am writing to kindly request a waiver for the Article Processing Charge (APC) regarding our manuscript submission.I am a full-time faculty member in Turkey. Currently, my monthly income is approximately 2,140 USD (90,000 TRY). Due to the challenging economic conditions and hyperinflation in our country, our university is unable to provide financial support for research publication fees. Throughout this study, all research costs were covered personally by the researchers.Consequently, we regrettably lack the institutional or personal funds to cover the APC. We kindly ask for your understanding and request a full waiver of the publication fee. We are ready to provide official salary statements (pay slips) or other documentation if required.We hope that this financial constraint will not negatively impact the scientific evaluation of our work.Sincerely, Bilge Türkoğlu. Authors’ contributions Data analysis was carried out collaboratively by all three researchers, who worked in coordination throughout the process. All authors read and approved the final manuscript. Funding The authors received no specific funding for this work. Data availability The datasets generated during the current study are not publicly available due to the privacy of participants but are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki. Data collection began following ethical approval granted by the Ondokuz Mayis University Social and Human Sciences Research Ethics Committee on May 27, 2022248. Informed consent was obtained from all participants. Consent for publication Participants were informed about the study’s purpose, content, confidentiality measures, and interview process. 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(286.4KB, pdf) Data Availability Statement The datasets generated during the current study are not publicly available due to the privacy of participants but are available from the corresponding author on reasonable request. 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