Maternal healthcare in urban Eswatini operates through a dual system of formal biomedical services and informal traditional care. The interactions between these sectors, patient pathways, and the consequences for maternal medicine are poorly understood. This study aimed to map the utilisation patterns of formal and informal maternal healthcare in urban Eswatini and to analyse the factors influencing women's choices and the perceived outcomes of using both systems. A sequential explanatory mixed methods design was used. A cross-sectional survey (n=450) was administered to postpartum women at urban health facilities. Subsequently, 35 in-depth interviews were conducted with a purposively selected sub-sample of survey participants, alongside 15 key informant interviews with healthcare providers and traditional practitioners. Survey data showed that 68% of women used both formal and informal services during pregnancy. Qualitative analysis identified a dominant theme of 'pragmatic pluralism'. Women strategically combined sectors to address perceived deficiencies, frequently seeking traditional care for culturally-defined ailments and formal services for clinical complications. Maternal healthcare in urban Eswatini is characterised by patient-driven integration, occurring without formal coordination between sectors. This self-directed practice presents potential for comprehensive care but also carries risks related to communication gaps and patient safety. Pilot programmes to establish structured dialogue and referral protocols between formal clinics and respected traditional practitioners should be developed. Pre-service and in-service training for midwives and doctors ought to include modules on culturally competent engagement with patients using dual systems. maternal health, healthcare utilisation, traditional medicine, health systems integration, urban health, Eswatini, mixed methods This study provides empirical evidence on the scale and rationale for dual healthcare sector use in a high-density urban African setting, offering a nuanced analysis of patient agency and the practical realities of integrated care.
Sipho Dlamini (Fri,) studied this question.