While previously neglected, the experience of care during ANC contacts has risen to prominence in the quality of care discourses as a critical element to promoting the health of women and newborns and ensuring a positive pregnancy experience. In this paper, we present that the experience of ANC contacts in rural Bangladesh, where social support and perceptions of privacy are reported to be better than other aspects such as consent, interpersonal communication and counselling. It is critical to work on ensuring these aspects of ANC in order to optimize the benefit of each contact which women have during pregnancy.
Consistent with other studies conducted in the context of rural Bangladesh, we found the coverage of ANC to be relatively low compared to the ambitious targets set at the global and national level (8, 12, 34, 35). With less than one-tenth of women attending at least four ANC contacts, the global vision of women attending eight visits as proposed in the most recent WHO guidelines seem that it will be difficult to achieve in the near term (2). Considering how rarely women attend ANC, it is particularly important to maintain the quality of each contact, both in the provision and experience of care. Each visit represents an opportunity for the formal health sector to influence the care of women and their fetus during the pregnancy period. The alternate way of looking at is through the perspectives of women. Approximately three-quarters of women attended at least one ANC contacts, and of them, one-third did not come back for the second contact. This is a missed opportunity for the health systems to capitalize on the first contact, which could be explained by the gaps in quality of care, particularly the experience of care.
Social support, or the support that women receive from their personal social network, i.e. from husbands, families, friends or neighbors, can help them feel more comfortable during the ANC contacts as the environment of the health facility or the health care provider can be “foreign” and intimidating for them. Moreover, the accompanying person can advocate for her health and preferences in this “foreign” context (36, 37). Our findings suggest that social support during ANC is quite high, with most of the women benefiting from the attendance of someone from among their social circle. In our study, around two-thirds of the women were accompanied by their family members. Although we do not have specific data, other studies conducted in similar settings reported that such social support was provided by a female member of the woman’s family, and sometimes a female person outside of the family (38). This is not surprising, given that pregnancy and childbirth are often considered women-centric life transitions (39).
However, men seem to be playing an important role in providing social support during ANC as well, with nearly half of women reporting that their husbands travelled with them to the health facility or health care provider for ANC. This companionship did not necessarily translate into men’s attendance during the contact, as women reported that their husbands remained present during less than a quarter of the ANC contacts. Studies suggest that involvement of husband during ANC contacts improves MNH utilization and skilled birth attendance (40, 41). This may be an important area to explore for increasing the use of skilled and appropriate services for women; however, this should only be promoted taking women’s preferences and expectations into consideration. Slightly over half of the women reported that they would like their husband to be present during the consultation. In order for this to happen, health services should be male-friendly (42), so that these preferences can be accommodated. We cannot assess the degree to which health facilities are male-friendly in our study, but given that few women in our study reported that a health service provider even asked whether they wanted their husbands to be present suggests that there is work to be done in this regard. Although the Maternal Health Strategy of Bangladesh emphasizes on quality of care, including the experience of care aspect, it does not explicitly provide guidance on promoting male involvement and male-friendly environment during ANC consultations (12).
Regarding respect and dignity, we found that women overwhelmingly consider that their privacy was maintained during ANC contacts. This was a bit surprising, given that privacy has been demonstrated as a major challenge in several studies across different settings (21, 23, 43-45). While it is possible that visual and auditory privacy was maintained during these visits such as conceptualized in global normative documents (2, 46, 47), it is also possible that women in Bangladesh conceptualize privacy differently and that their expectations of privacy are maintained even if others, particularly women, can see and hear them during the visit. Alternatively, it is possible that due to the prior experience in public health facilities or prior knowledge about the service delivery process in these facilities, women accepted those aspects challenging their privacy during ANC consultations (48). Women’s understandings, expectations and preferences around privacy should be explored to design actions to promote privacy which articulates with their conceptualizations and desires.
In addition, women rarely reported having been disrespected or abused by health service providers in any way during the contact. This finding stands in contrast to a number of studies which have documented disrespect and abuse of women when obtaining maternal health services, including ANC in various contexts (43, 49) (50-54). This contrast in our study compared to others may be explained by the strong social values around respect in the Bangladeshi context. It may also be related to expectations and conceptualizations around respect and dignity as an action considered as disrespectful in one context may not necessarily be interpreted as disrespectful in another (55, 56). However, our results are encouraging as the majority of the women felt that they were treated with respect during the ANC contacts. This may also encourage the community to use formal health services during pregnancy, for birth as well as following birth.
Consent is fundamental to the experience of care, which appeared to be an issue in our study as over half of women reporting that the health service provider asked for their permission prior to carrying out physical examinations, or that the provider explained what they were going to do beforehand. This suggests that obtaining consent was not routinely and appropriately practiced while providing maternal health services, which is also reported in other studies in similar settings (19, 22, 57, 58). This may be due to the heavy workload of health service providers, as they may be rushed to meet their obligations to provide services. A health care provider should take into account the physical and emotional discomfort/pain that physical examinations can cause to a woman. The cultural context of a place may lead a woman to hide her pain during invasive examinations. Moreover, religion plays an important role in Bangladesh, and there may be more resistance to physical examinations due to conceptualizations around shame and purdah (59, 60). Health service providers should be sensitive to this and be particularly careful to explain the processes of physical examinations and obtain consent prior to carrying out examinations.
The capacity of health workers to interact respectfully with women and families and to counsel them on MNH issues effectively is critical to improving women’s experiences of receiving MNH health services. Our findings suggest that counselling and interpersonal skills of health service providers is a major area for improvement, as few women reported that health service providers did this very well. These findings are consistent with other studies which looked at ANC counselling and found it to be a neglected component in routine practices (61-64). Our study also found that around half of the women could not understand the information provided by the healthcare provider during the ANC contacts, which is a reflection of the gaps in communication and counselling skills. For a positive patient-provider interaction, it is important that healthcare providers share information with women about their condition, procedures required, and advice on care. Effective communication, including active listening, understanding the context and involving women in finding solutions to their problems are important aspects emotional support as they help them in understanding the information better as well as taking care for themselves and their baby (65).
Training health workers to improve their interpersonal and communication skills can contribute to their capacity to counsel women and families on these topics adequately. However, current training programs of health service providers in Bangladesh tend to focus almost exclusively on the provision of services, typically neglecting aspects related to interpersonal communication and counselling. Further research is needed to understand which interventions and approaches are effective for improving interpersonal skills of MNH care providers in this context.
Finally, there were variations in the experience of care based on wealth, family size and education. This is important to note, as respectful care should be provided equitably, and not based on differences in socio-demographic characteristics. Efforts should be taken to ensure that all women are treated with dignity and benefit from support, counselling and positive interpersonal communication during their contacts with the formal health system. Indeed, efforts should be made to promote special care for women who may be disadvantaged, for instance, due to socioeconomic or educational status. This can be done by promotion of a culture of respect within the health services and building to capacities of health service providers to interact respectfully with women and families and identify and respond to those with specific needs.
Study strengths and limitation
The study was designed to assess the experience of care during ANC contacts adopting a cross-sectional design, and we acknowledge the limitation to infer causality of the associations that we have presented. However, we have conducted multiple logistic regression to adjust for the potential effect of confounders and covariates while presenting the relationships between social support and experience of care.
Another limitation of the study was that it adopted the experience of care standards from the global normative documents. While these are recommended based on available evidence and expert consultations, they may fail to adequately capture granularity and variations in expectations, conceptualizations and preferences specific to different contexts. We, therefore, recommend further research to explore in more depths these specificities in order to promote quality of ANC which corresponds to the local preferences and realities.
Another potential limitation of our study is recall error as we accepted up to 12 months of recall. We tried to minimize this by ensuring that the data collectors received extensive training to clarify different elements of the questionnaire to the respondents for their proper understanding and appropriate recall. Also, this recall period is much shorter than the 3 to 5 years recall period that is accepted by other surveys generating national estimates (12, 66, 67). Another potential limitation could be social desirability bias, which we tried to address by recruiting data collectors from local communities who are familiar with the local culture, language and norms. Moreover, rigorous pre-testing of the questionnaire was done to address this bias.
Finally, it is important to recognize the limitations of what we can learn regarding components of quality ANC like respect, dignity, privacy, and consent phenomena through such quantitative approaches. Therefore, we call for future research to better understand these dynamics through qualitative, and particularly ethnographic, approaches.