Exploring Perceptions of Pregnant Women on Antenatal Care visit during their First Trimester at Area 25 Health Center in Lilongwe, Malawi – A Qualitative Study

doi:10.21203/rs.3.rs-3140322/v1

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Research Article

Exploring Perceptions of Pregnant Women on Antenatal Care visit during their First Trimester at Area 25 Health Center in Lilongwe, Malawi – A Qualitative Study

https://doi.org/10.21203/rs.3.rs-3140322/v1

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Journal Publication

published 04 Dec, 2023

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Background

Initiation of antenatal care during the first trimester is crucial for reducing maternal and neonatal morbidity and mortality. Unfortunately, only 24% of pregnant women in Malawi initiate antenatal care during this time with even lower rates of 15% at Area 25 Health Centre in Lilongwe. Despite such cases, there is scarce literature on obstacles that prevent women from accessing first-trimester antenatal care in Malawi.

Aim

To explore perceptions of pregnant women and how they influence attendance during the first-trimester at Area 25 Health Centre in Lilongwe, Malawi.

Methods

We employed a qualitative exploratory study on 55 purposely identified pregnant women, aged between 18 and 42 years with gestational period of up to 36 weeks who were attending antenatal care at Area 25 Health Centre in Lilongwe urban, Malawi. Data was collected through a total of 15 In-depth Interviews (IDIs) and four Focus Group Discussions (FGDs) and were manually analyzed using thematic analysis, which included categorization and deductive theme identification with reference to the study objectives and the Health Belief Model (HBM).

Results

Pregnant women perceived that the first-trimester antenatal care visits are only for those experiencing ill health conditions like backache, headache, and HIV/AIDS during pregnancy. First trimester pregnancy was perceived as too small not worthy of seeking antenatal care, the women placed a low value on it. Majority of those who initiated antenatal care in the first trimester had previously experienced disorders and complications such as previous caesarean section and abortions. In addition to limited knowledge about the required total number of ANC visit, challenges such as long-distance, preoccupation with business, multiple antenatal visits, scheduling of antenatal care visits, negative attitude of health workers, adherence to COVID-19 containment measures, and inadequate partner support were identified as barriers to seeking early antenatal care.

Conclusion

Negative perceptions among pregnant women, coupled with various economic and infrastructure barriers, attribute to low attendance rates for first trimester antenatal care in Malawi. Addressing knowledge gaps and overcoming barriers related to economic, infrastructure and health care delivery can improve women’s early antenatal care visits. Future research should consider including pregnant women from diverse socioeconomic backgrounds to gain a better understanding of these perceptions and barriers.

First trimester

pregnant women

perceptions

antenatal care

Malawi

Starting antenatal care (ANC) in the first trimester (0 to 12 weeks gestation) is one of the key interventions to reduce maternal and neonatal morbidity and mortality ratios, as it helps early identification of high risk pregnancies and educates women for positive pregnancy and labor outcomes ¹. Globally, the Maternal Mortality Ratio (MMR) is high at 303 000/ 100 000 live births while 546 deaths per 100 000 live births occur in sub-Saharan Africa (SSA) ². Malawi is among the SSA countries with high MMR reported at 439 deaths/100,000 live births and a Neonatal Mortality Ratio (NMR) of 27/1000 live births.

Evidence indicate that ANC contact has been shown to improve positive pregnancy outcomes when the antenatal care starts within the first trimester and if the frequencies of contacts are adequate³. The World Health Organisation (WHO) recommends that pregnant women should initiate antenatal care in the first trimester with a total of 8 contact visits ⁴. Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits ⁵ not all pregnant women in Malawi initiate antenatal care in the first trimester.

According to the Malawi Demographic Survey (MDHS)⁶, only 24% of pregnant women start ANC in the first trimester ⁶. Furthermore, only 15% of pregnant women at Area 25 health centre start to attend ANC in their first trimester⁷. Late initiation of ANC poses risks as they may delay diagnosis of pregnancy related complications, such as anemia and pre-eclampsia, which can negatively affect maternal and fetal wellbeing ^6,8,9 According to the United Nations (UN) Sustainable Development Goal (SDG) number 3, MMR and NMR have to be reduced to less than 70 per 100000 live births and 12 per 1000 live births by 2030, respectively ¹⁰.

Pregnant women's perceptions towards attending ANC in the first-trimester significantly influence the utilization of antenatal services and hence pregnancy outcomes¹¹. However, there is lack of understanding on how these perceptions influence attendance of the ANC during the first-trimester. To our knowledge, no study in Malawi has been done to qualitatively understand the pregnant women's perceptions towards attending ANC in their first-trimester. Therefore, this study aimed at exploring the pregnant women’s perceptions towards antenatal care attendance during their first-trimester and examine the connection between these perceptions and actual attendance. By employing the Health Belief Model (HBM) as a theoretical framework, our study makes a valuable contribution to the research on identifying appropriate strategies to enhance first-trimester attendance in Malawi, ultimately reducing preventable maternal and neonatal deaths in sub-Saharan Africa.

The Health Belief Model (HBM)

The Health Belief Model by Becker (1974) was employed to guide the framework of exploring pregnant women’s perceptions towards attending ANC in the first-trimester. Perceived susceptibility, perceived severity, perceived threat and perceived barriers were the constructs which were used¹² (Figure,1).

Application of Health Belief Model

Perceived susceptibility: The HBM was used to understand whether pregnant women think their failure to attend antenatal care during the ANC during first trimester (0–12 weeks of gestation) can affect them. Thus, whether women feel susceptible to dangers that come with failure to attend the first trimester such as late diagnosis of complications which include anemia, and premature births ¹³. In interpretation, the greater the perceived risk, the greater the was likelihood of engaging in the aimed behaviors to decrease the risk ¹².

Severity: When pregnant women recognize that they are susceptible of getting an ill condition, it does not motivate them to take necessary action until they appreciate that getting the condition has serious physical, psychological, and social implications for themselves and their babies. In this study, pregnant women with previous and current complications such as previous caesarian section, and backache respectively, viewed themselves at greatest risk of severe complications which triggered them to start ANC in the first trimester. In Malawi, 439 pregnant women died per 100 000 live births because of complications related to pregnancy and childbirth ⁶.

Perceived threat: Pregnant women were assessed how they rated the threat that comes with not attending ANC in the first trimester. According to the HBM, women will not participate in preventative health care programs unless they view themselves as potentially vulnerable and the threat of the problem as serious.

Perceived barriers: Perceived barriers can affect women’s decision-making. Here, we searched for the barriers women face or anticipate facing in relation to attending antenatal care in the first trimester. Multiple visits, long distance and corona virus containment measures to were some of the barriers to first trimester antenatal care in this subset of the population.

Design

This study utilized exploratory qualitative research methods. Data was collected using in-depth interviews (IDIs) and focus group discussions (FGDs), which enabled an in-depth understanding of pregnant women's perceptions towards first trimester antenatal care attendance.

Study setting and population

The study was done at Area 25 antenatal clinic in Lilongwe urban district in Malawi. A purposeful sampling technique was used to identify study participants. An Inclusion-Exclusion criteria was employed to recruit study participants such that only pregnant women of the ages between 18 and 42 years who were attending ANC at the clinic, and had a gestation of 36 weeks or less, first trimester or not and women who came for the first and subsequent antenatal care visits, primigravidas and multigravidas were eligible for the study. Primigravidas were women with their first pregnancy, while multigravidas were women who had been pregnant more than once. A total of 55 respondents, which comprised 15 pregnant women for IDIs and 4 FGDs, participated in the study. A maximum variation of purposively sampled population was employed to inform the research questions. The respondents were both primigravidas and mulitigravidas in all the three trimesters of pregnancy regardless of their educational and marital status. This was to provide varuable insights into perceiptons, experiences and attitudes.

Data collection

Data collection was conducted through IDIs and FGDs using the interview guide between 19th March, 2021 to 16th April, 2021. Each FGD had 8 to 12 pregnant women. Participants were solicited while leaving the medical examination rooms. The interviews were done in Chichewa, a local language in Malawi, and were audio-recorded. The interviews and discussions lasted between 45 and 60 minutes. Data were collected until there was a saturation of thoughts, which was identified when no fresh ideas were voiced. Despite the COVID-19 presence, during the time of the study, IDIs and FGDs were both physically conducted whilst taking all the precautionary measures.

Data Analysis

Data were analyzed manually, guided by the six phases of thematic analysis as proposed by Braun and Clark¹⁴. The phases were; familiarizing yourself with data, generating initial codes, searching for themes, reviewing potential themes, defining and naming themes, and producing a report. To complete this analytical process, a code book was developed that was used to categorize and reduce raw data. The HBM constructs (Fig. 1), guided the analysis, and some of the initial codes, such as perceived dangers and barriers, originated from them.

In the first phase of the thematic analysis, the researchers had to familiarize and immerse themselves in the data by listening to all audio recordings repeatedly. This was followed by transcription verbatim in Chichewa which was later translated to English. Transcribed data was verified by re-reading while listening to the recorded data. Areas that were incomplete or incorrectly transcribed were noted and corrected. The second phase involved generation of the initial codes. The initial codes originated from the questions on the interview guide, study objectives and the HBM. Open coding was done deductively. There was a predefined list of coding categories such as initiation time, dangers, benefits, and barriers. Additional codes were added as themes emerged such as knowledge on antenatal visits. Transcripts were read repeatedly to identify patterns in the data and collated the codes with extracts. In the third phase of thematic analysis, the researcher verified the codes and extracts before categorizing. The groups of codes were then assessed further to identify potential themes. A coding tree was developed that had all codes, categories, and identified themes (Fig. 2). The deductive theme identification approach was used based on the study objectives and the HBM.

In the fourth phase, potential themes were reviewed in relation to coded extracts and the entire data set. There was also a validation of individual themes in relation to the data set to make sure that themes accurately reflected the meanings of the data set. In the fifth phase, each theme was defined clearly by identifying the essence of the theme and determining what aspect of data and research questions the theme fits under. This involved coming up with a concise and easily understandable names for each theme, for example, perceived susceptibility. Themes were then verified by checking them against the audio-recorded data. In the final phase, the researcher wrote a detailed account of the thematic analysis findings.

Ethical considerations

Ethical approval was sought from the College of Medicine Research and Ethics Committee (COMREC), an institutional review board of Kamuzu University of Health Sciences in March 2021 (reference number P.11/20/3206). Verbal and written informed consent were obtained from individual participants prior to their participation in the study and were free to withdraw from the study at any time. Participants were identified through code numbers during data manipulation and analysis to maintain privacy and promote anonymity.

The results are divided into the socio-demographics characteristics of study participants and the qualitative three themes, which are “knowledge and perceptions towards antenatal attendance during first trimester”, “Triggers of actual first trimester antenatal attendance”, and “perceived barriers”.

Socio-demographics characteristics of study participants

Out of 55 respondents, 12.7% (7) started ANC in the first trimester while the rest (87.3%) started after first trimester (Table.1). In this study half of the participants (50.9%) had reached secondary education (Table.1). 30.9% of women in this study had started antenatal care later than first trimester, and were within the age range of 18–22 and 28–32 (Table, 2). However out of the 7 women who initiated antenatal care in the first trimester, 3 of them were in the age range of 23–27 (Table,2). In addition, 5 (9.09%) married pregnant women started antenatal care in first trimester while 46 (83.63%) started after first trimester (Table, 3).

Table 1

Socio-demographic characteristics of study participants, N = 55
Characteristics	Category	Number	Percentage
Age in years	18–22	18	32.73
	23–27	11	20
	28–32	19	34.55
	33–37	7	12.72
	38–42	0	0
Marital status	Single	4	7.27
Marital status	Married	51	92.72
Religion	Christians	48	87.27
Religion	Moslems	7	12.72
Education	No education	1	1.81
	Primary	26	47.27
	Secondary	28	50.9
	Tertiary	0	0
Occupation	Housewife	23	41.81
	Business	25	45.45
	Farmer	4	7.27
	Employed	3	5.45
Gravidity	1	14	25.45
	2	12	21.81
	3	13	23.6
	4	11	20
	5	4	7.27
	6	1	1.81
Parity	0	14	25.45
	1	12	21.81
	2	12	21.81
	3	12	21.81
	4	4	7.27
	5	1	1.81
Previous mode of delivery	Operation	3	5.45
	Normal	52	94.54
	Breech	0	0
Gestation at the initial visit	First trimester (0–12 weeks	7	12.72
	Second trimester (13–27 weeks)	40	72.73
	Third trimester (28–36 weeks	8	14.54

Table 2

Gestational age at initial visit and age ranges among the participants
Gestation age at initial visit (in weeks)	Age range of women (in years)					Totals
	18–22	23–27	28–32	33–37	38–42
0–12	1 (1.81%)	3(5.45%)	2(3.63%)	1(1.81%)	0 (0%)	7
13 and above	17 (30.9%)	8 (14.54%)	17 (30.9%)	6 (10.9%)	0 (0%)	48
Totals	18	11	19	7	0	55

Table 3

Gestational age at initial visit and marital status of the participants
Gestation age at initial visit (in weeks)	Marital status		Total
	Single	Married
0–12	2 (3.63)	5 (9.09%)	7
13 and above	2 (3.63)	46(83.63)	48
Totals	4	51	55

Themes

Knowledge and perception towards antenatal care attendance during first trimester

The participants indicated their knowledge and perceptions of antenatal care in most of their sentiments. These are presented through subthemes of ANC initiation and number of visits, first trimester antenatal care is for the ill and first trimester pregnancy “too small” for antenatal care,

ANC initiation and Number of Visits

Through IDIs and FGDs with pregnant women it was found that most women knew the recommended time of starting ANC to be in as soon as they notice they are pregnant or in their first trimester. During the discussion, women mentioned that any pregnant women should start antenatal care within 3 months or any time she realizes that she is pregnant. When asked why it was important to start ANC during the first trimester, most women cited to know their maternal (gestational/pregnancy) health status and that of the developing fetus, to prevent mother to child transmission of infections like HIV, to know the presentation of the baby, to get vaccinations against tetanus, counselling, iron tablets, Sulfadoxine-Pyrimethamine and a mosquito net to protect them against malaria and early detection and management of pregnancy related health complications,.

The following statements from FGDs demonstrates this knowledge:

P.1. “A pregnant woman should start ANC when she has discovered that she is pregnant so that she knows her health status in terms of HIV and syphilis. The infections should not be transmitted to the unborn child and also if the pregnancy has been implanted on the right place".

P.4.” We (pregnant women) are supposed to start antenatal care within 3 months of pregnancy so that we can get appropriate treatment and care. For example, we get counseling about nutrition in pregnancy and also, we receive iron tablets to prevent us from anaemia and vaccines against tetanus”.

P. 8. “Pregnant women should start ANC within 3 months in order to have an HIV test and prevent the unborn child from acquiring the virus”

[Agreed by all participants]. (FGD1)

Similarly, the following were the views from IDIs:

“Pregnant woman should start ANC within 3 months of pregnancy to get a mosquito net which protects us from mosquito bites, vaccines against tetanus and other drugs but I have forgotten the names [IDI 1,30years, G6P5].

“When you start antenatal care in the first trimester as I have done this is the third month, you are protected from diseases because of the services you get such as HIV test, vaccination against tetanus and Fansida (Sulfadoxine- pyrimethamine) against malaria”. [IDI 3,33years, G4 P2 plus 1 previous tubal pregnancy]

“Pregnant women should start antenatal care at 3 months to know their health status, get iron tablets, mosquito net and Fansida (Sulfadoxine- pyrimethamine) against malaria. But I have started antenatal care at 7 months because I stay very far from the hospital about 8km”. [IDI 10, 21 years, G2 P1].

However, some women perceived that a pregnant woman is supposed to have 4 or 5 visits for the entire pregnancy. This showed that the women had inadequate knowledge on the recommended eight antenatal visits according to WHO 2016 guidelines which is very crucial in timing for antenatal initiation.

“A pregnant woman is supposed to have 4 antenatal visits. You are given appointment dates on alternate months” [IDI 2, 20years, married G2 P1].

“The total antenatal visits will be seven. Pregnant women are given monthly appointments especially when they start ANC at 3 months.” [IDI,9,26years G3P2]

“A pregnant woman is supposed to have 5 visits. The visits are adequate for the entire pregnancy as health workers are able to check on the health status of the unborn child.” [IDI, 14, 35years G5P4]

First trimester antenatal care is for the ill

Despite a good number of pregnant women having good knowledge as to when to start ANC (which is during first trimester) and benefits for doing the same, this study found that only a few actually started their antenatal care during the first trimester (only 7 out of 55). When prompted to understand their action which did not resonate with their knowledge, women in this study perceived that first trimester antenatal care was for those with ill health such as HIV, backache and headache.

For instance, some participants had this to say;

P.17. “An individual who is sick so often should start ANC early at least within 3 months and those who are not sick can start anytime may be to get vaccines such as tetanus

P.19. “Pregnant women should start antenatal care in the first trimester if they are HIV positive so that they can protect the unborn child from contracting the virus. When you are sick so often, your body becomes weak. There is need to receive help early because a pregnant woman is supposed to be healthy and strong”.

P.20. “We should start ANC at one month as pregnancies come in different ways because others are on ARVs (Antiretroviral drugs) so when we visit the ANC clinic you are taught the truth about your pregnancy and your health”

[Most participants nodded] (FGD2)

Similar views were expressed during IDIs

“I was having headache, and backache that’s why I came early for ANC services” [ IDI 6, 23 years GIPO].

“If you have problems then you can start in the first trimester like general body pains, backache. If you do not have any health problem you may start antenatal care in the first trimester if you may wish”. [ IDI12,35years G5P4]

First trimester pregnancy “too small” for antenatal care

Furthermore, pregnant women perceived first-trimester pregnancy, not a serious issue that required seeking antenatal care. They perceived that the pregnancy was too small and the doctors will not be able to palpate anything. Pregnant women did not value antenatal care in the first trimester.

Some of the respondents during interviews and discussions expressed the following views:

“The pregnancy is too small at 1 or 2 months to start ANC because doctors will not be able to examine properly” [IDI, 05, married, 23 years, G2P1].

“I started ANC at 6months (laughs) I was waiting for the fetus too grow. I was wrong because I did not follow the health protocols”. [IDI, 11, 27years]

“I feel that within three months, the pregnancy is very small and it’s too early to start antenatal care. when you feel fetal movements it’s when you really know that you are pregnant”. [Participant, 38, FGD4].

Triggers of actual first trimester antenatal care attendance

In this study, out of the seven participants that had started antenatal care in the first trimester, six, had pregnancy related health problems. Through In-depth interviews with these women (since we wanted to protect their privacy and keep their information confidential, we only asked about their health problems during IDIs), they mentioned that they started ANC during first trimester because of bad obstetric histories which included previous tubal pregnancy, caesarian section, neonatal death, backache and headache. Pregnant women cited that these complications triggered them to start antenatal early so that they can be assessed properly.

Some of the respondents during IDIs said that:

“I have started ANC early, this is the third month because the previous pregnancy was in a tube (ectopic pregnancy), and I ended up having an operation. I have come early so that I should be assessed if there are any problems.” [IDI, 3, married 33 years].

"This is my first pregnancy, I was having a headache, and backache that's why I came early for ANC so that I should be assisted.” [IDI, 06, married, 23 years, G1P0].

When other women who did not start at first trimester to share their perceptions, here is what some of them said:

“I started antenatal care at 6 months and today I am 8 months pregnant. Those who are sick frequently such as headache and backache are the ones who are supposed to start ANC in the first trimester, if they do not become sick there is no need of starting ANC in the first trimester.” [IDI, 13, married,26 years]

Pregnant women, who initiated ANC in the first trimester, viewed themselves as potentially vulnerable to complications related to non-adherence to first-trimester attendance such as abortion, compared to pregnant women who initiated late.

Perceived barriers to antenatal care attendance during the first trimester

Preoccupied with business

Some participants perceived that it was a waste of time to wait for a long period at the antenatal clinic because they earned a living through small-scale businesses such as selling flitters (Mandasi). It was a loss to spend the whole day without selling their products for the sake of antenatal services as a result they kept on postponing.

“In our location, the most common barrier to first trimester ANC is, we are always busy with our businesses and we feel it’s a loss and waste of time to wait on long queues at the clinic. You know life in town, you have to work to find food and other things” [IDI, 4, 24 years, married, GIP0].

“You know life in town; I was busy with business thinking that things are well with the pregnancy” [IDI, 12, married, 34 years, G4P3].

Frequent antenatal care appointments (visits)

It came out clearly during IDIs and FGDs that the pregnant women perceived antenatal visits as too much for them. Pregnant women cited that that they prefer few visits because frequent visits are not necessary to them as they will just get tired. They placed a low value on the significance of initiating antenatal care in the first trimester.

P.30. “We do not want to have many visits; better 3 visits mmmmh because we get tired as well as laziness but it's good to have 5 or 6 visits according to appointment dates given by midwives"

P.33. when you start ANC in first trimester, friends discourage us, saying you have started so early so how many visits are you going to have until the road develops pot holes? (mpaka njira ikumbike?), This is a local idiom stressing on the how frequent the antenatal visits are.

[All participants nodded] (FGD 4).

Similarly, during the IDIs, some respondents stated that:

“When you start antenatal care in the first trimester, you will have a lot of visits but there is no need to have such visits, we prefer to have few visits before delivery because we get tired. Few visits are better because we reduce the transport costs”. [Participant 1 IDI, 30years].

“I prefer to have few visits, going to the antenatal clinic every month is boring and tiresome. Health workers start work late may be around 10am and we go home around 3pm. I have started antenatal clinic at six months to reduce the visits. I just attend antenatal care as a routine that once one is pregnant has to go to the clinic for antenatal care services”. [Participant 9 IDI, 26 years, G3P2]

“What happens is that when you start antenatal care at 3 months, it may mean having so many antenatal visits up to 6. Doctors will tell you to visit the clinic every month. So, to avoid theses frequent visits, women start antenatal care after first trimester which is close to delivery. The visits are tiresome”. [participant 8, IDI, 24years, G2P1]

Long-distance to the health facility

From both the IDIs and FGDs, we found that long distances to the health facility influence decisions to postpone first-trimester antenatal care attendance visits. Some women reported traveling more than 7 km to the antenatal clinics. The pregnant women wait until they have adequate transport to travel, as a result, they postpone initiating antenatal care.

“We started antenatal late because some of us stay far from the hospital and transport was a problem, its more than 7 km, we do not have money, we are poor"[FGD3, married, 28 years, G4P3].

“I do have problems with transport, I stay far from the hospital, and I do not have money for transport and money to buy food such as snacks at the clinic” [IDI, 9, 26years, G3P2]

“In our location distance hinder us to start first trimester attendance it’s about 20km, and I came on the motor bike escorted by my husband”. [IDI, 13, 26years, G2 P1].

However, it was observed that some pregnant women who resided close to the facility also started ANC after the first trimester. Upon probing more from them, they cited laziness as the cause of the delay. Pregnant women did not recognize the significance of first trimester ANC.

For example, some respondents during the IDIs said that:

“In our location, it’s just deliberate and laziness there is nothing which can prevent someone to start antenatal care early” [IDI, 01, Married, 30 years, G6P5].

“In our community women are just lazy they just say I will go later we prefer to have few visits (Laughs). We think we are ok when we are not feeling anything abnormal”. IDI, 12, 35 years, G4P3)

Scheduling of antenatal care clinic days.

During the interviews and discussion, some women perceived scheduling of separate days for the women on initial visit from those coming for the subsequent antenatal care visit as deterrent to antenatal care in the first trimester. The women indicated that some healthcare providers at the antenatal clinic send them back, when the women came on a day when such services were not provided which discouraged them from accessing ANC in the first trimester. The women perceived that the health workers could have allowed them to access services any day because when they are sent back, they fail to come back due to other constraints like transport money.

“I was sent back last month, but I came from very far (X location), midwives said new visits do not come today, go back and come tomorrow’. My thinking was any day one can initiate ANC and it was very difficult for me to come back the following day due to transport problems” [IDI, 10, married 21 years, G2P1].

Similarly, participants in FGD 3 had the following views:

P. 21. “For me this is the third month for my pregnancy, I came yesterday and I was sent back. I was told to come today because yesterday was not a day for new visits”

P.23. “Mmmh, at this facility they send you back when you come a day when it’s not for new visits and it becomes difficult to find another transport to come on the stated days. You have to wait until you find money again for transport leading to delays for initiating antenatal care. When we are sent back, we might have unknown complications which may put us in danger”.

[All participants nodded] (FGD 3)

Negative attitude of healthcare providers towards women

Some pregnant women perceived attitude of health workers as one of deterrence to initiation of antenatal care in the first trimester. Pregnant women cited that they are mocked when health workers cannot palpate anything on the abdomen, shouting at them when they delay to put a wrapper on the bed before lying on the examination couch. Health workers behave as if we have ever quarreled before.

The pregnant women had the following views during FGDs:

P.33 “When we delay to put a wrapper (Chitenje) on the examination couch before lying and the other wrapper to cover ourselves. Health workers at the antenatal clinic shout at us as if we have ever quarreled before. They are harsh and rude. We fail to confront them because we are afraid, they may not assist us”.

P.35 “Health workers tell us to bring two pieces of wrappers when entering the examination room. One to put it on the examination coach, then the other wrapper to cover yourself. we are poor, we cannot afford to do that”.

P.38 I was mocked by the nurses at the antenatal clinic because they could not palpate anything on the abdomen, I felt it was an insult because it was like I was pretending to be pregnant. I was told go and buy pregnancy test kits to confirm if I was really pregnant. Nurses need to be merciful

[All participants agreed, FGD 4]

Long waiting time at the antenatal clinic

Long waiting time due to high numbers of women affected the timing of initiating ANC for the majority of the respondents whether primigravids or multigravidas. The antenatal clinic was congested due to high numbers of antenatal women, as a result women wait for long to be assisted. The facility has also inadequate human resource compared to the number of women at the clinic. The women on first antenatal visit expressed more delays due to the different stages they have to go through like HIV, syphilis test and the history taking. As a result, women are discouraged to start antenatal care early to avoid meeting such situations.

“We also get tired because we report at the facility around 6 am but health workers assist us very late. They start work around 10 am, this discourages us to start ANC early” [IDI, 9, 26 years, G3P2].

“At this facility (Ku koleji kuno), there are high volumes of women attending ANC. So even if you come in the morning, you are attended to late and go home in the late afternoon” [IDI, 3, 33 years, G4 P2^+ 1]

I always find a lot of women at the clinic as a result I skip some of the visits, the long queues as discouraging. This is my first pregnancy. [IDI, 6, 23 years, G1P0].

Adherence to COVID-19 containment measures

The study found that service delivery disruption due to COVID-19 pandemic had an influence on the first trimester antenatal attendance and the health care system in general. Some women explained that pregnant women were sent back to decongest the antenatal clinic. The health workers reduced the number of women to be seen in a day to 60 as one of the COVID-19 preventive measures. This was a missed opportunity to women who had an intention to initiate antenatal care early.

"We are being sent back to come the following day as health workers have a fixed number of 60 women to see in a day due to COVID 19 restrictions. So, when we return home, we face other challenges and fail to come back."[IDI, 4, married, 24 years, GIPO].

P.3. “I came early the other day, but I was sent back with other women. Nurses said they do not want congestion due to corona virus. They examined only 60 women per day the rest were sent back.

P.8 “We had to come very early to pick a number below 60, we had to scramble to get the number otherwise you are sent back to come the other day. We were discouraged and ended up starting antenatal late.”

[Some participants agreed]. (FGD1)

Late discovery of pregnancy

During the interviews and discussion, most women indicated that sometimes they fail to start ANC visits in their first trimester because they do not notice early enough that they are pregnant. Mostly, many of them, notice they are pregnant after 3 months and after experiencing pregnancy related symptoms like fetal movements or vomiting

Some participants during FGDs said that:

P.24. “I did not know that I was pregnant, I was on injectable family planning method, and I was not having menses. I was just vomiting. At first, I thought it was malaria but when I went to the hospital, it’s where I was told that I was 4 months pregnant.”

P.26. “My self I was doubting that I was pregnant and I used not to have menses because I was on a contraceptive method. When I tested positive for pregnancy I was on denial as it was unintended pregnancy (Inabwera mwangozi).

[Some participants agreed] (FGD 3)

I have started ANC late is I was not sure whether am pregnant or not since it is my first pregnancy and just married. [IDI4, 24years, GIPO]

Inadequate partner support

Pregnant women perceive inadequate support from their spouses. They expected their spouses to give them money for transport and snacks so that they can start antenatal care in the first trimester but spouses complain of high expenditures in the family. Pregnant women expressed that they expect to have new wrappers (Zitenje) from their partners for their initial antenatal visits. Pregnant women postpone initiation of antenatal care until they are provided with such resources.

“Spouses say if you start ANC early, it means expenditure will be high because the number of visits will increase. We also need money to buy a snack because we are given Sulfadoxine Pyrimethamine, an intermittent preventive treatment of malaria in pregnancy, to take at the clinic which makes us feel dizzy.” [IDI, 02, married, 20 years, G2P1].

“We like putting on new wrappers each visit, so some men are poor cannot afford as a result women do not report for ANC in the first trimester. At the clinic, they need 2 wrappers each visit, one to put on the bed and the other to cover up yourself during the examination, so women do not want to use old ones.” [FGD, 33, married, 30years, G3P2].

This study explored perceptions of pregnant women and how they influence attendance during the first-trimester at Area 25 Health Centre in Lilongwe, Malawi. Three themes emerged from the narratives. 1.) “Knowledge and perception towards antenatal care attendance during first trimester”, (i) Antenatal care initiation and number of visits, (ii) first trimester was for those with ill health (iii) First trimester pregnancy ‘too small’ for antenatal care. 2.) “Triggers of actual first trimester care”, (i) Obstetric complications which included previous tubal pregnancy, caesarian section, neonatal death, backache and headache.

and 3.) “Perceived barriers”. Participants perceived multiple barriers to the first-trimester attendance such as (i) Being preoccupied with business, (ii) Frequent antenatal visits, (iii) Long distance (iv)Scheduling of antenatal visits, negative attitude of health workers (v) Long waiting time (vi)Adherence to COVID19 measures (vii)late discovery of pregnancy, (vii) inadequate Partner support

Knowledge and perception towards antenatal care attendance during first trimester

We found that most women knew the recommended time of starting ANC to be as soon as they notice they are pregnant or in their first trimester. Despite a good number of pregnant women having good knowledge as to when to start ANC (which is during first trimester), this study found that only a few actually started their antenatal care during the first trimester (only 7 out of 55). Similar findings have been reported by other studies. Women in developing countries, particularly in Sub-Saharan Africa tend to wait to start ANC after first trimester ¹³.

In the present study some of women had inadequate knowledge on the total number of antenatal visits. They perceived that 4 or 5 visits were ideal for the entire pregnancy. The World Health Organization (WHO), however, recommended a minimum of eight contact visits ⁴ because the previous focused antenatal (FANC) model was associated with more perinatal ¹⁵. Evidence supports that the eight contact model improves outcomes for pregnant women and babies because of early identification and management of risk factors^16,17. The contact visits can only be achieved if women start ANC in the first trimester.

Pregnant women perceived that first-trimester attendance was only for those with ill health, such as backache, headache including HIV/AIDS. This is in agreement with^3,18 that Pregnant women who have health condition were more likely to initiate antenatal care in the first trimester. Pregnant women who felt they were healthy did not value first-trimester attendance because the pregnancy was not a disease, consistent with findings of¹⁹.This might be the case due to inadequate knowledge on the significance of early ANC¹⁵. We suggest that continuous sensitization of key stakeholders such as spouses, traditional and religious leaders on the significance of early antenatal care may be key to promoting first-trimester attendance in SSA ²⁰.

In addition, pregnant women felt that first trimester pregnancy was too small for antenatal care which was consistent with findings of ^20,21. They perceived that they were not at risk of dangers and complications with the small pregnancy. According to HBM, pregnant women who do not feel they are susceptible to dangers that come with non-adherence to first-trimester attendance were likely to start antenatal late than those who feel they are susceptible ^22,23. Pregnant women require an understanding of how pregnancy will affect them so that they can acknowledge that they are at risk of getting pregnancy complications²⁴. Therefore, low perceived susceptibility to bad pregnancy outcomes could be a driving force for late antenatal initiation in this subset of the population.

Triggers of actual first trimester antenatal attendance

In this study, most of the women (6) who initiated antenatal in the first trimester had issues, disorders and complications which triggered them to start antenatal care in the first trimester. The trend of first trimester antenatal care that emerged in this study was similar to that of other studies in Nigeria, Ethiopia, Cameroon where several pregnant women started ANC after first trimester^21,25,26. Evidence suggests that women with complications in the previous and current pregnancy were also associated with first trimester antenatal care than their counterparts ²⁷. In this study, perceptions such as the first- trimester care is for those with ill health likely contributed to low first trimester ANC, putting women at risk of complications such as abortions and anaemia. Low perceived susceptibility to adverse maternal and fetal outcomes might have contributed to low attendance in the first trimester. We suggest that pre-conception clinics and community awareness campaigns would be necessary tools to reach and encourage women to start antenatal early ^17,28.

Perceived barriers to antenatal care attendance during the first trimester

Participants perceived multiple barriers to the first-trimester attendance such as being preoccupied with business, late discovery of pregnancy, scheduling of antenatal visits, long distance.

The pregnant women felt it was a loss and waste of time to wait for a long period at the antenatal clinic without selling their products and they kept on postponing to start ANC. This concurs with results from a qualitative study in Guinea on factors affecting attendance and timing of ANC, where pregnant women were concerned with the opportunity cost of missing the whole day of selling their products because of ANC^25,29. This meant that low socio-economic status and occupation of some respondents such as business influenced decisions on the timing of first ANC putting women at risk of complications such as severe malaria and anaemia. The problem of long waiting time may indicate a weak health system in terms of service delivery.

Furthermore, some pregnant women were not aware that they were pregnant due to irregular or no periods due to contraceptive use. This concurs with ³⁰, that pregnant women did not recognize early that they were pregnant because of previous use of contraception. However evidence indicates that early recognition of pregnancy was found to be associated with first trimester antenatal care visit ³¹. Therefore, delay in recognition of pregnancy may appear to contribute to low antenatal attendance as some women were not aware they were pregnant.

In the present study, frequent visits, scheduling of antenatal visits and negative attitude of health workers were also cited as other barriers to ANC attendance. Similarly, qualitative studies done in Guinea and Nigeria on factors affecting attendance cited that frequent visits and unfriendly attitudes of health workers discouraged women to initiate ANC in the first trimester²⁹. This is in agreement with the Meta-Synthesis of qualitative studies on why women do not use antenatal services in low-and-middle income countries (LMIC) which indicated that the poor attitude of health workers was one of the barriers to first-trimester attendance, leading to delays in seeking health care ^32,33. The experiences influenced pregnant women timing of initiating ANC. We recommend that one of the primary responsibilities for any health-care setting should be to achieve high levels of patient satisfaction through quality improvement³⁴.

Furthermore, corona virus disease containment measures contributed to the low first-trimester antenatal attendance. Some pregnant women were sent back to come the other day to decongest the clinic as one of the preventive measures against the COVID-19 pandemic. Literature also indicates that refusal of care after the daily patient limit has been reached contribute to low antenatal attendance in the first trimester^35,36. Similarly, Pitale³⁷, in his study on the effectiveness of protocol-based ANC during the COVID-19 pandemic indicated that ANC services were challenging to offer but the services remain essential. The pregnant women perceived they were denied the services they deserve due to the pandemic. However, a protocol-based approach was key to the management of ANC in Bangladesh amidst the pandemic, where pregnant women were told in advance to come to the clinic according to the stipulated schedule ³⁷. Perhaps in future, SSA countries including Malawi could adopt Bangladesh strategies in case of related pandemics.

Long distance was cited as one of the perceived barriers to the early initiation of ANC by the respondents of this study. Gatarayiha, Mesenge, and Munyanshongore, ³⁸ in their mixed-method study on factors contributing to non-compliance to antenatal visits in Rwanda, also found that pregnant women who walked less than 30 minutes to the facility initiated antenatal early ³⁸. This meant that long distance to the facility might have contributed to low attendance in first trimester care. We suggest that mobile outreach antenatal services would be one of the effective strategies to reduce long distances, hence promoting first-trimester attendance³⁹.

However, in this study, some pregnant women who stayed close to the facility also started antenatal late. Ragolane’s study findings argued that even women who stayed close to the facility initiated ANC late due to laziness ⁴⁰. Shaw-Ree Chen et al,³⁹ further argued that individuals who perceived that they were at risk of a very harmful outcome considered all barriers as negligible.

Furthermore, it was found that inadequate partner support was identified as one of the barriers to first trimester care. Few pregnant women (5) out of the 51 who were married initiated antenatal care in the first trimester. However Suandi et al ^41,42 argued that male partner involvement in pregnancy care appeared to have the greatest effect on healthcare utilization. The pregnant women in this study perceived that they were not adequately supported by their partners

Strengths and limitations

The present study findings add value to the scanty literature by showing that negative perceptions of pregnant women and other cross-cutting issues such as COVID-19 pandemics are linked to low first trimester attendance rates. These results have been derived from a rich set of information which was acquired through data triangulation. Data triangulation was achieved by using diverse data sources such as the use of IDI on pregnant women, FGDs, and a mixture of primigravidas and multigravidas, whether in the first trimester or not.

Nonetheless, the study has some short-falls which give a room for improvement in future related studies. First, we used a small sample size which may apply to settings of similar context in line with transferability in qualitative research. Second, the exclusion of the age bracket, 15–17 years, might have limited some pregnant women in the study. However, some of their contributions might have been captured by the age bracket of 18–19 as they were in the same teenage group.

The present study sought to explore pregnant women’s perceptions towards attending antenatal care in the first-trimester. The study revealed that few pregnant women started antenatal care in the first trimester with a majority perceiving that first-trimester antenatal care is for pregnant women with ill including HIV/AIDS. The negative perceptions of pregnant women were linked to low first trimester attendance. Some pregnant women had inadequate knowledge of the recommended eight antenatal visits. Long-distance, preoccupied with business, multiple antenatal visits, and attitude of health workers and corona virus containment measures were perceived as barriers. The findings could be used in the refinement of policies and programs regarding first trimester ANC in similar settings, particularly if the health workers should put in measures to ensure health education messages and sensitization meetings should target the whole community, not just pregnant women so that couples and individuals can make informed decisions before they become pregnant. In addition, the health system managers should train health workers on respectful maternity care so as to create an environment that will motivate pregnant women to initiate antenatal care in the first trimester so that they can change their attitude towards women who attend ANC. Finally, traditional leaders, being custodians of custom, should come up with deliberate by-laws which can help in addressing some social issues so that women should start ANC early. In the event of a health pandemic, health managers should plan how to best provide essential services, such as first-trimester care, without compromising.

Ethics Approval and Consent to participate

Ethical approval was sought from the College of Medicine Research and Ethics Committee (COMREC), an institutional review board of Kamuzu University of Health Sciences in March 2021 (reference number P.11/20/3206). Verbal and written informed consent were obtained from individual participants prior to their participation in the study and were free to withdraw from the study at any time. All methods were carried out in accordance to with relevant guidelines and regulations or declaration of Helsinki.

Consent for Publication

Not Applicable.

Availability of data and materials

The data generated from the current study are not publicly available because we are still writing up from it, but will be available from the corresponding author on reasonable request.

Competing Interests

No competing Interest from the authors.

Funding

This study was self-funded. The authors declare that no external funding or financial support was received for the design, implementation, data collection, analysis, and interpretation of the study. The authors also confirm that they have no financial or personal obligations that could influence the content or outcome of this research.

Authors Contributions

Conceptualization, MN; Data Curation; MN; Formal analysis, MN, DM, AM, EM; Investigation MN, DM; Supervision, LN; Writing original draft MN; Writing, Review and editing, MN, DM, AM, EM, LN. All authors read, reviewed and approved the final manuscript.

Acknowledgements

We are grateful to all study participants in the study.

Authors’ Information (Optional)

School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
Malawi Ministry of Health and Population Services, Lilongwe District Health Office.
Department of Community Health Nursing, Kamuzu University of Health Sciences, Lilongwe, Malawi.
Department of Midwifery, Kamuzu University of Health Sciences, Lilongwe, Malawi.
Department of Mathematical Sciences, University of Malawi, Zomba, Malawi

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No competing interests reported.

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Exploring Perceptions of Pregnant Women on Antenatal Care visit during their First Trimester at Area 25 Health Center in Lilongwe, Malawi – A Qualitative Study

Status:

Journal Publication

Version 1

Abstract

Background

Aim

Methods

Results

Conclusion

Figures

BACKGROUND

The Health Belief Model (HBM)

METHODS

Design

Study setting and population

Data collection

Data Analysis

Ethical considerations

RESULTS

Socio-demographics characteristics of study participants

Themes

Knowledge and perception towards antenatal care attendance during first trimester

ANC initiation and Number of Visits

[Agreed by all participants]. (FGD1)

First trimester antenatal care is for the ill

[Most participants nodded] (FGD2)

First trimester pregnancy “too small” for antenatal care

Triggers of actual first trimester antenatal care attendance

Perceived barriers to antenatal care attendance during the first trimester

Preoccupied with business

Frequent antenatal care appointments (visits)

Long-distance to the health facility

[All participants nodded] (FGD 3)

Negative attitude of healthcare providers towards women

[All participants agreed, FGD 4]

Long waiting time at the antenatal clinic

Adherence to COVID-19 containment measures

Late discovery of pregnancy

Inadequate partner support

Discussion

Knowledge and perception towards antenatal care attendance during first trimester

Triggers of actual first trimester antenatal attendance

Perceived barriers to antenatal care attendance during the first trimester

Strengths and limitations

Conclusion(s)

Declarations

References

Additional Declarations

Status:

Journal Publication

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