Eighteen pregnant women and three midwives were interviewed. The socio demographic details of the pregnant women are summarized on Table 2. The interviews identified a variety of reasons for late initiation of antenatal care which are summarized according to the following themes:
Perceived susceptibility/ perceived severity
- Value of early antenatal care
- Pregnancy as normal health condition
- Ideal Misconception of booking time
- Obstetric history
- Accessibility of antenatal care services
- High cost of initiating antenatal care
- Distance to health facility
Cues to action
- Community health education
- Pregnancy disclosure
- Support from spouse
- Reaction from parents
The participants and researcher’s reflections about the setting and context were incorporated into the findings to give a richer description of perceptions on reasons for late initiation of antenatal care.
Perceived susceptibility/perceived severity of antenatal care
These are perceptions that early initiation of antenatal care is not relevant or that there are no serious health implications of being pregnant that require early initiation of antenatal care. Themes that emerged under these perceptions were; value of early antenatal care, pregnancy as normal health condition, ideal booking time.
Value of early antenatal care: Some of the pregnant women had the perception that the main purpose of early initiation of antenatal care was to know the state of the baby and since the baby was not fully formed in the first trimester, early initiation of antenatal care was perceived as a waste of time or waste of money.
I could not come for ANC by one or two months [of being pregnant] because the fetus was not yet formed so that I can do echography and know how the baby was doing. It was so early, so being so early like that it would have just been waste of time. (P1, single, age 22, parity 0)
You need to go for antenatal care when pregnancy is big so that they can check the baby well. It’s just that when I hear someone saying they are going for antenatal at two or three months [of pregnancy], I judge that it’s because they have money to waste. I cannot just waste money like that. (P7, married, age 21, parity 2)
Some women recognized the importance of early antenatal care but lacked the insights of its purpose for pregnant women and instead had a general understanding that pregnancy required antenatal care at some point.
Early antenatal is good…because I am pregnant, and it [antenatal clinic] is a place where when you are pregnant and preparing to deliver you must appear. Had it been I was not pregnant, I could not be here, so I believe I am in the right place. (P8, married, age 22, parity 1)
Pregnancy as a normal health condition: Many of the pregnant women considered pregnancy as a normal life event rather than as a condition that requires attention of health personnel. Some of the pregnant women said they waited to seek antenatal care only when they felt unwell.
For me I don’t really see it that necessary to come for antenatal care clinic that early at two or three months because first of all am not sick, am just normal, am fine and there’s nothing wrong with me. (P17, married, age 40, parity 3)
There was no problem within the first three months, so if there was a problem, that’s when I would have rushed and come earlier. (P2, married, age 27, parity 0)
Key informants also said most of the pregnant women who initiated late perceive antenatal care as a curative rather than as a preventive service.
They [pregnant women who initiate antenatal care late] feel antenatal care is curative issue meanwhile that’s not the case. Antenatal care is preventive……this causes them to wait until they have a health problem before they come for antenatal care. (KI1)
Ideal Misconception of booking time: Some women said because the purpose of initiating antenatal care was to diagnose any problems that the baby may be having, the ideal booking time is after the first trimester when the baby must have been properly formed.
I know that it is normal [ideal time] to come for antenatal clinic as from four or five months… at that time you can be able to know better how the baby is fairing. (P13, married, age 27, parity 2)
Many women did not have correct information on the ideal booking time due to misinformation from family members, inadequate health education during clinics.
As I was growing, my mother used to teach me all those things, that when a woman is pregnant she needs to go for clinic as from 4 to 5 months of pregnancy so that the nurses can know if the baby is doing fine. (P2, married, age 27, parity 1)
[The nurses] in the health talk [education] when I came here last time when I was pregnant [for five months] did not tell us that a pregnant woman should start clinic when she is just one, two or three months pregnant. I have not heard this before, it is very new to me. (P12, married, age 23, parity 1)
Obstetric history: Women with positive obstetric history perceived pregnancy and safe delivery as normal experience and did not see the need to initiate antenatal care early.
[As for previous deliveries] I did not have complications, am always fine. I always come for antenatal care clinic later than this [five months] usually seven months when its almost time for me to give birth. I have always been delivering safely so I have no problem … I believe is just going to be the same because the previous ones I just delivered safely, and this is even the forth pregnancy. (P17, married, age 40, parity 3)
Key informant midwives said positive obstetric history caused some pregnant women to see antenatal care as a routine and preferred to book later.
As women deliver more some of them think they know much and will not want to come and book earlier. They think that antenatal care clinic is just a routine, they just think that since they have been going for antenatal care clinic for the previous pregnancies there’s no need booking early. (KI2)
Among the pregnant women, there was one case with a negative obstetric history. Due to her blood group and that of her spouse, all their previous children had the sickle cell disease and did not survive. This influenced her to delay initiating antenatal care because she was contemplating terminating the pregnancy.
I lost two children in the past due to our electrophoresis status [incompatibility of her blood group with that of her spouse]. I aborted the third and this is the forth pregnancy and I am not happy about it all…I decided to come now because I was still thinking whether to keep the pregnancy or not [terminate]. (P16, married, age 27, parity 0)
Perceived barriers to antenatal care
These are barriers that prevent pregnant women from initiating antenatal care early. Themes that emerge under perceived barriers are; accessibility of antenatal care services and distance to health facility.
Accessibility of antenatal care services: Some women said the booking system was user-unfriendly, with long waiting times and some of the staff were rude making accessibility of services difficult and stressful. This influenced their timing of booking antenatal care.
The problem is the place is too congested, the population is too much, when you come you need to stand on a very long line and aahh its really stressing…standing on the long lines every month from the first month [of pregnancy] and for nine months is something I can’t really do….. So I decided to come from five months to the last month so that at least I will not have to stress a lot. (P11, single, age 20, parity 0)
I was not really pleased with the way the welcome was at the clinic, some of them are very rude, they don’t take time to explain things and end up just shouting at us and that’s even the most reason why some of us don’t like to come early for clinic because we don’t want to interact with them. (P18, married, age 38, parity 3)
High cost of initiating antenatal care: Some of the pregnant women said it was expensive to initiate antenatal care. They had to delay initiating care because they needed to plan and raise money to pay for the services.
Let me say within the first two months, things were really difficult for us, so even if I was to start by then, I won’t have started. Because you know the town is shaking [socio political tensions] now so everything is difficult. Money is difficult to get …… there would have been no money to pay for tests and drugs within the first two months. (P5, married, age 27, parity 1).
Some women said they could not afford to pay for antenatal care services and delayed initiating antenatal care in order to reduce the number of clinic visits, thereby reducing the total cost of antenatal care during the entire pregnancy period.
You know there are financial challenges, there is a lot of hardship here and you have to pay for the cost of antenatal care … to start coming from the first month [of pregnancy] to the last month like that I don’t really have money because it is expensive to be coming from the first month to the last month, no, no, I cannot afford money to pay. (P17, married, age 40, parity 3)
Midwives concurred that initiating antenatal care is expensive ($26) to many pregnant women and lack of finances is one of the reasons why many of them book late. This amount is too high for women within this community to afford in order to initiate antenatal care.
For first booking you spend at least 13,000 fcfa [$26] and they always see early booking to be expensive to them…… we always at least attend to them and give them services according to the money they are able to have and tell them to go and look for money and come and finish their lab tests. (KI3)
Distance to health facility: Some women said that the distance to the health facility was far and that transportation difficulties to get to the facility caused them to postpone initiating antenatal care early.
I do have difficulties of transport to come for clinic. You know the distance is far and I use bike [motor cycle], am always very dizzy, that makes it difficult [to initiate clinic early] (P11, single, age 20, parity 0)
Even though we have tarred road but the only means of transport is bike we don’t have taxi. It’s difficult with this pregnancy to climb on a bike, you are not confortable, you are not sitting well so most at times you find yourself trekking for long to where you can see a taxi to come for the clinic …when you just think how you start trekking or climbing on a bike and start rolling down a long distance with all the wind it discourages you from going [initiating] for clinic early. (P18, married, age 38, parity 3)
Cues to action
These are triggers that can cause a pregnant woman to take necessary action to initiate antenatal care early. The absence of these cues can caused pregnant women to initiate antenatal care late. The theme that emerged under cues to action was community health education.
Community health education: The absence of community outreach programs that could sensitize women on the need to initiate antenatal care early caused some pregnant women to initiate late.
To say health workers come to the community to educate us on how to go about [early antenatal care initiation] when you are pregnant, I have not seen that… [As far as] seeing a doctor or a nurse coming around our quarter to help us enlighten [educate] us on pregnancy and [early] antenatal care, I have never seen. (P18, married, age 38, parity 3)
These pregnant women are ignorant on things about pregnancy and [early] antenatal, they lack education…we lack a forum where we can really educate women in the community on early start of antenatal clinic… (KI1)
Self – Efficacy
This is the confidence that enables a pregnant woman to be motivated to take action. It is influenced by socio economic and demographic factors. In this study, some pregnant women did not believe that they were capable of taking the decision to initiate antenatal care within the first trimester. Themes that emerged under self – efficacy were; cost of initiating antenatal care, pregnancy disclosure, support from spouse, reaction from parents
Pregnancy disclosure: Some of the participants initiated antenatal care late because they wanted to delay making the pregnancy public because of fear of perceived “enemies” who may harm their pregnancy.
I did not come before this time because I did not want people to know especially people who don’t wish me well, my enemies. (P2, married, age 27, parity 1)
Other women said they delayed making their pregnancy public because they were shy or ashamed when the pregnancy was still small. It was noted that stigma associated with early pregnancy disclosure influenced both married and unmarried women on the timing for antenatal care booking.
Pregnancy in our culture even though you are married it has some types of conceptions. At times I am shy and so I will not want my neighbors and people around to first of all know …. Culturally you feel shy…. even though married, it has a little aspect of shame related, you don’t feel comfortable you just feel a type [unconfortable]. (P18, married, age 38, parity 3).
One of the key informant midwives said unmarried women especially young girls also hide the pregnancy within the first trimester due to the shame that information of their pregnancy will bring on their parents.
Most pregnant women at the beginning of pregnancy are always shy especially those who are not married, they shy away first of all because they don’t want their neighbors, or their immediate family members to know that they are pregnant so they hide the pregnancy seriously……some are ashamed for fear of stigma that their neighbors will laugh at their parents that though she was so holy she is not married but is pregnant. (KI1)
Some of the women said community members consider early antenatal care as a show of pride and do mock at women who initiate antenatal care early.
So for us we believe that you only start going for clinic when the stomach is already very big as from six months. Because when you go for antenatal care at one or two months when the baby is still small is like you are boosting of something, proud which does not really speak well of you[in the community]. (P17, married, age 40, parity 3)
Support from spouse: In some cases, lack of support of the spouse contributed to late initiation. Lack of trust made some husbands not to believe their wives when they (wives) told them that they were pregnant. This made the husbands to be reluctant to provide money for early initiation of antenatal care.
Whenever I tell the father of my children that I am pregnant he usually take it for a lie…each time I request for money to go for clinic he is not willing and will ask me to wait and he will give it [money] at his own time. (P7, married, age 21, parity2)
Lack of knowledge on ideal booking time by husbands also contributed in weakening the support they gave to their wives to initiate antenatal care early
I was not given money on time by my husband and when I said I was pregnant and needed to go for antenatal care early he thought I was lying…It took many months before he gave me money….. He thought one needed to go for antenatal care at 6 months [of pregnancy]. (P14, married, age 18, parity 0)
Marital misunderstanding was also identified as one of the reasons that caused many husbands not to support their wives to book early.
Sometimes he [husband] is not understanding, what I will actually want from him he will not even give me. Like this food they are telling us to go and eat, I don’t know how I will explain to him because according to him he thinks that I just want to take his money and eat… he just get angry and say, why are you struggling to go, you just want to waste my money. (P18, married, age 38, parity 3).
Reaction from parents: Most of the unmarried women especially young girls said fear of negative reaction from parents led to late disclosure of pregnancy and hence contributed to late initiation of antenatal care.
My parents were not going to welcome the pregnancy since I was just a student …so telling them when the pregnancy was still one or two months or so it would have been a taboo or something and I will surely be beaten…my parents are wild and there could do anything, so I was scared [and decided to hide the pregnancy from them]. (P11, single, age 20, parity 0)