Overall, findings revealed three dominating themes that triggered different patterns of ANC seeking behavior, which consequently resulted in inadequate uptake of ANC, especially among vulnerable women in Aleppo (who generally had low educational level and socio-economic status and who often had limited mobility and reduced access to finances); not seeking ANC at all, seeking care with unqualified providers (independent midwives) or discontinuing care. Our findings indicated on several occasions that ANC services may have been more available, accessible and acceptable for women in Latakia than they were for women in Aleppo, however, they also showed that women’s perceptions of ANC benefits and their accessibility and acceptability of ANC services were also shaped by traditions and the beliefs and experiences of others such as family members, friends and other women in their communities.
The majority of women who did not seek ANC were from rural Aleppo where services were often accessible (within easy reach and free of charge) but the doctors practicing at those public health centers may have not been always available. Nevertheless, even if the doctors were available, it would have been unlikely for such women to seek ANC as they were willing to seek care only when they perceived their case as risky. Women’s emic definitions of risk, which affected their perception of ANC benefits, differ from the etic or medical definitions which consider any pregnant woman at risk of developing complications. Whereas in those communities, pregnancy continues to be seen as a normal event that does not require regular medical follow-up, especially among multiparous women and women who did not experience any health complications or had a normal previous delivery.
Generally, women in traditional communities worry about the harmful effect of the evil eye on the unborn baby, which obliges many women to remain discrete about their pregnancy until their baby is born (24). A number of women in rural and poor urban areas in Aleppo brought up the concept of “evil eye,” and a few were convinced that it was responsible for their previous miscarriages, possibly because they were given no alternative explanations. Women’s fear of the harmful effect of the ”evil eye” in these communities could have discouraged them or delayed them from seeking care, as seeking ANC would have been a clear announcement of their pregnancy.
Some women stated that infertility issues or serious health problems are two essential reasons why women should seek care. Since women in traditional Arab societies gain status by their ability to produce children, seeking care might indicate that they are experiencing problems conceiving or experiencing problems with their current pregnancies, thus undermining their status in their communities. Therefore, women might feel obliged to meet the expectations of their family and community by not complaining about their health publicly in order not to compromise their position in the household and in their communities.
These perceptions of ANC were related to prevailing cultural norms and the influence of others, which resulted in not perceiving ANC as being beneficial and which could have prevented vulnerable women, who had lower educational level and socio economic status, from seeking adequate care. These findings are in line with findings from other studies included in a recent review of factors influencing women’s uptake of ANC (13). Fourteen studies in the review confirmed the influence of traditional beliefs on shaping women’s ANC seeking behavior, which translated into avoiding biomedical care (13). Additionally, 16 studies that were included in the review established that for many women, pregnancy is still considered as a normal event that does not require medical attention, especially in LMICs (13).
These traditional beliefs are unlikely to be solely religious in nature, as many Muslim women in other rural areas in Aleppo, such as Afrin district and in rural Latakia, did seek ANC. These beliefs are perhaps more likely to be associated with adopted values, based on shared information in certain communities which did not disappear with time, or changed via positive interaction with the health system, possibly due to the isolation of these communities as well as the lack of interaction with other communities or the medical system, which may have contributed to increasing those women’s vulnerability. Consequently, alternative logical explanations of illnesses may have been less available to the women in these communities. This was unlikely the case for Latakia, as its smaller size and its geographical location on the Mediterranean sea may have permitted additional exposure to the outer world, increased their access to education and consequently resulted in a wider exposure to endorsed information.
When women considered seeking ANC or managed to seek care, issues related to accessibility (geographical and financial) and acceptability of different types of ANC services arose. Women’s accessibility to and acceptability of ANC services they were exposed to resulted in seeking care with unqualified providers such as midwives or discontinuing their care.
Women often evaluated the risks entailed in accessing ANC services. Accessibility of services was a challenge for many women in Aleppo, especially for vulnerable women with limited mobility and restricted access to financial resources. For instance, services were not always located within close proximity to where women lived especially for poor women in urban Aleppo. Some of these women considered the road trip to seek ANC as risky given the poor road conditions and the lack of regular transportation. Additionally, although it was not brought up during the interviews, women in traditional societies such as in Aleppo, are not allowed to leave the house unaccompanied, which makes seeking care even harder when services are not easily accessible. Therefore, even when women wanted to seek care despite their communities’ beliefs that did not perceive ANC as important, they were often faced with traditional norms that did not favor women going out alone. Accessing ANC becomes even more challenging when women are obliged to pay for transportation to go to a public health center or pay for ANC provided at private clinics that are closer to where they live. Travel related risks resulting from inadequate infrastructure, distance to health facilities and lack of transportation were also brought up as barriers to ANC uptake in several studies included in a review that looked at reasons why women do not use ANC in LMICs (14).
Other concerns that women brought up regarding seeking ANC with qualified providers were fear of hearing false bad news and fear of undergoing a cesarean section. Such fears clearly reflect the women’s lack of trust in biomedical care. Preferences for normal vaginal childbirth were brought by women in rural Bangladesh in a study that examined women and obstetricians’ attitudes towards cesarean delivery (25), however, the study revealed that women trusted their doctors’ decisions performing cesarean sections unlike the women in this study who decided to discontinue ANC or seek care with midwives. Those concerns are likely to have been transmitted to those women by other members in their community, which considered seeking ANC as risky and which resulted in inadequate uptake of ANC.
A positive pregnancy experience is of extreme importance to women across different socioeconomic and cultural backgrounds (26). Many women seeking ANC at public health facilities found ANC services provided at those health facilities to be unacceptable or less satisfactory. Some women brought up issues of lack of trust in public health care providers and being maltreated at public health centers (PHCs), which translated into either going to a private doctor, seeking care with an independent midwife or discontinuing ANC when women could not afford private health care. Poor staff attitude was among the main factors that prevent women from seeking ANC as demonstrated by a review that examined reasons why women seek ANC in LMICs (14). Similarly, a recent study in Saudi Arabia demonstrated that the negative attitude of the staff and poor communication prevented women from attending ANC despite their awareness of its importance (27). The same study also demonstrated the importance of the beliefs of others including family and community members and how they impaired women’s access to ANC (27).
To avoid undergoing a cesarean section, to avoid being mistreated by doctors practicing at the public health sector and to avoid paying for private care, many women resorted to seeking care with midwives in Aleppo who charged lower fees than private doctors. Another potential explanation of why many women preferred care with midwives, which was not brought up by women, was because they preferred seeking care with a female health provider, which is particularly important for traditional women in Aleppo. A previous study that included 500 women in Damascus, Syria, confirmed women’s preferences for females as birth attendants (28), so we assume that this might have been the case for women in Aleppo. Our results indicated that some women were willing to travel and pay for transportation to seek care with midwives whose clinics were not necessarily close to where they lived, which is also an indication that women are willing to overcome accessibility barriers when they perceive services as being acceptable. Although, acceptability of services was sometimes based on women’s own experiences, our interviews indicated that on many occasions, women’s choice for certain health providers was largely influenced by stories they heard from others in their communities, which considered ANC provided at PHCs that could have been available and accessible as being unacceptable.
The above-discussed issues relate to women’s agency and putting to use the ideas and knowledge present in their families and communities. However, it is important to note that women’s agency in the evaluation and decision whether to use services, is imbedded within gendered hierarchical structures of families and communities. In rural and poor urban areas in Aleppo, women appeared to be more vulnerable given their lower educational level and socio-economic status, which consequently may have limited their mobility and reduced their access to financial resources. Those women did not present themselves as having a great deal of control or insight into the management of their pregnancy. The majority of women living in Manbij district justified not seeking care at a health facility or with a private doctor in relation to the prevalent socio-cultural norms in their community. The role of social networks and the influence of community were also evident in relation to access to resources such as transport and financial resources. Even when women wished to seek care despite their community beliefs, the socio-cultural norms may have prevented them.
The results of the current study have important implications for consideration of introducing low cost interventions that address the demand side barriers to adequate uptake of ANC. Figure 1 provides an overview of the main themes and sub-themes resulting from this study. Theme 1 translates into perceptions of benefits of ANC, which were related to the availability and acceptability of services. Theme 2 translates into perceptions of risks of seeking ANC, which were related to accessibility to (geographical and financial) as well as acceptability of services. Theme 3 translates into perceptions of quality of ANC services, which were related to availability and acceptability of certain types of ANC services. Overall, this study demonstrated that perceptions of benefits, risks and quality of ANC were largely related to the beliefs and experiences of others in the community and were often dependent on misconceptions that resulted in inadequate uptake of ANC.
Although universal health coverage is important to achieve positive health outcomes, its effectiveness becomes limited when services are not used or under-used. Our study demonstrated that vulnerable women, such as women in Aleppo were less likely to demand for ANC services even when they were available and accessible. Future interventions intending to increase adequate uptake of ANC should aim at addressing the needs of vulnerable women and strengthening their capacity and capabilities to enable them to make their own decisions without having to depend on the opinions of others (18). We recommend 3 promising and inter-related approaches to strengthen women’s competencies and eventually improve their uptake of ANC: education, empowerment using women’s groups and Mobile Health Technologies (mHealth) as potential platforms to deliver education and empowerment interventions.
Increasing women’s access to education improves their status in the household and the community, improves their knowledge of ANC benefits and their knowledge about existing services and appropriate types of providers, thus increasing the likelihood of their adequate uptake of ANC. When education is coupled with empowerment, it improves women’s accessibility to health services especially when women are able to go out without the need to have a companion and when they have an increased access to financial resources. Additionally, education and empowerment improve women’s ability to communicate effectively with health care providers thus enabling them to raise their concerns regarding any negative news they may receive or regarding undergoing a caesarean section hence reducing the likelihood of being mistreated by health providers, and consequently improving their acceptability of ANC services that are offered by qualified health providers.
Empowerment using community mobilization through women’s groups has been shown to be an effective strategy in improving maternal and birth outcomes in poor settings (18, 29–32). Women’s groups are particularly recommended in poor settings to provide support to pregnant women, giving them the opportunity to discuss their needs and the barriers they face when seeking care and encourage them to seek care at health facilities (31–33).
The use of mobile phones was not widespread around the time of the study, especially among rural and poor women. Additionally, social platforms such as WhatsApp, which permits the free exchange of text and audio messages, were also not available. Given the high prevalence of mobile phones use these days, using Mobile Health technologies (mHealth) offers an effective and a low cost platform to promote behavior change and increase vulnerable women’s uptake of ANC. A systematic review on the effectiveness of using mHealth in improving usage of ANC demonstrated that there is a strong evidence that delivering text messages reminders and education to the phones of pregnant women can improve their uptake of ANC (34).
When designing interventions for vulnerable women with limited mobility and reduced access to financial resources, it is important to consider interventions with a delivery mechanism that meets their needs. In the context of Syria, mHealth can be an effective platform to deliver such interventions without the need for women to leave their homes or use transportation, which is particularly important in settings where insecurity remains to be a major concern. Such platforms can be used to send text messages reminders and deliver educational text and audio recorded messages on the importance of seeking ANC, risks of not seeking care and on available PHCs that provide ANC that are close to where women live. Also, mHealth can be an effective platform to deliver empowerment interventions. Such low cost interventions using existing resources are worth being explored in a low resource setting such as in Syria.
One of the main strengths of this study is that, unlike many studies, it interviewed many women twice and at different stages of their pregnancy, thus, it allowed to explore the effects of the pregnancy progress as well as the interaction with the health system on women’s health care seeking behavior and their choice of different types of ANC providers. The study also employed participant observation sessions, which aided in triangulation of the results.
The sample included in this study is not be representative of all women in both governorates, but as in any qualitative research, the sample is not usually selected for statistical representativeness, as the main objective of the study is to understand social processes. We could have missed important information by not including more women in rural Latakia. However, quantitative analyses of earlier surveys demonstrated that both rural and urban women in Latakia seek adequate ANC.
Using observation as a data collection tool involves some limitations. Firstly, observation is a subjective event and susceptible to observer bias. The researcher ensured to report the events as they occurred without allowing her own judgment to influence her notes, but she also recorded her own perception and reactions to the events. The second drawback of observation is the “Hawthorne effect,” that is, people usually perform better when they know they are being observed. The researcher’s presence in health facilities where she conducted observation sessions might have made doctors and staff working at those settings uncomfortable thus influencing their behaviour. The researcher tried to avoid that by visiting those settings several times and at different circumstances, so doctors and staff were used to her presence. When possible, she visited the same settings at different days and different times to assess the processes of care in different circumstances. We suspect that the researcher’s presence did not change the doctors’ daily behaviour during the visits, as she did not specify what she was looking for during these observation sessions.
Interviewing women at home made them feel more at ease, since they were at a familiar setting. However, since many of them lived in households with many family members, interviews were often interrupted, and other family members like mothers and mothers in –law who participated occasionally. Moreover, the presence of other family members might have made women feel less comfortable discussing their health seeking behaviour and biased their answers. Thus, to avoid this kind of bias, we interviewed women in Aleppo for a second time and for a longer period, which helped to build rapport, encouraging the women to feel more at ease and comfortable sharing information about their ANC practices, and providing more opportunities to interview them alone.
Courtesy bias, where women tried to give answers in favour of their doctors might have occurred with women in Latakia, as most participants preferred to be interviewed at health facilitates. Consequently, being interviewed at health facilities where those women received ANC might have biased their answers towards favouring the services they have received at these particular clinics or health centres and might have discouraged them from discussing the issues that they were not entirely satisfied with.