The study conformed to three overarching and interrelated categories that shape the uptake of ANC in Surabaya, Indonesia: ‘Individual Circumstances’; ‘Cultural and Social Dynamics’; ‘Community and Health Care Conditions.’
The results of this study revealed that knowledge of pregnancy differs greatly for many pregnant women. Although several midwives commented that women are mostly aware when they first arrive at the community health facility that they are pregnant, several participants had limited knowledge on pregnancy risks or emergency signs. In addition, one midwife explained, “They (pregnant women) think that pregnancy is the normal process. So, they have in their mind that it is okay if they do not go to the health facility.” (MW5-P3)
For unplanned pregnancies, there was often late pregnancy awareness which resulted in late uptake of ANC. This aligns with research conducted in the United States, which found maternal awareness of pregnancy being significantly later for unintended pregnancies versus those that were intended (p<0.01) . Within this study there was a noted significance of early pregnancy detection and ANC for improving pregnancy outcomes due to the critical window of foetal development in the first trimester . Further, timely uptake of ANC was also shaped by not experiencing nausea or feeling that they were too old to be pregnant. “First time I came to midwife when my pregnancy had been 3 months. I did not realise that I was pregnant already because there is no symptom like dizziness or nausea.” (FGD5-P1)
Similarly, it was demonstrated some women associate symptoms of nausea as the first signs of pregnancy, however the authors acknowledge that this symptom typically occurs during pregnancy weeks 6-8 and peaks in weeks 11-13 . Consequently, not having nausea until later in the first trimester could shape the early uptake of a first ANC . Separately, a study conducted in Kenya showed one of the main reasons for a late ANC booking was “not feeling sick” . Likewise, a study in in Northern Ghana it was highlighted that no visible signs of pregnancy such as no sickness can contribute to delayed or lack of ANC . The authors conclude female education, intensification of health promotion activities by health workers, non-governmental organisations, community and religious leaders to sensitise communities on the benefits of initiating ANC at the onset of pregnancy is required in order to improve first trimester ANC attendance . Therefore, promotion and investment in female education within the districts of Surabaya should be considered to improve the early recognition of pregnancy and early uptake of ANC.
For this study population, the importance of ANC was widely acknowledged by the pregnant women and midwives. Several of the expectant mothers shared their opinions with a general consensus of wanting to “know my baby is healthy and developing” (FGD5-P2). In a study investigating enablers and barriers to ANC service use in India, it was demonstrated that understanding the importance of ANC was essential for uptake of this service . Further, the authors suggest community health education on the importance of ANC in increasing ANC uptake to achieve sufficient ANC coverage (minimum 4 visits) . Despite the shared understandings of the importance of ANC, a common view reported by the pregnant women was a fear of receiving a negative diagnosis upon their first visit at the community health facility. Several of the women explained for themselves and their neighbours that they were often afraid to be diagnosed with a problem in their pregnancies. For example, one mother explained, “I am afraid at the community health facility if it does not give me an excellent service. But the service is ok, but I am more concerned if there is something wrong with my baby.” (FGD1-P4)
“…There was a mother who felt scared to check from the first time she knew she was pregnant to 9 months of pregnancy; she never went to the health facility... her condition became critical in labour. Fortunately, both mother and baby were okay.” (FGD3-P2)
It is well documented in research within the United States identified reasons for avoiding the doctor includes fear of having a serious illness . Separately, other women shared in this current study that they were fearful of contracting an infection whilst at the community health facility. Consequently, focus should be placed within the community by the Surabaya City Health Office on ensuring mothers’ feel comfortable and supported to seek ANC without fear of negative diagnosis or contracting infections.
Affordability of ANC
In a South Sudan study examining barriers to utilisation of ANC, having a low income and not being able to afford health care was found to discourage uptake of ANC services . However, the majority of women within the current study population held Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS), which administers the Indonesian national health insurance. As a result, the ANC services are free to the women holding BPJS making ANC affordable for this study population. Similarly, for those who do not have BPJS it was shared that the services were perceived inexpensive, so there was no financial problem in accessing ANC, “I choose this community health facility, because the community health facility is cheap” (FGD1-P5). However, it is well recognised in the literature within low-middle income countries the challenge financial constraints impose on ANC uptake [33, 35]. Therefore, while for this study population there was a consensus that ANC was affordable, this needs to be continued to be considered in future health promotion interventions as the finding cannot be generalised for the whole of Surabaya and Indonesia.
Cultural and Social Dynamics
Myths associated with pregnancy
The beliefs, attitudes and behaviours of pregnant women could strongly shape whether a mother chose to attend ANC for a minimum of 4 visits, and more generally, could also shape pregnancy outcomes. The results of this study show that nearly all the participants had a personal belief about pregnancy or shared the views of others when considering when they could come to the community health facility and when they could safely leave the house. It emerged from this study there was often a delayed initiation of ANC due to upholding beliefs.
“I came to community health facility for the first time in the fifth month… The reason I only came in the fifth month is because I had nausea before, and I was told (by my family) that the nausea should end first before I can go to the community health facility.” (FGD1-P6)
In South Africa one it was demonstrated of the well documented risk factors for late uptake of ANC is cultural beliefs . One of the midwives commented on the importance of health promotion and education to debunk myths within the community.
“It is pivotal (for pregnant women to feel safe). Most of people in this area are middle-to-low-income and have a low level of education. So, they have to be taken care of. If not, they will easily believe in myths…” (MW3-P2)
Influence of family and friends
In a Balinese study on pregnant women, the findings showed that pregnant women tend to take advice from their family without question because they trusted them . Further, several admitted they followed their family’s advice so they would be happy with them . Within this study, several women commented that their husbands had recommended the community health facility for them. Alternatively, a friend or family member had suggested the facility, “My husband recommends this community health facility for me. I have heard from my family and friends to come here” (FGD1-P1). Certainly, husbands’ involvement in ANC was regarded as pivotal by one of the midwives to ensure everyone was well informed.
“It is pivotal (for both pregnant woman and father of baby to attend the visits) in order for the information to be known by the pregnant woman but also by her husband. Perhaps, the husband has something they want to share with the midwife. So, there is a good communication between everyone.” (MW3-P2)
Certainly, male partner participation in ANC is vital to bettering maternal and neonatal birth outcomes . Whilst it was showed within Ethiopia women who reported at least one ANC visit with their husbands were 6.27 times more likely to use skilled birth attendants in comparison to their counterparts who attended ANC alone . Likewise, a separate study showed a significance for women whose partners attended ANC in receiving urine and blood tests and counselling regarding pregnancy complications compared to those who attended alone . As previously established, husbands can play a pivotal role in decision making within a home, and therefore participation in ANC is vital if pregnant women are to fully utilise and benefit from the offered services. Therefore, involving husbands within community based educational programs on the importance of ANC should be considered to improve overall rates of ANC uptake.
Lastly, a qualitative study within the UK investigating understanding delayed access to ANC reported that women postponed ANC uptake to avoid negative family reactions on how they might cope with the birth of another child . Within this study, it was discussed the shame felt by the pregnant women from the community if the pregnancy was too close to a previously born child. Certainly, the participants shared that not seeking ANC or slow uptake of ANC was often shaped by this shame experienced, “So when she (neighbour) went to give birth, she had only checked her pregnancy once. 1 month before giving birth. Sometimes it is a shame, when the pregnancy is too close to the first child” (FGD2-P4).
This research displayed the importance of husbands, family and friends in pregnancy and decision-making regarding pregnancy. Efforts to increase ANC uptake and decrease negative pregnancy outcomes in Surabaya could include community level health promotion and education directed towards husbands, family and friends. Whilst importance should be placed in the empowerment of women to ensure pregnant mothers are confident in controlling and making decisions surrounding their own health alongside their child’s and not a reliance on husbands, family or friends. Indeed, through supporting the empowerment of women in Surabaya may lead to improvements in their health. This is supported by a review on women’s empowerment related to pregnancy and childbirth, which demonstrated a link between the empowerment of women, improved health, particularly in areas where disparities are highest such as maternal mortality .
Community and Health Care Conditions
Availability of Services
The participants in this study expressed their concern over the limited waiting seats within the community health facility. This often resulted in the pregnant women having to “wait by standing”, and several suggested the installation of additional seats would facilitate a more comfortable waiting area.
These long waiting times at community health facilities have been highlighted in other Indonesian studies. In particular, one study explained that the long waiting times made the facilities less convenient and limited the enjoyment of the service . In addition, in some cases it can act a barrier to service uptake with participants of this study choosing to leave the clinic or attend a private hospital rather than cueing at the community health facility . This was similar to the participants in this present study, where one woman commented, “I went to a midwife clinic (private) for my first pregnancy because I did not need to wait” (FGD4-P1).”
Despite the long waiting times, the participants of this study commented on the effectiveness of the online booking system and the ability to book through WhatsApp streaming processes, “Nowadays, we can register it by online. The registration is fast, but the queue is long. The service sometimes does not match to the time written as it is sometimes delayed” (FGD4-P5). A mixed-methods evaluation of e-booking in medical practices showed that the majority of patients appreciate the system due to the flexibility and time savings associated . In addition, the system’s automated reminders helped significantly in reducing the number of missed appointments . Such technology could be considered to be used in Surabaya in order to inform patients on waiting times, and if a delay in their appointment is going to occur to reduce long waiting times and improve overall comfort of attending ANC appointments.
In addition, participants commented that due to the high number of patients at the community health facilities, their consults would often be short, and participants felt they were unable to receive all the information they required, “I think they should add more professionals because there are a lot of patients, so we need more time with the professional to consult more” (FGD1-P5). Certainly, qualitative research on women’s and care providers’ perspectives of quality prenatal care across Canada indicated that more time spent between the patient and health care professional often can facilitate a relationship-centred model of care . It was demonstrated that this can be effective in improving patient satisfaction with care and ultimately reducing negative birth outcomes . Indeed, it was shown that women often desire longer appointments in order to feel more comfortable with the visit and not rushed on receiving information surrounding any concerns .
Whilst research on accessing emergency maternal care in Indonesia reported that being able to access a community health facility is influenced by available transport . Within this study, transportation was not considered a factor in shaping uptake of ANC, “For the access, especially transportation, this place is very easy to access. For the road is good as well, because the road here has been paved all” (MW5-P5). As recent Indonesian research indicates place of residence as an influencing factor in the uptake of ANC services it was important to highlight whether the community facility was close in proximity to the participants . There was a general consensus that the distance to the community health facility was not an influencing factor shaping uptake of ANC for this study population due to the close proximity. Several women shared that the facilities could easily be accessed by walking or riding their scooters in less than 10 minutes, and many would come to the facility for reasons other than their pregnancy.
A qualitative study conducted in Malawi on the patient-provider relationship and ANC uptake showed that the patient-provider relationship appears to have a large impact on ANC participation . Further, the results of the study suggest the attitudes of the health care provider can influence uptake of ANC and improving the patient-provider relationship may increase ANC attendance and consequently decrease pregnancy complications . Within this present study, the patients highlighted the importance of satisfaction between the patient and the health care providers. Namely, the quality and friendliness of service delivered, alongside feeling like enough information was shared, “The doctor is pleasant, he asks, “What do you feel? What's the complaint?” It is nice for someone to care like that” (FGD2-P6).
In particular, one of the pregnant women who was previously receiving ANC from her local hospital exclaimed that she changed health care providers and health facilities due to the perceived negative treatment from her doctor where she felt she was more of an annoyance, “Sometimes there are doctors who care, sometimes there are people who are too annoyed by their patients” (FGD2-P6). Whilst none of the other participants highlighted any negative patient-provider relationship interactions as a reason influencing their uptake of ANC, many believed it was a reason shaping the uptake of ANC within their communities.
In addition, a study exploring the provision and uptake of routine ANC services in low and middle income countries reported that perceived poor quality of ANC can influence uptake of services . Within the present study, rumours associated with community health facility staff being inadequate were influencing the pregnant women in the area accessing that facility. One of the midwives explained that it was a reason why women in the area chose not to come to the facility, as they believed the staff were “not good”. Conversely, one midwife explained that several patients come to their community health facility due to the open community and closeness with the patients. Certainly, continuing to improve the (perception of) quality of the ANC delivered within the communities could improve ANC uptake and patient satisfaction. Lastly, the findings of the present study suggest future research could be directed towards the quality of the ANC being delivered to continue to understand why ANC coverage is high, yet the MR also remains high.
Midwife perceptions on no-shows
In some cases, the midwives shared that it is because the pregnant women are afraid to be referred to the hospital if it is a high-risk pregnancy. For some, it is believed that being referred to hospital means they will need to undergo a caesarean section at childbirth which raises feelings of apprehension. Certainly, this indicates the urgent need of health promotion and educational interventions directed towards mothers to address these concerns.
Lastly, in order to ensure pregnant women are attending ANC for the entirety of their pregnancies, the community health facility midwives arrange routine appointments and utilise the volunteer health workers within the communities. Indeed, the volunteer health workers seem to be crucial in shaping uptake of ANC and ensuring return visits.
“We, as a midwife, arrange the schedule for the upcoming antenatal visit routinely. So, they have already known when they have to come back. In addition, I also have kaders as my extension to follow up the condition of pregnant woman and remind them to come to the community health facility.” (MW2-P1)
Limitations of the Study
Despite the study following a strict protocol, there were a number of contextual factors which may limit the results. For example, for several of the FGDs for a period of time the chief of the community health facility and the associated midwives would sit in on the discussions. Although after time these health professionals would leave, the beginning of the FGDs results could have been impacted by these personnel being present. In addition, in one FGD, a husband was present due to cultural factors and this could have again altered the results of the study. Further, the set-up of two of the FGDs were not welcoming due to the participants being seated in rows and microphones needed to hear what each participant was saying. Indeed, under reporting is a distinct possibility within this setting also due to potential recall bias or the sensitive nature of the questions. In addition, due to the FGD and semi-structured interviews being carried out in Bahasa Indonesia and the principal investigator not fluent in this language, the study relied on translations to English. At times, meanings can be lost in translation and therefore interpretation of the results in English could miss the true meaning. In order to overcome this limitation, translations were checked by a minimum of 2 individuals, and the qualitative data was reviewed by the corresponding author fluent in both languages to ensure no meaning was lost in translation. Finally, the findings of the study are limited to a small sample in the city and urban areas of Surabaya and those attending ANC services in community health facilities therefore, the findings should not be considered generalisable to the broader population.