Understanding delayed access to antenatal care: a qualitative study

Background
Delayed access to antenatal care (‘late booking’) is linked to poor maternal, fetal and neonatal outcomes. There have been few studies of women’s attitudes towards the initiation of antenatal care in the UK. The aim of the study was to understand why some women delay accessing antenatal care, and ultimately to improve such access and outcomes.

Methods
The synthesis of a large and methodologically diverse body of evidence, around perceptions and beliefs towards late booking for antenatal care, identified that antenatal care participation behaviour is complex, with a broad range of interacting barriers. A qualitative study was undertaken in Sheffield, interviewing 27 women presenting for their first hospital booking appointment after 19 weeks gestation, in community and maternity hospital settings. The interviews were transcribed verbatim and an iterative thematic analysis completed.

Results
The women were diverse in terms of age, parity, socioeconomic status and educational attainment. Three key themes relating to late booking were identified:
• ‘not knowing’: realisation (absence of classic symptoms, misinterpretation), belief (age, subfertility, contraceptive use, lay hindrance);
• ‘knowing’: avoidance (ambivalence, fear, self-care), postponement (fear, location, not valuing care, self-care);
• ‘delayed’ (professional and system failures, knowledge and empowerment issues).

Conclusions
The analysis suggests a new taxonomy of themes around late booking, reflecting the interaction of cognitive, emotional, social and environmental factors which must be navigated prior to a woman’s first antenatal appointment. Common themes were evident across the social spectrum, including poor reproductive health knowledge and delayed recognition of pregnancy, but also the influence of a pregnancy ‘mindset’ and previous pregnancy experience, and the perceived priority of antenatal care. Three recommendations are made, namely to
1. address unintended pregnancies through improved reproductive health literacy,
2. enhance access to early antenatal care, and
3. improve the quality and focus of care, thus influencing women’s perceptions of its value and relevance.
In combination these will facilitate the provision of timely antenatal care for all women.