Influence of traditional beliefs

For many women in low‐ and middle‐income countries (LMICs), and particularly for those living in rural areas, there were a variety of medical, spiritual and supernatural beliefs that they saw as preferable alternatives to engagement with formal ANC services. In these contexts biomedical approaches to health care were not culturally normative. Women used community resources, including TBAs and shamen, to treat pregnancy‐related conditions and allay concerns about pregnancy outcomes. In some contexts women were precluded from attending antenatal facilities because of supernatural fears relating to pregnancy disclosure. Sometimes these fears were based on religious beliefs, but in most cases the influence of sinister forces, described as evil spirits or 'the evil eye', restricted or delayed ANC engagement, “It is a traditional belief; there are some people that when you tell them and they have evil eyes and mind they can destroy it [the foetus] so unless the pregnancy shows then you tell. If not when it is two or three months you cannot tell” (Dako‐Gyeke 2013, Ghana). In other contexts, faith in the knowledge of traditional or spiritual healers limited ANC engagement, "When some women conceive they always have pain. This kind of pain could provoke a miscarriage. They must find the person who knows how to treat this. A curandeiro [traditional healer] or pastor could treat this, but it depends on the woman. There are some cramps that are from your body, and there are illnesses provoked by mal espirito [evil spirit]. Only a prophet or curandeiro can say which is which. In the hospital they don’t know how to differentiate. But neither the hospital nor the curandeiro can cure without God’s help" (Chapman 2003, Mozambique). Where women felt their traditional beliefs were ignored or disrespected by healthcare providers their inclination to visit formal antenatal services was reduced (Family Care International 2003, Kenya), but in other instances where healthcare providers made cultural understanding of traditional beliefs an engagement priority, women appreciated the efforts and were more likely to engage, "There are doctors who know the plants here, from our area and they make us see that our plants do serve us so we don't have to take only the pure medicine [Western medicine]" (Mayca 2009, Peru).

In many LMICs a woman's decision to engage with antenatal services was influenced by a variety of different people, including family members, community representatives and community health workers. The influence might be positive or negative and could depend on financial considerations, traditional beliefs or familial hierarchies, or both. In some cultures deference to an older female family member (usually the mother, or more often the mother‐in‐law) restricted ANC attendance because of a lack of knowledge of ANC or a belief in perpetuating and protecting traditional practices, "My mother‐in‐law said that pregnant women didn't go for antenatal check‐ups in the old days. She told me that she had all her children without any antenatal check‐ups and all are fine. She questioned why different foods and antenatal check‐ups are necessary for pregnant women. That's why I didn't go" (Simkhada 2010, Nepal).

Influence of local beliefs and traditional maternity practices

In rural communities of LMICs where providers were able to co‐operate effectively with influential community members or TBAs, use of ANC services was perceived to be better than where such co‐operation was not present. This is starkly illustrated in a study from rural Ethiopia where 'good performing clinics' (with high ANC coverage rates) were compared with contextually similar 'poor performing clinics' (with low ANC coverage rates) (Bradley 2012, Ethiopia). In the 'good performing clinics' the importance of community engagement was identified by the providers as being one of the keys to their success, "There are priests and there are also sheiks. These people are community leaders; therefore we go to them and we tell them that such and such person is not willing to listen to us and we ask them to help us get through to them. After that, they would go to the community with us and they would tell people that what we had taught them was true"; (Bradley 2012, Ethiopia). In the 'poor performing clinics' these kinds of connections were limited or non‐existent. In some rural African communities where tension sometimes existed between the traditional practices adopted by TBAs and the modern approaches used by community midwives, an emphasis on co‐operation rather than confrontation was seen as a way of encouraging women to attend ANC services, "Government should put more effort into TBA's because the community has trust in them. They are living with them, some of them are friends and relatives so we need to be nearer to them" (Franngard 2006, Uganda). In a variety of LMICs the reliance on traditional maternity practices was viewed as a barrier to ANC engagement by local providers. Health professionals acknowledged that women sometimes preferred to be seen by a TBA because of their understanding of community‐derived customs and rituals relating to pregnancy. This mutual understanding generated a sense of trust in traditional practices, especially when biomedical approaches to ANC conflicted with cultural beliefs, “For some of the pregnant women when you talk to them like that and tell them about a complication, if there is any TBA around they rather go to that place, rather than the health facility they have been referred to” (Dako‐Gyeke 2013, Ghana).

Pregnancy as a healthy state

Across a wide variety of settings and contexts, including urban and rural locations, women perceived pregnancy to be a healthy state and saw no reason to attend an antenatal clinic unless they felt unwell, “We go to the doctor only if the child is unwell or if the mother has excessive bleeding”. (Khoso 2016, Pakistan). Some women viewed pregnancy as a positive experience and held no particular fears or concerns about potential danger signs or complications. This view is clearly reflected in the following statement from a woman in rural West Java, (Indonesia), “I think pregnancy is a normal process so you do not need to think bad thoughts about it" (Agus 2012, Indonesia). Support for this belief was also evident in urban locations where arguably public health messages about the value of antenatal care were more likely to be received and operationalised, as this quote from a woman in Dakka, Bangladesh implies, "As no one expects to be sick during pregnancy, visiting the centre for a check‐up is not necessary. What is the point for going for a check‐up in a healthy condition" (Chowdhury 2003, Bangladesh). Even in high‐income settings, some women postponed or delayed engagement with ANC services because of a perception of feeling well or because of previous experiences with healthy pregnancies, "I think if there were any previous problems with them [previous pregnancies] I would have probably found out but I just felt healthy, I felt OK you know, I just felt normal basically and I suddenly saw my belly getting a bit bigger and my clothes weren’t fitting as much”. (Haddrill 2014, UK).

Selective use of antenatal care

In certain settings women made selective use of ANC services, and in some instances this was simply based on their desire to confirm a pregnancy. Women were aware that a test at the clinic would prove their pregnancy status and, provided the clinic was reasonably accessible, would take advantage of this service. However, this did not necessarily mean that women visited a clinic at the first sign of pregnancy or even within the first three months, "I started going to the clinic when I was 5 months pregnant; I was not sure that I was pregnant and therefore decided to go and confirm it" (Mrisho 2009, Tanzania). Selective use of ANC was also evident in contexts where women saw a value in obtaining a paper record of their ANC visit(s) in the form of an 'ANC Card'. This finding was peculiar to an African context where the card was viewed as an insurance policy or a passport allowing access to a hospital or health facility when the time came to give birth, "If you come to the clinic for an antenatal care card, you are booking yourself a bed in the clinic. . . . How could you deliver in the clinic without a card?" (Myer 2003, South Africa). In these contexts, however, the value was placed on the card rather than on antenatal care per se and some women just went to receive the card without any understanding of the wider benefits of antenatal care, "I am just afraid of being denied services when I need them, so one must just go [to ANC] to get the [clinic] card. If you do not have a card, they will not accept you when there is a problem.... Otherwise, we could just rest at home" (Mrisho 2009, Tanzania).

Gender issues

Our findings also highlighted several issues relating to gender which generally restricted women's engagement with ANC. The first of these, relating to women's financial dependence on their husband, was demonstrated in a small number of settings where patriarchal systems were dominant. In these contexts women had to ask for money to visit ANC facilities and, even if their husbands were supportive of antenatal care, the issue often came down to whether there was enough money to go. In some settings these power structures limited ANC engagement but in others women found ways of subverting the hierarchy, especially if they valued antenatal services. "Let me tell you, things are very hard now, my husband does not have money and even when he has, he pretends he does not and will hardly give you anything. It is only when I am going to the hospital that he gives me money and often times I will tell him an amount more than I will pay in the hospital and use the rest for other things" (Umeora 2008, Nigeria). Studies conducted in Pakistan and Bangladesh also revealed that cultural limits placed on women's freedom of movement sometimes restricted their ability to visit ANC facilities. Even in situations where women were convinced of the benefits of antenatal care their inability to travel independently sometimes prevented them from doing so, "I wanted to go for check‐up in the hospital but I could not convince anybody in the house to accompany me. Everybody asked me to stay home" (Chowdhury 2003, Bangladesh).

Also relating to gender, women sometimes felt a sense of shame with being pregnant. In studies conducted in Pakistan and Bangladesh. This was because of an association with sex, whilst in other settings the shame was associated with criticism from health providers or other women about the size of their families or their perceived promiscuity "You know the mothers, while sitting down and waiting for the clinic they will start to make comments, "That woman used to roam around and show off now she is here at the clinic" (Andrew 2014, Papua New Guinea). For other women, particularly in studies from South America, the sense of shame or embarrassment was associated with physical examinations, "Mothers do not want nurses to see the vagina, it is very difficult for them, and for that reason I think many mothers do not attend health clinics, it is because of the shame" (Mayca 2009, Peru). This latter issue was of particular concern when the health professional doing routine examinations was male. Some women found this particularly embarrassing “Being palpated by a man, oh, that was worse! That young man who palpated me was actually inspecting my private parts! In fact he frankly told me before, that I must remove most clothes and leave my abdomen exposed. I felt very embarrassed to undress in front of a male stranger” (Maputle 2013, South Africa). For others the preference to be seen by a female health professional was related to a sense of affinity or gender kinship, "I didn’t trust him. The health worker who checked me was a man…that’s why I only went once…I only trust the female workers. I am scared of going. Because I’m older, I want to go [to ANC] this time, but I will have to do without it" (Ayala 2013, Peru).

Local infrastructure

The proximity of a clinic acted as both a barrier and a facilitator to ANC access, depending on where it was located. For some women, the convenience of having a clinic close by was viewed very positively, “It’s actually quite convenient ‘cause I can walk there [from work] on the nice days. ... It’s close to my husband’s work as well" (Sword 2012, Canada); while for others, particularly those in more rural locations or for those with relatively modest incomes, the inconvenience of getting to a clinic was perceived negatively, "If the obstetric care was located here in the neighbourhood, it would have been better. And the person who does not have a car, how do they get to the specialist unit?" (Cabral 2013, Brazil). Proximity of ANC services was also noted by midwives in a rural area of Nigeria where the creation of a 'grassroots' health centre serving the local community appeared to have a positive effect on maternal and infant morbidity (Chimezie 2013, Nigeria).

In some LMICs, where women faced the prospect of making relatively long journeys (sometimes on foot) to reach an ANC clinic, the local infrastructure could have a negative impact, "I never visited the health center to check my pregnancy because it is so far and the road condition is too bad" (Matsuoka 2010, Cambodia). These areas were often devoid of useful and affordable public transport systems, making travel to ANC clinics even more difficult, "There were cars but they were all full. I waited for a while but it was getting late so I started to worry how I would get back afterwards, so I just decided not to go to clinic" (Andrew 2014, Papua New Guinea). Transport difficulties were also recognised by providers, particularly in low‐income settings where the hazardous terrain in some rural areas restricted ANC access and presented serious safety concerns for women in distress, "Because of muddy and difficulty topography, the pregnant women in remote areas will not be able to be picked up by the ambulance car from their home. Thus, we have to carry them… This is one of the problems that we have to deal with until the road is constructed" (Bradley 2012, Ethiopia). Providers working in rural areas also bemoaned the lack of available transport options to take them to and from work and the effect this had on the service they were able to provide, "There are no transports for nurses; the authorities should make transportation available for us. We need transport so that we can come early and give effective focused antenatal service, then.... I think the big people should think seriously about it because it will bring more productivity" (Baffour‐Awuah 2015, Ghana).

Cost of services

Although publicly‐funded ANC services are provided free of charge in almost all countries around the world, the indirect costs of getting to and from clinics, the additional charges associated with the purchase of medicines, the loss of vital income to families who rely on women's contributions and the corruptive practices of some healthcare staff all limited women's engagement with ANC. Our findings showed that even when women were convinced of the benefits of ANC and lived in an area where there were no infrastructure issues, if they did not have the money to pay for transport they could not go, "The problem is I did not have any money to pay the transport. I want to have my pregnancy checked by the doctor or the midwife every month, but their places are so far away. I needed transport to get there. Instead, I went and sought traditional birth attendants" (Titaley 2010, Indonesia). In relatively impoverished settings the costs of getting to and from a clinic were sometimes overtaken by more immediate concerns relating to women taking time off from family duties or vital income‐generating activities, "When I had a third pregnancy, it was harvest season. So I wanted to help my husband, even during the pregnancy" (Matsuoka 2010, Cambodia). Even in fairly affluent countries the additional costs of purchasing essential medicines or tests hampered ANC attendance in contexts where women were living in relative poverty, “The doctors got angry with me because they wanted me to have an ultrasound but I did not have money” (Coverston 2004, Argentina). Although these issues were occasionally compounded by corrupt healthcare employees selling medicines to women that were supposed to be supplied free of charge (Rahmani 2013, Afghanistan), a number of healthcare providers in a variety of settings also recognised the indirect costs of ANC attendance as a potential barrier to access, "The pregnant women living in rural areas have financial and time constraints for examination [since they need to work]. I have to explain to them that they might experience complications affecting themselves and their unborn child during their pregnancy" (Graner 2013, Vietnam).

Clinic environment

In situations where women made the decision to visit an ANC facility and had the time and resources to do so, the environment they encountered at the clinic could have a significant impact on their willingness to return. In a number of settings, including high‐income countries (HICs), the amount of time women were kept waiting was hugely disproportionate to the amount of time they actually spent with a health professional, and generated feelings of frustration and resentment, "I mean I have waited so long and I was thinking, oh, why do they even give you an appointment time because I am never in there on my appointment time. I normally have to wait for an hour and it is so frustrating and then you are only in there for what, five minutes?". (Worley 2004, New Zealand). The issue of time was just as important to health professionals as it was to women, and midwives in a variety of contexts expressed their frustration with the lack of time available at each appointment, "When they [mothers] are many you don't attend to them. You simply examine her, you listen to complaints, you don't treat, there is no time" (Franngard 2006, Uganda). Health professionals recognised the importance of the antenatal appointment as an opportunity to establish meaningful relationships with women beyond the tick box requirements of a formal antenatal consultation, "Women want time. They want to be able to talk about what they are doing, and for women who aren’t educated, don’t know the right questions, or how to say things, it often takes a lot of time just sitting with them to open to the point where they will talk about a bad discharge smell or… the baby hasn’t been moving for the last two days … It really is having enough time to get to know the woman and for them to feel like they are welcomed and they are listened to and they are not hurried out." (Heaman 2015, Canada), Both midwives and women also agreed that a lack of privacy in busy clinics sometimes discouraged women from further attendance, "....if I go to the clinic, there are so many other people sitting there. Everybody is listening to what you are telling the nurses…sometimes, there are things you want to tell only the nurse or you want to ask the nurse alone. But because there are other patients, you can’t" (Ganle 2014, Ghana). In several LMICs providers felt that the condition of the clinic itself acted as a deterrent to women's attendance and, in some cases, was not fit for purpose, "Just look at the building. You cannot tell it is a health centre, the health centre is . . . remote . . . the working conditions are poor, there is no transport, no telephone . . . It becomes sad if you have an emergency and you cannot call an ambulance. At times you watch patients dying and you cannot help in any way" (Mathole 2005, Zimababwe)

Organisation of services

Both women and providers felt that in certain settings, particularly LMICs, ANC services were poorly organised and hampered regular attendance. A study in Uganda, for example, revealed that whilst antenatal appointments were offered on a daily basis, antenatal education sessions were only offered twice a week on an ad hoc basis, so women had no idea when to attend or what was being taught. “We ask them to return after one month; in between, we do not follow it up. So when they come, the topic they find is the one they shall listen [to], but we do not repeat.” (Conrad 2012, Uganda). Of more concern to both providers and women in a variety of settings was the flexibility of appointment times and the availability of health professionals. In some contexts appointment systems were organised with a provider focus so that heavy caseloads could be managed more effectively, but these systems were not necessarily convenient for women, "They come and we give them dates, except Thursdays . . . normally Thursday is not a working day in this community, so to them Thursday is a clinic visiting day . . . Even when given a date, they wait for Thursday . . . they never observe the dates" (Mathole 2005, Zimababwe). In contrast, where appointment systems were deemed to be more flexible or where health professionals were perceived to be more available women appreciated the ease of access and the extra reassurance this provided, "I think being able to call and get somebody to call you back in about 10 or 15 minutes has been really great. I think that ‐ I don’t know that I wouldn’t have had as healthy a pregnancy ‐ but I think I would’ve felt a little bit more stressed out about certain things" (Sword 2012, Canada).

Resource issues and working conditions

Although some women in LMICs bemoaned the lack of equipment, medicines and supplies at local health facilities and viewed this as a disincentive to ANC engagement (Conrad 2012; Matsuoka 2010; Shabila 2014) issues relating to resources and working conditions were largely highlighted by health professionals. Poor pay, lack of career progression opportunities and a lack of recognition were cited by health professionals in a number of LMICs, “We are paid less by the state government and also there is no promotion, no bonus or reward, and the salary is not enough for us to feed our families” (Mugo 2018, South Sudan). Staff shortages were a particular issue and, although identified in one or two high‐income settings (Alderson 2004, UK; Novick 2013, USA), the most severe shortages were noted in LMICs, especially Africa. "Understaffing is a problem, just now I cannot go for a home visit . . . I cannot go because there will be no‐one. I can’t go off . . . I am always here. I work throughout the day and night" (Mathole 2005, Zimbabwe). For some health professionals the lack of staff, coupled with a heavy workload, generated feelings of frustration and anger and the desperate acknowledgement that women were inevitably receiving sub‐standard care, "You are doing research on maternal health access…you have been here, you have seen our staff strength and you have seen the kind of resources and equipment we are working with. How can we ensure that all women have access to good care? Just look at me, I am the only midwife, and look at all the women sitting outside, how can one person take proper care of all of them. Sometimes, I believe the women are right for not coming to us" (Ganle 2014, Ghana). Health professionals also complained of inadequate training, particularly in their ability to deal with pregnancy complications, whilst more experienced staff felt the opportunities for much‐needed refresher courses or 'updates' were curtailed by limited resources, “We hardly go to any training or workshops nor do we receive any tuition reimbursement or bursary for advanced education.” (Chimezie 2013, Nigeria). In addition, poor working conditions and shortages of relatively basic equipment and supplies contributed to inadequate care in a number of LMICs, "We have no essential equipments such as a weighing scale or labour kits for childbirth. We have stopped providing DPT‐ Hepatitis B vaccine because we have no syringes" (Mrisho 2009, Tanzania). In situations where staff felt supported by their managers they felt better able to deal with the various challenges they encountered, "We get huge assistance from the woreda [local government].They supervise every week…by mobile phone and by presenting themselves at the health center. There are annual, quarterly, weekly action plans. They follow up on the implementation of these activities. There are experts assigned to provide support for us" (Bradley 2012, Ethiopia). However, where these relationships were strained or viewed as unsupportive, health professionals became frustrated and disengaged, "The first thing that people from the woreda [local government] and the health center ask us when they come here is ‘how many babies did you deliver?’ But there might be bleedings, and we don’t even have gloves here. We can’t even get any gloves when we go and ask for them… We are always asking and we are saying that we are missing these things… They do not even supply gloves. We always raise the problem, and the woreda always skip it" (Bradley 2012, Ethiopia).

(Over‐) emphasis on risk

In several countries (the UK, Zimababwe, Uganda and Tanzania) health professionals felt that the use of screening procedures to determine risk status hindered their ability to deliver quality antenatal care. Midwives felt that the amount of time required to complete all of the necessary screening procedures during a relatively short antenatal appointment left little time to discuss any woman‐initiated concerns or offer genuine care, "It is the dilemma we are grappling with, and personally I think screening has been introduced without the resource commitment being taken on board" (Alderson 2004, UK).

Sub‐domain 3a: Personalised, supportive care

Sub‐domain 3b: Information and safety

The third domain also encompasses issues that are important to women and staff, and focuses on antenatal care as a source of information and as a context for clinical safety.