Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill

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Understanding delayed access to antenatal care: a qualitative study

Rosalind Haddrill

A thesis submitted in fulfilment of the requirement for the degree of Doctor of Philosophy in the Faculty of Medicine, Dentistry and Health: School of Health and Related Research, University of Sheffield.

The results, discussions and conclusions presented herein are identical to those in the printed version, with the exclusion of some appendices. The final, full, awarded and examined version is available for consultation via the University Library.
October 2015


This work has been undertaken whilst working clinically as a midwife, and more recently as a midwifery lecturer in Sheffield. I would like to take this opportunity to thank some of those who have been integral to its completion.

Firstly, I would like to thank my wonderful husband Mark for his love, tolerance and support, which has sustained me throughout the protracted and often challenging process of completing this study and thesis. We first met after I had started this work, so he has only known me ‘doing my PhD’. We are both looking forward to life together post-thesis. Similarly, I want to thank my beautiful, clever daughters, Freyja and Esmé, for their understanding. A large part of their childhood has been overshadowed by this thesis. I hope my studying has been a positive influence, an inspiration to them for their own futures, whatever they are. I am looking forward to being more of a mum and less of a recluse in the future.
I would like to thank all my supervisors, but particularly Dr Georgina Jones and Dr Caroline Mitchell, for their attention to detail and dedication to my work. They have offered support and direction but also firm guidance at times, which was needed. Also thanks to my thesis mentor Dr Lucy Mayblin, and my friend, fellow midwife and PhD student Phoebe Pallotti, for their encouragement, and to Sheffield Health and Social Research Consortium for funding the project. Thanks goes to everyone who has expressed an interest in the work as it has progressed, from personal, professional and academic circles, and following its presentation and publication. You have all sustained this process and enabled me to complete this work.
Finally, I would like to thank all the women who participated in the study. They allowed me into their lives and pregnancies, and talked openly to someone who was essentially a stranger, at a time when many may have felt that they would be judged for lack of knowledge or poor choices. As a midwife and teacher I have learned a lot from both our conversations and the research process, and have tried to incorporate this into my practice. I hope I have managed to do justice to their stories and to make a positive contribution, however small, to improving future antenatal access.
Publications and presentations from this work

Haddrill R, Jones GL, Mitchell CA and Anumba DOC. Abstract: Why do women attend late for antenatal booking? A qualitative interview study exploring the perspectives of service users and stakeholders. Part 1: the service users. Archives of Disease in Childhood - Fetal and Neonatal Edition 2012, 97: A113.

Haddrill R, Jones GL, Mitchell CA and Anumba DOC. Understanding delayed access to antenatal care: a qualitative interview study. BMC Pregnancy and Childbirth

2014, 14: 207 (appendix 6.2)


Society of Academic Primary Care annual conference, June 2011, Bristol.

Abstract accepted for oral presentation in the Antenatal Care session; presented by myself and Dr Caroline Mitchell.

Royal College of General Practitioners annual conference, October 2011, Liverpool.

Selected as as one of the highest rated abstracts submitted to the SAPC conference, and invited to present at the RCGP annual conference in a session entitled Making a difference: cutting edge Primary Care research. Presented by myself and Dr Caroline Mitchell.

Sheffield Infant Mortality Forum Stakeholder Event, January 2012, Sheffield.

Findings from the study were presented by the Head of Midwifery at Sheffield Teaching Hospitals NHS Foundation Trust, Dotty Watkins, and used as the basis of a workshop among practitioners considering antenatal access.


Royal College of Midwives annual conference 2012, Brighton.

British Maternal & Fetal Medicine Society annual conference 2012, Glasgow.
Understanding delayed access to antenatal care:

a qualitative study
Volume 1

Acknowledgements i

Publications and presentations from this work ii

Table of contents iii

Abstract x

Thesis outline xi

List of abbreviations and acronyms used in the thesis xvi
Chapter 1: Introduction to late booking for antenatal care

1.1 The background to late booking 1

1.1.1 Midwifery and ‘bookingfor antenatal care 1

1.1.2 The pattern of antenatal care and recommendations for early booking 2

Table 1.1.2: Antenatal booking recommendations from different countries

1.1.3 Why is late booking important? 5 Maternal wellbeing Fetal/neonatal wellbeing

1.1.4 How many women are accessing antenatal care late? 10

1.1.5 Who are the late booking women? 11

Table 1.1.5: Chronological summary of UK and European studies of maternal characteristics associated with later initiation of or reduced attendance for antenatal care.

1.2 UK public health guidance in relation to health inequality and access to 15

antenatal care

Table 1.2: Chronological summary of significant publications relevant to access to maternity care in England.
1.3 The need to examine women’s perceptions and beliefs towards late 20


1.3.1 My personal perspective as a midwife 22
1.4 Conclusions 23
Chapter 2: A literature review and critical interpretive synthesis of perceptions and beliefs towards late booking for antenatal care

2.1 Introduction 24
2.2 Method 27

Table 2.2.1: phases of a critical interpretive synthesis

2.2.1 Formulating the review question, defining late booking 28

2.2.2 Searching the literature and sampling 29

Table 2.2.2 Literature search summary

2.2.3 Determination of quality 32

Table 2.2.3: summary of studies included in synthesis, by type and chronology

2.2.4 Data extraction 44

2.2.5 Conducting the interpretive synthesis 44
2.3 Findings 46

Table 2.3.1: Constructs and concepts relating to late booking from the literature: women’s perceptions and beliefs

Table 2.3.2: Occurrence of synthetic constructs relating to late booking in the literature: women’s perceptions and beliefs

2.3.1 Acceptance of the private pregnancy: the pregnancy mindset 51 “I didn’t know I was pregnant” - knowledge of/recognition of pregnancy. “I can’t do nothing but stick with it” - pregnancy intention, desire “Not thinking straight” - emotional and psychological factors “Didn’t want to be bothered with me” - social support for pregnancy

2.3.2 Acceptance of the public pregnancy: social consequences, antenatal care 53

relevance and priority “Nothing in it for me” – the necessity of antenatal care “Knew what should be done” - previous experience “I feel fine” - feeling well “Not up to going for care” – psychological and physical factors “I can do this on my own” - self-care, self-reliance “Out of my hands”- fate, acceptance “Not very important to those close” - social support for antenatal care “Need time, energy to deal with other problems” - other priorities in life “No means” - practical/site related/system factors “The cost of getting care is too high” - financial issues, economic hardship “I already knew I was pregnant” - knowledge of antenatal care, the 'system' “Like you’re a piece of meat” - previous healthcare experience, dislike of care “Cultural and religious differences” - cultural factors

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