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

5.2.2.2 Postponement

The number of women postponing their antenatal care until a future date was larger than those avoiding care (11 women), with a broad range of themes emerging, including both passive and active postponement of care. For this group of women, it was evident that although they didn’t access antenatal care on time, their intentions were to always access it ‘at some point’ in the future.

5.2.2.2.1 Fear and ambivalence

Fear of the ‘consequences’ of pregnancy

Like the women who avoided care, fear and ambivalence were prevalent themes amongst the postponing women, presenting in different ways, as women considered the consequences of their pregnancies. Some planned but then postponed antenatal care as they struggled with the consequences of the pregnancy for themselves, and feared the reaction and potential judgement of family members. Again, unplanned or mistimed pregnancies planning were common amongst this group of women. For example, one woman admitted her ambivalence towards an ‘inconvenient’ pregnancy, discovered just before a long family holiday. She acknowledged that she had been in denial and felt that official confirmation of the pregnancy would influence her physical and psychological wellbeing, as she would start ‘feeling’ pregnant and this would spoil her holiday.

“I went on holiday abroad for three months and while I was there I was having these sort of symptoms but everyone kept saying ‘oh have a test, have a test’ and I said ‘no, because if I know I am then I’m going to start feeling ill and I just want to enjoy my holiday, get home and then I’ll find out for sure’. I could tell I was [pregnant] but at the same time I was trying not to think about it”

(#11, G3P2)

Two other women considered how they might cope with another baby, having recently given birth.

“It was still going in my head: what am I going to do? How am I going to cope? It’s too hard to cope with tired toddlers. I don’t know, it just took me ages to go to the GP.”

(#8, G3P2)
“I was really in a bad state, depressed, we’d just moved here and looked for work and we are planning to go back home for a holiday, two months, and I’ve got some plans about studying and you know, when I found something was… I was depressed for three weeks, it was like you know, run around, I lost my appetite, I stopped eating… how can I be, my life with two children just being, you know, being close to each other, yes and I have to study hard to join the university, it’s so difficult.”

(#18, G2P1)

For one of these women an unexpected pregnancy also brought back disturbing memories of recent traumatic childbirth:

“It was going through my head what am I going to do, how am I going to cope, because my last was a c-section. A caesarean, and it was terrible… I just couldn't go before, I was so frightened, I didn't want to think about it… I knew I should go but I just couldn't, I just kept saying 'I'll go next week' and then the weeks went by and I was busy with the children and I just put it to the back of my mind, I didn't want to think about it, because of last time, because it was so horrible. I wasn't ready for another baby I think. I didn't know how I was going to cope.”

(#8, G3P2)
Another woman explained how it was her fear of blood tests which had contributed to her postponement:

“I mean I’m scared of having my blood taken, I’m petrified, I wouldn’t have gone if I’d had to have that took.” (#2, G1 P0)

5.2.2.2.2 Considering termination

Another key reason for women postponing access was because they were considering termination. Four women planned to have a termination but couldn’t go through with it for a variety of reasons. For three of them it was because they were already at quite an advanced gestation when they found out that they were pregnant. This led to a delay in accessing antenatal care whilst women considered their options: women only ‘booked’ when the decision to continue with the pregnancy had been made. This resulted in an almost passive acceptance of antenatal care, as when the pregnancy became ‘inevitable’ women felt that they had no choice but to access care.

“[going to the GP] were to get things sorted and that and, like, see what the options were but, obviously, there weren’t any options at all.”

(#22, G1P0, age 15)

“so I went to the hospital and they did a scan and actually said that I was eighteen weeks so it was quite a surprise and even then having done that I was actually going to go for a termination and the difficulty came when they said they couldn’t do the termination because I was too far gone, I was over eighteen weeks and the stop is 18 weeks unless there is medical problems so they gave me a number to phone and I started getting quite upset about the situation because by the time the termination could have taken place in London at one of the clinics I would have been one day off 24 weeks… I said I don’t think I can go through with it and that took like couple of weeks umming and aahing to myself so then I went to my official Ante Natal appointment it would have been week 22 and there I had all the assessments and I thought I couldn’t have gone through with it”

(#1, G1P0)

“I didn’t know how I were going to cope, so I were going to go have an abortion. I couldn’t go, I couldn’t go ahead with it. I thought, fine, I won’t be able to cope now, but when a few years have gone I will regret it. I was thinking about it a lot, whether it’s a boy or a girl… so I thought I can’t do it. I can’t, it’s killing something inside you, and I thought no I can’t.”

(#8, G3P2)

“I were just waiting for, to find out my options and stuff but, bit late on to get rid of it and I ain’t got heart to put it up for adoption”

(#24, G1P0, age 15)

5.2.2.2.3 Pressure to have a termination

‘Protecting the pregnancy’

For one woman there was active postponement of her antenatal care until she was ‘safe’ from a perceived obligation to have a termination, after a negative response to the pregnancy from the baby’s father. This woman admitted that she didn’t want to be forced into a decision but wanted to choose for herself whether to carry on with the pregnancy. She acknowledged that she had taken responsibility for the pregnancy and would accept the consequences of her decision, even the judgment from healthcare professionals she met.

“I knew that S, my husband, didn’t really want one, so I kept it to myself for a while hoping that maybe it was wrong in one way and in another way it wasn’t, but, and then when I did tell him, he wasn’t happy at all and we went back to the doctors... I cancelled the appointment because I really just did not want to go through with it and then I just kept putting off going back to the doctors and going back to the doctors thinking, I’ve put it off that long, they’re not going to be able to do anything about it and we will have to carry on… I really think it should be my decision, not just his, that’s why I didn’t present til later. I’ve thought about it and if the baby is born and there is anything wrong with it then it is my fault, but there again, it was what I had to do to keep this baby. It was a hard decision but it were one that I had to do. So, maybe they do look down on you but, there again, it’s my choice, my body and my baby.”

(#26, G2P1)
5.2.2.2.4 Early antenatal care not a priority

A good past experience of pregnancy

For some of the postponing women their perception of the value and priority of early care, and ultimately convenience issues, affected their decision to access care. For many this was influenced by past experience, with some multigravid women feeling well antenatally and therefore choosing to seek care at a time convenient to their own perceptions about the appropriate timing of antenatal care. An acceptance of or fatalistic attitude towards the pregnancy meant some were in no hurry to access antenatal care, usually influenced by a good past experience of pregnancy. For many of these women, it appeared that underlying this postponement was the belief that antenatal care was only needed if they felt unwell. For example, one woman trusted her considerable past experience of normal pregnancy:

“they’ve all been normal thank God and I think if there were any previous problems with them I would have probably, you know, 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 as when I first arrived there. That’s it basically… I thought hopefully when I get home everything is going to be all right… they’d all gone all right thank God so I just assumed I’d be all right.”

(#11, G4P3)

Several other multiparous women also expressed confidence in and acceptance of their pregnancies, based on previous knowledge and experience and their general wellbeing.

“I was thinking about after the baby was born. Because I’d got experience of being pregnant so it’s probably, it’s ok… I knew about everything to do with pregnancy.”

(#19, G2P1)

Partner: “There wasn’t any reason, we just didn’t go! (discussion in Russian) She felt very well, that’s why. She’s got experiences, it’s going to be fine… She was worried about the baby but because she felt very well, that’s why she didn’t go (discussion in Russian)… whatever was going to happen, it will happen, that’s why… According to her experience, because it wasn’t the first one.”

(#20, G4P3)

“if I’d have felt that there was something wrong I would have probably have gone, but because I felt alright in myself, I thought I was better off waiting that little bit longer… I knew what to look for and stuff, like I said, if I’d have been worried I’d have gone”

(#26, G2P1)

Previous concealed pregnancy/late booking

Four women reported booking late in a previous pregnancy and hence had not (and in one case never) experienced the recommended early antenatal checks. Two of the women said their previous experience had made them more relaxed about what to expect in early pregnancy and about not needing care.

I: “this time you’re twenty weeks now when you’re having your first appointment, was it so late with the other boys?

partner: Yes, no, with the second one it was the exact…

woman: Third one.

I: The third one?

partner: (laughs) Ah yes, the third one was the same (both laugh)… he was six months I think!

I: really!

partner: Yeh, or eight months!”

(#20, G4P3)

“Yes… I didn’t actually tell anybody I was pregnant, that’s probably why I wasn’t so worried about it in the early stages”

(#5, G2P1, previous concealed pregnancy age 17)

In addition, three other women had direct family experience of late booking and/or concealed pregnancies.

Acceptance

For five women this acceptance of the pregnancy reflected their instinct, a perception of pregnancy as a ‘normal’ healthy state of being, and their religious beliefs. This was usually, but not exclusively, associated with previous pregnancy experience. These women suggested that they were less interested in accessing early antenatal care because antenatal screening for foetal abnormality, a significant part of this, was less important to them.

“We are Muslims so we are not allowed to have abortion. But after 40 days from the pregnancy it’s not allowed for you, and before the 40 days you should have some serious problem like your heart’s not good or the baby is very damaged, so it’s not just, I don’t want it, because I have already one child or like that, so I didn’t think about that at all. I have to accept that really and thank God for it.”

(#19, G2P1)

“I’ve never had that [screening] before. I don’t think I’ve ever chosen to have that before. Maybe with one of them but because of, you know, religious reasons and everything I just feel that if there is a disability then it won’t change my mind about having a baby or anything… I just believe that if it was going to happen then I’d get through it. I just hope that everything’s all right, you know, everything’s healthy. About them tests, I’m not that really bothered.”

(#11, G4P3)

“And I would say to myself, I shouldn’t worry even if I don’t have the test. That because I feel so well I should expect to have a healthy baby, and in some way I felt sometimes in the past they didn’t have all these tests”

(#9, G1P0)

Antenatal self-care

Another woman, with previous pregnancy experience, described her antenatal self-care, which again included self-monitoring, observing the baby’s growth and movements, and staying ‘well’ and healthy. For this particular woman the care was perceived as a temporary measure, a coping strategy and means of control, promoting and monitoring the healthy progress of the pregnancy until she felt able to access conventional care, when the termination her husband wanted was no longer possible.

“I’d done everything that I could possibly do myself because obviously with having A, I knew what you could eat, what you couldn’t eat, this that and other, so I followed everything religiously, took my Pregnacare every single day, made sure I drunk plenty, had plenty of rest, so I carried out what I knew, but obviously I’d had no checks to make sure everything was progressing alright, I’d had movement, I noted down when I’d had movement and things like that, so I’d done all I could … [friends] did try and say to me ‘go and see the doctor’ and I kept saying ‘no I’m fine, I’m doing everything that I should be doing’,”

(#26, G2P1)

Being ‘on the move’

In some instances, being ‘on the move’ and not in a familiar environment or stable place acted as a barrier to women accessing antenatal care on time. For five women this was the primary reason for their late booking. Women described practical difficulties and convenience issues in making appointments, work pressures and the social isolation of being away from home. Overall, the responses suggested a lack of understanding of the 'portability' and timing of antenatal care and its value in general.

For example, a few women were travelling abroad or working elsewhere in the UK and described waiting to access antenatal care until they felt settled in a place of trust or safety: ‘home’. One woman, on a three-month family holiday to her husband’s country, had admitted a reluctance to confirm her pregnancy. She expressed a distrust of foreign hospitals and preferred to wait until returning to the UK.

“It was such a long way away, I don’t know, I just prefer here and I trust the hospitals here and everything. I just didn’t want to ruin my holiday feeling ill with morning sickness and things like that, so I just left it… I was pretty sure but I just wanted to know for definite, but not there… I just trust these hospitals because I’ve had all three of them here. Maybe if I lived over there, you know, of course I would have gone but I thought no, I’m coming home soon so everything should be all right.” (#11, G3P2)

For one Arab woman home now was the UK, where her first child had been born. She acknowledged that she had considered accessing care whilst visiting family in her home country, but that it was inconvenient.

“I was thinking about it but because it was like a holiday, visiting, doing camping, lots of social activities, so there was no time, but I was really thinking about doing a scan.”

(#18, G2P1)

Another woman, working in another city temporarily, described the isolation and stress of her working situation and how this had impacted on her ability to access care. She was reluctant to access care in a place she didn’t know and when she knew her baby would be born in Sheffield, so had waited to return home.

“I didn’t know York, I didn’t have no transport when my partner was out at work every day. I didn’t know where buses used to go… I think if I was in Sheffield at the time I probably would have [accessed care]. Because I wouldn’t have been working all the hours of the day. We were working and just totally stressed as well because we didn’t know anybody in the area.”
“I didn’t want to change my doctor, because I’m going back home to my own house. I wanted to have my baby in Jessops, I didn’t want to have my baby in a town that I didn’t know. I weren’t registered, I weren’t going to live in York. I was coming back.”

(#5, G2P1)

Similarly, a woman moving to another northern city from Sheffield, and back again in early pregnancy, identified delays caused by changing locations and GPs as the reason for booking late.

“It were because I moved to Manchester, I was child-minding and then found out I was pregnant but I’d just changed doctors to that one and then I came back to Sheffield and I had to mess about changing doctors and stuff all again and things. That’s why it were a bit late”

(#3, G2P1)
For another woman, whose family were recent migrants living in temporary accommodation, there was an expressed need to ‘get settled’: to sort out their home and locate local services before adding the additional complexity of antenatal clinic appointments in different locations across the city.

(discussion in Russian between woman and partner)

Partner: “she was going to come, soon, because we changed a few places and we didn’t know where we were going to stay… we were waiting to move to this temporary accommodation, where we live at the moment, and she was going afterwards when we got this house, she was going to visit.”

(#20, G4P3)

The same woman was the only person interviewed who mentioned practical difficulties which had further influenced her ability to access antenatal care. These were linked to the family’s changing location but also language limitations and the necessity to attend appointments with their three young children.

“Partner: I wanted her to go to see a doctor, but for some reasons she always, she wanted to go but something happens then… it’s difficult, because when you go with the whole family, children, it’s very… (discussion in Russian) and there is no place to leave them, in nursery or somewhere, to come. This is the problem… she doesn’t know where to go, how to get there.”

(#20, G4P3)

5.2.3 Delayed

5.2.3.1 Professional failures in primary care

The delayed group of women had been aware from a relatively early stage that they were pregnant and were willing to engage in timely antenatal care. However, due to a combination of reasons they had booked late. One reason for this was perceived professional failures which occurred within primary care. For nine women, both primigravid and mulitiparous, there were examples of GP/nurse misdiagnosis in primary care which contributed to a delayed presentation. For example, attribution of pregnancy symptoms to urinary tract infections or other lifestyle/medical causes led to several primary care consultations before pregnancy was confirmed for one woman:

“I began to feel really sick and really unwell and lo and behold I was pregnant. But I’d gone to the doctors and I’d gone to see the nurse and I’d gone back repeatedly and they said because you’ve stopped drinking, stopped smoking it’s just all the toxins and such like coming out so nothing to worry about… they’d convinced me because I had a completely new lifestyle, a new job and nothing to worry about so –

I: How many times was this that you’d gone to see them feeling unwell?

Och, maybe five or six times… the doctors had been feeling my stomach all the way up until the last time and they never… they’d just said I had a kidney infection.”

(#16 G1P0)

This misdiagnosis was subsequently compounded by the opinion of the local midwife who insisted that the woman wasn’t pregnant, despite a positive pregnancy test, causing fear and anxiety.

“I went to see her, she said ‘oh you’re not pregnant’, she says ‘I can’t feel anything, the doctors don’t know what they’re talking about’, she says ‘I don’t even know why you’re here’… And she said ‘oh I don’t know if you are actually pregnant, are you sure’ sort of thing. Maybe a young girl making it up? I don’t know, just the impression I got. I’d left my first midwife appointment and I thought ‘well maybe, there’s something wrong maybe, It’s a tumour’, you know, you begin to think about, the doctor can feel something in your stomach and you’ve been feeling very unwell.”

(#16, G1P0)
For one multigravid woman, in her late 30s, it was the GPs suggestion of menopause rather than pregnancy that delayed diagnosis and referral for antenatal care:

“I went to the doctor’s about this because I was quite concerned and they thought I was going through the change… they did all these blood tests and that to see if I was on the change or was I diabetic or things like that.

I: So they didn’t really know either?

No, they didn’t know”

(#14, G5P4, age 37)

One primigravid woman with PCOS had ovarian ultrasound scans arranged by her GP when she was, in fact, six weeks and four months pregnant. The pregnancy was apparently not detected, which the woman remained incredulous about:

“I just hadn’t been on for six month, so they went and did that internal scan, but I must have been pregnant when they first did that and they’ve not known and then I went back again to have another one and they didn’t see ‘owt then, they just saw, like, little eggs they said. And I must have been, what, last one I had I must have been four month pregnant and they’d not found out. That's what we can’t get over now, I’m just like thinking, aaaahhhh, How could they not have known?”

(#22, G1P0, PCOS)
In one young primigravid woman’s case the midwife had not attempted to ascertain how many weeks pregnant she was, despite being uncertain of her dates. As a result the midwife underestimated the gestation and the woman received a routine appointment approximately eight weeks after the initial pregnancy test, booking eventually at 20 weeks gestation

“I: how many weeks was it from doing the pregnancy test to actually going to the hospital and having your first scan do you think?

About two months.

I: when she [community midwife] saw you here or at the GP’s, did she say how pregnant she thought you were?

No.

I: And did you tell her how pregnant you thought you were?

No, I just said I didn’t know how long.

I: Did she feel your tummy or do anything?

No.

I: Right. But you weren’t showing at all?

No.

I: Right. So she didn’t say ‘oh I think you’re three months’.

No, nothing like that”.

I: She came to see you two weeks later?

Yeah.

I: And when she came to see you at home did she feel your tummy or see how pregnant you were?

No.”

(#15, G1P0, age 16)

Another woman, who’d chosen not to access care to protect her pregnancy from her partner who wanted her to have a termination, mentioned that her midwife had known she was still pregnant but had decided not to do anything to encourage her to book for antenatal care.

“she’d [community midwife] put me to the back of the pile thinking that, well she’ll come and get in touch with me, and she did say ‘I’d just about given up that you were going to come.’”

(#26, G2P1)
Some women experienced bleeding in early pregnancy which had led either to the assumption of complete miscarriage or mis-estimation of gestation by health professionals. This consequently led to slight delays in referring for antenatal care. However, these typically occurred very early within the first trimester and once the pregnancy was confirmed timely presentation to antenatal care could have been achieved.

“I didn’t know I was pregnant, so, and I couldn’t know because I was still having some kind of bleeding, so I thought it was probably my period. I had the first visit to the GP. After eight weeks, it was the first days of week nine I guess, and I was asked to have another appointment for the next week to have a test to verify that I was pregnant. Or that I was still pregnant because of the light bleeding. It could probably be a miscarriage”

(#9, G1P0)
“I started with some bleeding and I had about a week of continuous bleeding, went to my GP and explained that I had done a test, he didn’t do another test, he just said ‘have you done a test?’ I said ‘yes’, explained the bleeding and he said ‘well I think you have probably miscarried so there is nothing we can do at this stage, come back when you are seven weeks pregnant‘, which would be another couple of weeks” (#13, G1P0)