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

5.2.3.2 System failures

Eight women were delayed by the referral process in primary care, sometimes as a result of delays between GP and midwife appointments, slow referral procedures or professional failures. This often compounded delays due to late initial diagnosis of pregnancy. Some of the women interviewed were highly aware of what needed to be done and expressed frustration at the bureaucracy of the ‘system’ and the resulting delays, and its impact on antenatal screening:

“And with me having to change doctors and stuff and mess about and have to wait too… then you have to go and see a midwife and then get referred to a GP and then go and have a scan, and they have to write to hospital and they have to write to you, and it does take a long time, it took three weeks from when I seen my midwife to going to have a scan.”

(#3, G2P1)

“I eventually did see the midwife and she worked it out I was 18 weeks pregnant, at that point. So if she knew I was 18 weeks pregnant at that point why didn’t she phone me through for a quick scan, instead of waiting 3 weeks in the post for it to come back here? So when I came here I was 22 weeks. I was really upset then because I couldn’t have a proper scan. And it seems like these weeks have been wasted through bureaucracy, rather than getting to the point of it all.”

(#5, G2P1)

“When I asked for the appointment and they said it was Monday the 13th I knew it was too late for blood… I just knew when I was at the appointment that these two blood tests – Spina bifida and Down’s Syndrome – were not possible any more because it was too late.”

(#9, G1P0)

Other system failures also occurred in secondary care, for example wrongly scheduled appointments or letters not being sent and/or received, despite the efforts of GPs and midwives.

“I got it within that two week period, which would have been between about week 11 and about week 13, but it came through with the date and the date was actually - I can’t think of the date, I have got it in my diary, but it was exactly 21 weeks on that day - it were a Tuesday and it made me exactly 21 weeks”

(#13, G1P0)
“they did try and she said ‘we want to do it as quick as possible’ and then I didn’t hear anything, so I phoned her back to see if I had missed them or - and she said that they were still trying to get me an appointment, she tried to fax it through, because I was so far on, but I were 27 weeks before I even had my first scan… they had sent me a letter out, well they said they had sent me a letter out but it had basically gone - I hadn’t got the letter”

(#10, G1P0)

5.2.3.3 Women’s knowledge and empowerment issues

The women affected by these failures in primary and secondary care were primigravidas or in one case a multigravid woman who had booked late before. Despite these being system and professional failures a key theme underlying the reason for delay was empowerment, as many of the delayed women were relatively passive in accepting delayed appointments and typically did not challenge health professional misdiagnosis of early pregnancy symptoms. Though often acknowledging that something ‘wasn’t right’ about the delayed appointment, the women had a lack of knowledge of pregnancy and the antenatal care ‘system’ and appropriate scheduling of appointments, or language difficulties which prevented them from challenging delays. Some women openly admitted their lack of knowledge:

“I had been a little bit concerned but I had never had a baby before, we hadn’t really got any babies in my family and my mum’s next door neighbour she had three children and she didn’t seem to think it was very strange at all that I had not had any [appointments]”

(#13, G1 P0)

“I didn’t see anybody until seven month [in previous pregnancy] so I don’t know what they did in early pregnancy.”

(#5, G2 P1, previous concealed pregnancy)

“I aint got a clue [about antenatal care]! It’s me first one so I wouldn’t have a clue.” (#6, G1 P0, learning difficulties)
“I didn’t know how these things work here.”

(#9, G1P0, Mexican)

Where they did challenge the delay, two women expressed acceptance of the reasons given primarily due to lack of knowledge and an inherent trust in the professional’s (wrong) opinion on the delay. They subsequently appeared to rationalise the delay that had occurred.

“I thought ‘well this seems a long time away’… I said ‘but I have got my appointment, but it is this date, actually it does actually make me quite late’ and she said ‘oh, that’s a little bit strange, I am not quite sure why that is, there must be a big influx of people at the moment’ and she said ‘well don’t worry about it, you are supposed to have a scan early on and then one at 20 weeks, now obviously you will have missed that, but what I would think they will do is give you a detailed scan when you go in and it is 21 weeks’… I kept thinking ‘well it seems a long time for me not [to be seen]’… I could have pushed it more at week 15 if I had thought about it, if I had had more knowledge, but I foolishly thought because I had been given the date that that was it. I wasn’t as on the ball as I would have been and to be fair, I trusted the midwife”

(#13, G1P0)
“I told her that according to the information in the book and leaflets, the blood tests, I needed two blood tests, one that week and then another in the later weeks, but I was not going to be able to have those on time. She [the midwife] told me that even if the tests were a bit later I was going to be able to have them. And I said well maybe this is not the optimal time to have them, but I am still having the possibility of having those tests. So I tried to leave that. Maybe I could have those tests later, but maybe they were not the optimal time to have them but that it was possible.

I: Did you feel reassured by what she said?

Yes. I didn’t feel worried about them. I thought ok, this is just going to be later.”

(#9, G1P0, Mexican)

Another reason for some women’s acceptance was because they felt well and felt that there was no need to challenge the delay, or they were influenced by advice given by friends:

“Something that prevented me to do something was that in some way I have felt fine, I haven’t had any kind of nauseous or problematic symptoms. I feel almost as normal, except for my tummy’s growing. I felt really well. 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… they [friends with babies] always told me that it’s a very good signal that I don’t have these symptoms and that it would be very likely for me to have a very healthy… well at the end you don’t know but they sort of gave me this positive messages and in some way I also believed. I also thought that there was no problem about having the tests a little bit later, as far as I had them, it was going to be ok. I never thought that this delay would affect or impact on something.”

(#9, G1P0, Mexican)
“Yes, I think I wait three months [for an appointment]. I ask the GP why long two months and they sent the paper from this hospital on 28th January. I think I’m healthy, I’m ok, just I’m wait for the 28th January, because I’m ok, I’m alright.”

(#19, G2 P1, Eritrean)

Two women also rationalised their acceptance of the delay by acknowledging that because the pregnancy was unplanned or mistimed they were not in a pregnancy mindset and not as well prepared for pregnancy as they might have been. This had affected them focusing on the number of weeks they were pregnant and what care they should have been receiving:

“I didn’t maybe focus on it perhaps as a mum who had been planning her baby for two years and it arrives and she is absolutely spot on and she has read every book that there is. I think probably if I had I would have been thinking ‘hang on a minute I should have had this at 12 weeks’.”

(#13 G1P0)
“I guess if you’re planning a pregnancy then you get all the information beforehand and you can read in a book about it, and think “well yes I need to go to the doctors then, then, then”, but that weren’t pinpointed in my brain. If I’d been planning I would have known what to do”.

(#5, G2P1)

5.2.4 Triggers for accessing care

5.2.4.1 The influence of mothers

For many of the primigravid women, particularly those avoiding care, it was their mothers who were decisive in helping them confirm the pregnancy and organising care. Sometimes the women saw this as a positive thing, however others were fearful of a negative reaction or annoyed with something they saw as interference:

“She [her mum] just asked me if I thought I were and I said I weren’t sure, so she went and got a pregnancy test for me… my mum did, she went through it with me. Just what to expect really.”

(#14, G1P0)

“My mum did think but she didn’t want to say anything, because she didn’t want it, for me to feel like I were anything bad, or just like to insult me or anything… But she just couldn’t ask me so she kept putting it to the back of her mind and then one day she just thought I need to know so she just came and asked me… It’s a positive thing and I thought they were going to be horrible but she’s not, she’s been really good about it, she’s really excited”

(#7, G1P0, age 18)

“I didn’t want to tell my mum. It was very bad [her reaction]. I had to tell her because I was just going out of my brain really.”

(#5, G2P1, previous concealed pregnancy)

“My Mum telled me to keep going, she were getting on my nerves.”

(#23, G1P0, learning difficulties)

5.2.4.2 Needing positive/official confirmation of pregnancy

For the women who postponed their care, it was the women themselves who eventually decided that they needed antenatal care, and particularly confirmation that everything was well with the pregnancy. There were key triggers for access: two women acknowledged that feeling the fetus moving made the pregnancy ‘real’ for them and therefore antenatal care more urgent.

“I: So when did the baby become real then, do you think?

After making movement. When I went to my country. About 2 weeks there I felt some movement”

(#18 G2P1)

“I was curious and wanted to know everything was alright, and I started to feel the baby moving, so I went to the GP.”

(#8, G3P2)

Other women became worried that they might become too late for any care, that they needed to get into ‘the system’ and make their pregnancies official:

“I’d done what all I could, but I just thought, I’ve got to go now otherwise it’s going to be too late, as in to get any care.”

(#26, G2P1)
“I thought if I am quite late then they might not give me anything. I didn’t know what they were going to do. I thought if I’ve missed the twenty weeks period they might not offer me a scan and I really wanted that… I was so worried thinking this time what if I’m really far and what if I go into labour before even the hospital has registered me or anything?... I did start to get a bit worried, I thought no, I need to know for a fact that that baby’s in there and it’s got a healthy heartbeat and get me on the register”

(#11, G4P3)

5.2.5 Attitudes towards having booked late

Women expressed a range of attitudes towards their late booking. Most of the women interviewed were aware of the optimum time to access antenatal care and were clear that they would have booked early if they had known. This included young women and primigravidas. Many expressed regret at not accessing care earlier. Several of the women, both those who had known they were pregnant and those who hadn’t, and one woman’s husband, acknowledged the desirability of attending for early antenatal care. They were clear about what they would have done if circumstances had been different.

“If I had known I would have come virtually the first couple of weeks I knew, if you know what I mean, but as I say, I had no clue, no idea. I would have gone straightaway, yes, I would advise anybody to do that straightaway, yes.”

(#12, G5P4)

“If I did know and if I did keep it, then I would have gone to see someone at two to three months, but I didn’t know”

(#24, G1P0, age 15)

“When you first find out really, if you find out early on, that’s the best time [to go]. Around eight weeks? Probably it is when the baby starts to develop and things.”

(#14, G1P0)

“The best time to find out is about 12 weeks, something like that, or a bit earlier, before that. There’s some find out about that week, don’t they? They have a scan about 12 weeks, and they find out a bit earlier. But I didn’t even know how far I were.”

(#6, G1P0, learning difficulties)

One multiparous woman suggested this was particularly important when pregnant for the first time:

“When you realise that you are pregnant, you should go, immediately, because first times, in general, pregnancy I think it’s something you should take care about… you might discover something that you might regret after.”

(#18, G2P1)
There was further recognition of the accepted convention of early care, as opposed to its intrinsic value:

“I’d go straight away. If I’d have found, if I’d have known, if I’d have had regular periods and I’d have missed one, I’d have gone straight away and then I’d have done it from then. I think it, I just, I think it’s because that’s what everyone does, isn’t it? From when they first find out, that’s when it all starts, isn’t it.”

(#22, G1P0)
Partner: “But she should have gone earlier I think, because, anyway, four months is late, you need to go earlier to see what, what’s correct.”

(#20, G4P3)

Another woman expressed her view of accessing antenatal care as the reassurance of ‘getting things sorted’ and making the pregnancy ‘official’.

“I would have gone straight away. As soon as I found out I was pregnant I would have gone. That’s just me, I just like it, I like to start from the beginning, let them talk me through it and get everything sorted…get me on the hospital register and things like that. I think it's nice just to have that regularity.”

(#11, G4P3)
However, as one of them observed, their understanding of what was theoretically ‘correct’ and desirable in terms of antenatal care might bear little relation to what had happened in their own pregnancy and the choices they had made:

“I would advise anybody who knew to go. I just don’t take my own advice!”

(#26, G2P1)
5.2.5.1 Guilt, regret

Many women expressed feelings of guilt and regret at accessing care late. Some were concerned about care that they had missed, particularly screening, and changes to their lifestyle that they could have made in preparation for pregnancy.

“I’m more annoyed with myself, because I didn’t, because I, like I say, I put up all those barriers straightaway, because then I was still, like, drinking and probably not eating that healthily and that kind of thing”

(#17, G1P0)

“It’s a worry, it still is a worry, I’m pleased, you know, that I haven’t been drinking or smoking at all, but then, you know, there’s things I think oh if I had my time again, if I’d known, what would I have done differently? I feel like I’ve missed out on a lot of care, a lot of things I feel maybe could have been doing at that time.”

(#16, G1P0)

“I thought I’m leaving it too late, I should go now in case there is something wrong… I missed out on folic acid; I regret that very much. I took it with my other children. In some ways I think I let this baby down, I didn't give it what the others had, but I just couldn't go. I feel guilty about that.”

(#8, G3P2)

“The only thing I’m upset about is that I just couldn’t have my 20 week scan. And that’s it… Just knowing that baby’s healthy really. Just knowing that, that if I did have that scan…”

(#5, G2P1)

5.2.5.2 Pleased to have ‘missed’ early pregnancy

Regret was not a universal response however, to a delay in making the pregnancy ‘official’ by booking for antenatal care. Some women who had not known they were pregnant were pleased to have ‘missed’ part of the pregnancy: impatience for the pregnancy to be over and their baby to arrive was expressed by several women and their partners.

I: “how did you feel about the fact that you were quite a bit further along?

Alright. I were loving it. I were going out buying baby stuff, I were loving it already. I were loving it.”

(#27, G2P1, learning difficulties)

“it was good, it was really good because I thought I won’t have to wait as long, because nine months is a long, even now, I feel like it’s been such a long time.”

(#16, G1P0)

“I were right excited, because I missed everything, [the] worst bit. I’m right impatient, so if I’d have found out when I were first it would have dragged, cos it’s felt ages now… I’d rather do this way again!”

(#22, G1P0)

Another woman was happy with her decision and pleased to be in an advanced gestation. She was disappointed not to be even further on in her pregnancy:

“I didn’t feel guilty at all because it wasn’t my fault, I’d been on holiday, I couldn’t help the fact that I’d been, you know, I’d planned to stay there quite a long time so I didn’t feel guilty at all… I was really hoping that I was quite far on and then when she said ‘oh no, I think that’s right’ and she measured it and everything so I was a bit disappointed with that.”

(#11, G4P3)

5.3 Conclusions

Chapter five has presented the themes and sub-themes emerging from the analysis of interviews with a diverse sample of 27 women who booked for antenatal care after 19 weeks gestation. The interviews were undertaken to gain a deeper understanding, to answer the research question ‘what perceptions and beliefs do late booking women express about the delayed initiation of antenatal care?’

Three major themes emerged from the women’s interviews. These were women not realising or believing they were pregnant and therefore not accessing care (not knowing), women knowing they were pregnant and avoiding or postponing antenatal care (knowing), and women being prevented from accessing care as a result of professional and system failures (delayed). Sub-themes relating to individual circumstances, including pregnancy expectation and women’s knowledge and experience of pregnancy and antenatal care, but also empowerment and socio-cultural factors, were significant. Such influences were frequently overlapping and interrelated. In addition, women expressed a wide range of attitudes towards their late booking. These themes are discussed in the following chapter, in the context of previous research around antenatal access and women’s perceptions of care.

Chapter 6: Discussion of the findings from the qualitative study
6.1 Introduction
The purpose of this qualitative research was to gain a deeper understanding of the reasons why some pregnant women delay booking for antenatal care. It was undertaken to consider the women’s perspective, to provide insights into the perceptions, behaviours and social processes surrounding late booking, in a way that would not be possible using quantitative methods. This purpose was reflected in the overall research question underpinning the study: “what perceptions and beliefs do late booking women express about the delayed initiation of antenatal care?” Twenty seven late booking pregnant women were interviewed individually, using a semi-structured interview format. From the thematic analysis a taxonomy (table 5.1.3) of themes and sub-themes relating to late booking for antenatal care was developed, with three major themes: ‘not knowing’, ‘knowing’ and ‘delayed’, and explanatory sub-themes relating to individual circumstances, empowerment and socio-cultural factors. These include the recognition of pregnancy and the influence of a pregnancy ‘mindset’, the perceived value of antenatal care and the influence of previous pregnancy experience. Other sub-themes include avoidance and postponement strategies and the acceptance of delay.
As appendix 4.15 illustrates, the taxonomy is not always mutually exclusive, with all women having primary and secondary exacerbating factors which resulted in late booking. These interrelated, and sometimes sequential, factors acted as barriers to early antenatal care, delaying, curtailing or preventing access. They can be divided up into those which were primarily practical or organisational (for example the delayed women) and those which were personal (realisation, belief), motivational or attitudinal (avoidance, postponement) (Dartnall et al 2005, Downe et al 2009, Callaghan, Buller and Murray 2011). It appears that the timing of initial access to antenatal care is determined by a spectrum of choices, influenced by women’s acceptance of their personal and public pregnancies, as first mentioned in chapter two, from acceptance through a more passive non-acceptance to an active rejection of the pregnancy and/or the need for antenatal care. This suggests a linear process, however in some cases the reality is less structured, reflecting a ‘web’ of these choices, bound up with preventative factors. This process is influenced by a complex interaction of psychological, social and demographic factors, which must be negotiated prior to a woman’s first antenatal appointment. By the time she sees a midwife or doctor, a woman has already overcome the majority of common barriers to antenatal care (Downe et al 2009, Philippi 2009).
Whilst for the majority of pregnant women, the convention of early access to maternity services is an accepted ‘norm’, a different, and more complex, picture exists amongst those women who have been identified as vulnerable or ‘hard-to-reach’. As Dartnall et al (2005) comment, groups such as teenagers, women with learning difficulties, substance misusing women and those from outside the UK, may access services at different points and for different reasons. These women formed a significant part of the Sheffield study. However, there were also other women, from a range of ages, parities and backgrounds, who would not be considered vulnerable, who were also interviewed, as part of the inclusive approach to recruitment and the maximum variety sample for the study. Many themes associated with late booking found in previous studies of marginalised women are evident amongst these women, across the social, educational and cultural spectrum. The women demonstrated a wide range of attitudes and experiences, and reveal a view of pregnancy and antenatal care not usually considered.
The similarities and differences between existing research and the Sheffield study are examined in the following discussion, and the concept of personal and public pregnancies is explored in relation to the themes identified from the data. The majority of the high quality studies (see chapter two, section 2.2.3 for consideration of quality appraisal) of antenatal access cited are from urban settings within the USA; consequently studies from the UK, Canada (CAN) and Europe (EUR) are identified as such throughout this chapter for clarity. The US studies share an urban context with the Sheffield study, however the different health and social care systems that exist in the UK and USA mean that caution is required when making comparisons. However, as previously acknowledged in chapter two, there are common themes across the countries, and evidence that many of the barriers experienced by American women may be transferable to the UK (Lavender et al 2007).

6.2 Not knowing: accepting the personal pregnancy
Acceptance of pregnancy, and the need for antenatal care, begins with a woman’s internal recognition and acknowledgement of her personal pregnancy. This is linked to a woman’s intention and expectations of becoming pregnant (her pregnancy ‘mindset’) and her ability to recognise the pregnancy itself. The latter is influenced by a woman’s knowledge, her physical and psychological wellbeing, but also potentially by those in her immediate social network. Such acceptance may not be an immediate response to pregnancy discovery, but may follow a prolonged period of uncertainty and reflection, as discussed later in the chapter. The major theme of ‘not knowing’ from the Sheffield study illustrates this non-acceptance of the personal pregnancy. The study found two key sub-themes amongst women who had not known that they were pregnant, leading to delayed confirmation of pregnancy and access to antenatal care. These related to women’s realisation: their (non) recognition of pregnancy signs and symptoms, but also to belief: their expectation of becoming pregnant and the influence of a pregnancy mindset. Central to this mindset was a lack of pregnancy planning, a theme running throughout the study and influencing women’s acceptance of both their personal and public pregnancies.
6.2.1. Recognising the pregnancy

‘I didn’t know I was pregnant’ was a common explanation for late entry into antenatal care. The majority of the women (22 out of the 27) interviewed in the Sheffield study said that they had not known they were pregnant for weeks or sometimes months. This had delayed them accessing care. This was expressed as women not realising that they were pregnant and women not believing that they could be pregnant (for most of the 22 women a combination of these two factors was evident). Several other studies have identified delayed confirmation of pregnancy as a major factor in preventing early initiation of antenatal care (Harvey and Faber 1993, Rogers and Schiff 1996, Peacock et al 2001). Sable et al’s (1990) study of low income women in Missouri USA found those who did not recognise their pregnancies in the first four months were nine times more likely to have received inadequate care. This is particularly apparent amongst young women (as identified by Leatherman et al 1990, Gazmararian et al 1997, Mackey and Tiller 1998); all seven women aged 20 years or less in the Sheffield study expressed some degree of delay in recognising and confirming their pregnancies.
This study suggests that for some women ‘not knowing’ that they are pregnant is a combination of lack of recognition, acknowledgement and acceptance of the signs, symptoms and consequences of pregnancy. It is influenced by several factors, such as a woman’s knowledge and experience of pregnancy, both personally and amongst a woman’s social network. Her physical health but also her psychological wellbeing, including stress, anxiety and/or depression, alongside her expectation of becoming pregnant, are also influential. Peacock et al’s (2001) qualitative study of low-income women in Chicago USA recognised this interplay of realisation and belief, and the involvement and influence of others in the process of a woman ‘knowing’ she is pregnant:

“Recognition of a pregnancy can be a complex and sometimes protracted process that includes assessing pregnancy risk, perceiving and correctly interpreting pregnancy signs and symptoms, seeking confirmation, accepting (or denying) the pregnancy” (p110)
The concept of ‘knowing’ in this context suggests identification and understanding; an acknowledgement of the physical and social consequences of the pregnancy from the woman and potentially those around her. Whilst some acknowledge pregnancy recognition as an influence on access, few studies, particularly quantitative ones, have demonstrated the complex relationship of influences and the importance of this pregnancy mindset.
6.2.1.1 Lack of reproductive knowledge

The pregnancy mindset is influenced by many factors. Lack of reproductive knowledge, in all its facets, is a thread running through the results from the study, and has been identified as a major factor in the delayed initiation of antenatal care in many other studies. These facets include a lack of recognition of early pregnancy symptoms; lack of knowledge of antenatal care and its value; lack of pregnancy planning and contraceptive failure. It was most evident amongst nulliparous women and women with risk factors such as learning disabilities, substance misuse and for whom English was not their first language; often those identified as most at risk in previous UK maternal mortality reports (Lewis 2007, CMACE 2011 (UK)).
Women’s apparent poor knowledge and awareness of pregnancy, and their failure to recognise many early signs and symptoms, were common themes in this study and have been widely reported in a range of qualitative studies from the USA (Gazmararian et al 1997, Mackey and Tiller 1998, Peacock et al 2001, Daniels, Noe and Mayberry 2006). This lack of knowledge and/or skills relating to pregnancy has been identified as linked to low educational achievement (Braveman et al 2000) and was particularly (though not exclusively) evident amongst younger women and women with learning difficulties. Peacock et al suggest that this potentially demonstrates “a lack of understanding of the processes underlying conception and pregnancy” (2001: 112). Whilst a lack of reproductive knowledge is evident, to label women as ignorant would be simplistic and judgemental. For example, how much understanding of her body, let alone the realities of pregnancy, might a young woman of 15 or 16 be expected to have? Brubaker’s (2007) US study of BME teenagers found that before they became pregnant, formal health care and knowledge about health, sexuality and pregnancy were largely absent from their experience, resulting in delays in disclosing sexual activity and pregnancy, and subsequently the initiation of care.
Perhaps more significant however were the eleven women, six of whom were primigravidas, in the Sheffield study who considered that they had not experienced any pregnancy symptoms at all. Some authors discuss a point at which the pregnancy becomes physically ‘apparent’, to women, suggesting this is when fetal movements are felt or the pregnancy is visible (Gazmararian et al 1997, Callaghan, Buller and Murray 2011 (UK)). However many of the women in the Sheffield study confirmed their pregnancies well after the time when these symptoms would have been evident and, it could be argued, obvious. This is in contrast to Browner and Press (1996), who discuss women’s use of ‘embodied knowledge’ (the subjective knowledge derived from a woman’s perceptions of her body and its natural processes) in antenatal decision-making. Rather, these findings suggest a lack of knowledge or self-awareness, or that denial or some other personal perceptions were influential.
6.2.1.2 Misinterpretation

Several women in the Sheffield study misinterpreted pregnancy symptoms and attributed them to other events in their lives, such as stress, exhaustion or weight gain or loss, or to medical conditions. It was common to attribute even multiple symptoms to causes other than pregnancy, especially when their perceived likelihood of becoming pregnant was low, for example for age, health or contraceptive reasons. Other authors have acknowledged this attribution of pregnancy symptoms to medical conditions, but only in relation to irregular periods. In contrast, bloating and heaviness were attributed to Polycystic Ovary Syndrome (PCOS) and a water infection by two women in the Sheffield study. This suggests another level to women’s interpretation of physical symptoms. Recognition of the similarity of pregnancy symptoms with those of stress and physical illness and psychological distress, leading to misinterpretation and delayed recognition, has been noted elsewhere (Lia-Hoagberg et al 1990, Peacock et al 2001). This was identified by several of the women in the study.
Some women also experienced irregular or absent periods, which were a normal part of their lives and which impacted on their ability to diagnose pregnancy. Other authors have recognised this as a contributing factor (Chisholm 1989 (UK), Lia-Hoagberg et al 1990), often in combination with other factors such as a lack of expectation of becoming pregnant. As in other studies, women with unplanned pregnancies were much less likely to be aware of amenorrhoea, potentially a significant symptom of pregnancy. In Napravnik et al’s (2000) qualitative study of HIV positive women, they considered this symptom as not significant, as they weren’t thinking about having children. Lack of periods, as a result of substance misuse, was a significant factor in one woman’s case in the Sheffield study, though there was no admission of the effects of intoxication on pregnancy recognition, as seen elsewhere, such as Dartnall et al’s UK study of ‘hard to reach’ groups (2005).
Some women in the Sheffield study, especially those experiencing irregular periods, dismissed a missed period as an unreliable indicator of pregnancy. Women created their own ‘normality’: one woman said that she had been encouraged by her GP to see irregular periods as normal for her, others expressed acceptance of the situation, so did not consider amenorrhoea as unusual. In addition, women were more likely to consider any bleeding as a normal event not associated with pregnancy, potentially masking the pregnancy further. This personal ‘normality’ forms part of a woman’s embodied knowledge and suggests women’s acceptance of their bodies, which may contribute to explaining why some of the women said that they had not noticed any pregnancy symptoms at all.
6.2.2 Planning the pregnancy

“whether or not a woman intends to get pregnant and how she feels about the pregnancy appear to be central elements in the obtainment of prenatal care” (Sable et al 1990: 554).
The majority of women in the Sheffield study had not planned to become pregnant at the time they did and therefore had not made any preparations for pregnancy. Seventeen of the 27 women stated that they had not planned to become pregnant, and for another six this was implicit in their reaction to pregnancy discovery. Other women suggested that their pregnancy was intended but mistimed. This lack of planning affected women’s mindset and in some cases influenced recognition of their pregnancies, which delayed confirmation and subsequent care.
It has been suggested that lack of pregnancy planning or intention plays a significant part in delayed attendance for antenatal care (Peacock et al 2001), but this is usually discussed in the context of the fear and ambivalence women feel after a pregnancy is confirmed, rather than the initial recognition of pregnancy signs and symptoms. As Braveman et al (2000) found, in their survey of more than 3000 low-income women in California, women who were consciously planning to become pregnant were likely to be much more vigilant about potential pregnancy signs and symptoms during the first trimester. In their study two-thirds of pregnancies were unplanned, and they concluded that the greatest risk factor for ‘untimely’ care was an unwanted or unplanned pregnancy.
Research suggests that unplanned pregnancies are particularly prevalent amongst low socio-economic status women, who may feel a lack of control over their health, lives and futures (Sable et al 1990, DoH 2004c (UK)). This in turn may influence their use of contraception, but also their possible acceptance of a pregnancy as ‘inevitable’. Downe et al’s (2009) meta-synthesis of studies from the USA, UK and Canada suggests that indicators of pregnancy are more likely to be missed in unplanned and unexpected pregnancies among (primarily young) women, because of ‘youth and physiological naivety’, learning difficulties and the lack of a pregnancy ‘mindset’. However, numerous US studies suggest that ambivalence and negative views of pregnancy are major factors in delayed access to antenatal care for women across the social spectrum, and in large part are linked to lack of pregnancy planning (Lia-Hoagberg et al 1990, Sable et al 1990, Mayer 1997, Roberts et al 1998, Nothnagle et al 2000, Johnson et al 2003, Sunil et al 2010).
Multiple factors influence a woman’s perception of the likelihood of her conceiving. Contraceptive use and its influence on a woman’s acceptance of pregnancy has not been mentioned in other studies but was highly significant in this study. The shocked comments of the eight women using contraception suggest a combination of factors. Perhaps a lack of knowledge about conception and the risks of pregnancy whilst using (incorrectly perhaps) oral or other forms of contraception, but more importantly a lack of belief in becoming pregnant. Other factors influenced this mindset, including the two women who thought age would influence their chances of becoming pregnant. Callaghan, Buller and Murray (2011), in their London-based qualitative study, interviewed one woman who thought she was too old to conceive, but again it is a subject that has been largely unreported in studies of late booking.



As Peacock et al (2001) comment, acknowledging pregnancy is as much about a woman’s attention to as well as her knowledge of pregnancy signs and symptoms. The shock, confusion and potential anxiety of conceiving outside of optimum conditions, for example where a pregnancy is unplanned or unexpected (i.e. the majority of women in this study), may have resulted in an inability to place pregnancy symptoms into what they call a ‘meaningful whole’, leading to misinterpretation and delay. Many women in the Sheffield study described that they had not put all their symptoms together to build a picture of themselves as pregnant; they had not created a pregnancy identity. It was only after a trigger, for example a test result or an explanation of symptoms they had been experiencing, that the pieces of the puzzle fell into place.
Recognition of an unplanned pregnancy led to feelings of fear and ambivalence amongst some women in the study, particularly related to the consequences of the pregnancy. This resulted in denial, avoidance and delayed entry into the maternity care system. This mirrors the picture widely reported in US research, both qualitative and quantitative (Harvey and Faber 1993, Roberts et al 1998, Mackey and Tiller 1998, Peacock et al 2001, Daniels, Noe and Mayberry 2006, Downe et al 2009, Philippi 2009). The ambivalence women felt meant that they were more likely to ignore or deny early signs and delay confirming their pregnancy, despite first trimester awareness. This was also noted by Chisholm (1989) in Manchester (UK) as a reason why women had delayed seeing their GP. As Lia-Hoagberg et al (1990), in their mixed-method study in Midwestern USA, comment:

“many women may be denying or repressing the reality of an unplanned and often unwanted pregnancy. Seeking early prenatal care would only confirm and force them to confront what they did not want to recognize or acknowledge” (p491).
As in other studies, some late initiators of antenatal care were, at best, indifferent, if not distraught, at becoming pregnant, with feelings of depression, psychological stress and pregnancy rejection that led to denial and concealment, and hindered access (Hulsey 2001, Daniels, Noe and Mayberry 2006, Johnson et al 2007). As Downe et al (2009) comment:

“In contrast to the delight experienced by many women when a pregnancy is planned, the recognition of an unplanned pregnancy can be devastating. Many women recalled struggling to accept their situation” (p521)
These are themes identified amongst different groups of women, including multiparous women and adolescents (Chisholm 1989 (UK), Mackey and Tiller 1998, Teagle and Brindis 1998, Hulsey 2001), the latter in sharp contrast to the common perception that teenage pregnancy is a lifestyle choice. This was evident with two of the postponing women in the Sheffield study, as they struggled with the idea of coping with another child.
Many quantitative and mixed method studies from the USA have documented this lack of motivation and low mood resulting from an unexpected pregnancy, with women not feeling ‘up to’ going for care (Kalmuss and Fennelly 1990, Leatherman et al 1990, Oberg et al 1990, Cook et al 1999, Pagnini and Reichman 2000, Sunil et al 2010). Johnson et al’s (2003) study of BME women in Washington DC found that unhappiness with being pregnant was linked to low self-esteem and was identified as making women ‘not think straight’, suggesting its influence on women’s judgements about their need for care. Other US studies suggest that this personal distress resulted from the combination of a stressful life situation and lack of support and encouragement, with an unintended pregnancy, which made attending for care seem too difficult, particularly amongst young women (Mikhail 1999, Napravnik et al 2000, Luecken et al 2009). Dartnall et al’s (2005) UK study of hard to reach groups also discusses the importance of this support, in combination with women’s acceptance of their pregnancy and an understanding the role of the maternity services, on women’s engagement, again almost like pieces in a puzzle which need to fit together. Lack of support was not particularly evident in the Sheffield study however.
A small number of the women interviewed had considered having a termination, which led to a delay while they considered their options. This has been a common theme in other research and linked to stress, ambivalence, indecision and, again, lack of support (Lia-Hoagberg et al 1990, Sable et al 1990, Mayer 1997, Teagle and Brindis 1998, Napravnik et al 2000, Johnson et al 2007, Callaghan, Buller and Murray 2011 (UK)). Johnson et al (2003) found that considering abortion was the most important factor in delayed initiation of care, particularly amongst younger women. In the Sheffield study this factor was evident amongst a range of women, aged between 15 and 36 years.
Some women in the Sheffield study expressed ambivalence towards their pregnancies, particularly those who had considered a termination, and those who felt most likely to be judged, such as teenagers and substance misusing women. As Peacock et al (2001) note in their qualitative Chicago-based study, ambivalence, even when pregnancy is desired, is a common reaction to the discovery of an unplanned pregnancy, amongst women, their partners and families, and has the potential to lead to significant delay in accessing care. However, as Hulsey (2001) comments, unwanted and unintended pregnancies are quite different things, though both may be associated with an initial indifference, influencing initiation of antenatal care. A woman’s attitude is also likely to change during pregnancy; wantedness of a baby is not the same as wantedness of pregnancy (Sable et al 1990). Ambivalence was not a common theme in the Sheffield study, and far less prevalent than in other studies. This may partially be a characteristic of the women who were prepared to be interviewed, but also the effect of being interviewed by a midwife, even one not involved in their care: women are unlikely to admit that their baby is unwanted to such a person.



Whilst studies suggest that young and other vulnerable women, and particularly teenagers, are more likely to not know that that are pregnant, this study and others shows it is a more complicated picture than simply lack of knowledge, with young women fearful both of finding out they were pregnant themselves and of others finding out (Leatherman et al 1990, Mackey and Tiller 1998). The relationship between a pregnant woman and others influences the ‘discovery’ of a pregnancy, the boundaries between not knowing and knowing, the creation of a woman’s pregnancy identity and her public or ‘social’ pregnancy, which is discussed further in the next section.
Such boundaries, between not knowing and knowing, recognition, acknowledgement and acceptance of a pregnancy are far from clear however. The concept of knowing in this context suggests identification and understanding, an acknowledgement of the physical and social consequences of the pregnancy, from the woman and also potentially those around her. As diagram 6.2 suggests, based on the findings from the Sheffield study and previous research, it is not a fixed point in the pregnancy. There is the potential for prolonged periods of ‘consideration’ before the pregnancy and the need for care are accepted and care is sought. This consideration and rationalisation, and ultimate resolution (however protracted), also creates overlapping boundaries between a woman’s personal and public pregnancies.
Diagram 6.2: A diagram to illustrate the initial stages of pregnancy recognition, acceptance and care seeking

Stage Response