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

T I M E

T I M E

Not pregnant I’m not pregnant
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In between Something’s happening? ?

Pregnancy possibility Could I be pregnant? recognition of symptoms?

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do a test?
Pregnancy discovery I am (a little bit) pregnant !

Pregnancy consideration Ok, so now what? do something?

tell someone?


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e g n a n c y
Pregnancy acknowledgement I am pregnant and I need what to do?

to do something about it who to tell?

Pregnancy consideration Ok, so now what? do something?

tell someone?
Pregnancy acceptance I am pregnant and I want I’ve told…

to keep the baby -

I need to act.



or non-acceptance I am pregnant and I don’t I’ve told…

want to keep the baby -

I need to act.
Pregnancy ‘official’ - I’m having a baby. I’m there’s no going

accessing care (public going for care. back…

knowledge)

6.3 Knowing – accepting the public pregnancy



Acceptance of the need for antenatal care, and accessing the care itself, also requires a woman to acknowledge that their pregnancy exists beyond the personal, to open up their pregnancy to the outside world and make it ‘official’. This ‘public’ pregnancy stems from an acceptance of the social consequences of the pregnancy and the creation and development of a woman’s pregnancy identity, with its accepted norms and potential consequences. However, it also reflects a woman’s acceptance of the purpose of antenatal care, and potentially the relevance and value of such care. Such acceptance may not be an immediate response to pregnancy confirmation, but may once again follow a period of reflection, a weighing up of priorities, linked to previous experience, her current life circumstances and personal perceptions of health and healthcare.
The major theme of ‘knowing’ from the Sheffield study illustrates a non-acceptance of this public pregnancy. The study found three key sub-themes amongst women who knew they were pregnant but did not access early antenatal care: avoidance, postponement and being delayed by others. Avoidance and postponement were themes emerging from 14 of the 27 interviews. Whereas women avoiding care had made no plans to access care, women who postponed their care intended to access care ‘at some point’ in the future. Avoidance suggests a denial or rejection of the pregnancy and its consequences, postponement suggests a reluctant acceptance or at least some consideration of the pregnancy. Both were linked to feelings of fear and ambivalence for some women, though the boundary between avoidance and postponement was sometimes indistinct. For some of these women what began as avoidance became postponement; in some cases a passive avoidance or postponement, in others women actively chose to conceal their pregnancies or delay access. These themes are discussed in the context of social influences on women’s acceptance of pregnancy, and their perceptions the relevance, value and priority of antenatal care.
6.3.1 The ‘social pregnancy’

“Pregnancy discovery and acceptance… is a complex process… pregnancy exists as a socially constructed phenomenon as well as a biological reality” (Peacock et al 2001: 113-4).



Pregnancy is a social and cultural as well as physiological phenomenon, which exists for women at private and public levels; the concept of ‘being pregnant’ is complex, with many consequences and parties involved (Peacock et al 2001). Society as a whole interprets and gives meaning to this ‘natural’ event, which has changed from a purely private to a far more public experience through history, bringing with it whole new range of meanings and interpretations (Symonds and Hunt 1996). Women need a certain amount of approval and social support before the need for antenatal care, can be acknowledged and accepted, both by the woman herself and her social network (Lia-Hoagberg et al 1990, Johnson, Primas and Coe 1994, Peacock et al 2001, Daniels, Noe and Mayberry 2006). The dynamics of this negotiation between a pregnant woman and others influence both the ‘discovery’ of a pregnancy and the creation of a woman’s pregnancy identity and her ‘social pregnancy’. The notion of a social pregnancy moves beyond the individual and includes her family, partner and peers, extending to a network involving a woman’s community and to antenatal care providers as well (Daniels, Noe and Mayberry 2006). All of these become influences in the process of pregnancy acceptance. Access to antenatal care is heavily influenced by a woman’s willingness to embrace her pregnancy and particularly these social aspects of the pregnancy (Dartnall et al 2005 (UK)).
Supportive relationships within a woman’s social network can strongly influence the coping mechanisms of women, and reduce and prevent delay in accessing care. As Schaffer and Lia-Hoagberg (1997) argue in their US study of low income urban women, the perception of being loved and valued is a significant part of the process of initiating and continuing antenatal care. For many women, once they are able to share their pregnancies it becomes easier to seek support and access care. As with other studies, families, partners and peers of the Sheffield women played an important role in their pregnancies and attitudes towards seeking antenatal care; offering support, information and advice, and acting as a significant motivator (Lia-Hoagberg et al 1990, Napravnik et al 2000, Daniels, Noe and Mayberry 2006). For many primigravid women, pregnancy, and the need for care, was often recognised by someone else. Particularly amongst the younger women in the Sheffield study, it was their mothers who were pivotal in confirming the pregnancy and ensuring they access antenatal care. These were similar findings to Mackey and Tiller (1998) who found pregnant teenagers in the Southeastern USA tended to let their mothers manage their pregnancies.
The social and cultural norms of a woman’s primary reference group could also be highly influential on a woman’s acceptance of care in both positive and negative ways, potentially contributing to “a continuing cycle of women ranking prenatal care low on their list of priorities” (Daniels, Noe and Mayberry 2006: 196). Studies from the USA and UK suggest these cultural norms might reflect a more fatalistic outlook towards pregnancy and/or a rejection of mainstream services, of which antenatal care is a part (Johnson, Primas and Coe 1994, Milligan et al 2002, Dartnall et al 2005 (UK), Daniels, Noe and Mayberry 2006). This applied to many of the ‘postponing’ and ‘delayed’ women, several of whom talked about family and peer influences.
6.3.1.1 Fear of consequences

For some of the avoiding and postponing women in the Sheffield study pregnancy acceptance was linked to their initial disclosure of the pregnancy to family and friends and whether they received support and approval. For some women this relationship was a positive one, but for others it was less so. Several women admitted that they had ignored suggestions (which were perceived as interfering or irrelevant) that they might be pregnant and/or should access care, sometimes for weeks or months. Others talked about the negative influence of partners and families on their acceptance of the pregnancy and the choices they made, for example the fear of parental reactions and partner disapproval of a pregnancy. Where support was perceived to be lacking there was a reluctance to reveal the pregnancy, and thus to access care, for fear of disapproval, rejection, or other ‘consequences’.
A lack of support and approval within a woman’s social network, for example from the baby’s father, or stressful home circumstances, will inevitably influence a woman’s acknowledgement and acceptance of her pregnancy and the need for antenatal care. The resulting isolation has been identified as a barrier to care. In one US study of low-income urban women, those who did not want family and friends to know about their pregnancy were nearly five times more likely to receive inadequate care (Cook et al 1999). As Peacock et al (2001) comment

“when a woman conceives outside of circumstances that are considered acceptable within her social context, and particularly without an adequate support network, she may perceive pregnancy as a situation too threatening to contemplate” (p114)

Lutz’s (2005) US study of women experiencing domestic abuse discusses the idea of pregnancy as ‘public life’: an external, idealised view of the woman’s life, pregnancy and family. A pregnancy becomes public property once disclosed and made official, for example, by booking for antenatal care. As such many women may feel the need to assume a role which presents a positive image of themselves as capable, pregnant women, happy to be pregnant. This may not be the reality of the situation. Booking for care also crosses a line of inevitability, and demonstrates publicly a commitment to the pregnancy. As several women in the Sheffield study indicated, fear of judgement, stigma, scrutiny or even the consequences of the pregnancy, such as coping with another child, meant that they were not ready to take this step, leading to avoidance or postponement of care. As Young et al (1989) comment in their US literature review of access to antenatal care:

“the process of acknowledgement and acceptance of the pregnancy often was prolonged and filled with conflict… women frequently appeared reluctant to assume the roles of expectant mother and prenatal patient by their denial of symptoms of pregnancy and their subsequent failure to participate in an organized prenatal care program” (p243).



This delayed acceptance contrasts with Jomeen’s (2006) UK study of women’s choices in early pregnancy, which found that following pregnancy confirmation women adopted a ‘pregnant woman identity’, which “imbues women with an immediate personal responsibility to their foetuses” (p e198) and ownership of the pregnancy. Women did eventually reach this point but for some it was not an immediate response to pregnancy discovery, reflecting the unintended nature of their pregnancies. Some talked about the motivation to ‘get things sorted’ when their bump began to show and the pregnancy could no longer be hidden from their social network.
As with other studies, the fear of judgement and the consequences of pregnancy was particularly apparent amongst vulnerable women. Fear, whether fear of tests, examinations or doctors, or a fear of others discovering the pregnancy and the consequences of this, has been identified as a common factor for delayed attendance amongst pregnant adolescents, but also other women, in many US studies (Leatherman et al 1990, Lia-Hoagberg et al 1990, Mikhail 1999, Rogers and Schiff 1996, Teagle and Brindis 1998, Young et al 1989). Dartnall et al’s (2005) UK-based qualitative study of hard to reach women identifies particularly vulnerable groups such as substance misusing women and teenagers as lacking the confidence to engage fully with services, for fear of being labelled or facing discrimination and unwanted intervention. This was borne out in the Sheffield study, though other identified groups such as women with learning difficulties and recent immigrants did not articulate this fear. One of the teenagers in the study expressed her fear of the stigma of teenage pregnancy, which led to her avoiding care, a theme also identified by Callaghan, Buller and Murray (2011) in their UK study of late booking in London.
As Roberts and Pies (2011) acknowledge, in their qualitative study from California USA, the situation with substance misusing women is a particularly complex interaction of individual, interpersonal and system factors, which creates multiple barriers. Substance misuse can act as an influence on the acknowledgement and acceptance of both pregnancy and the need for care, due to the impact of intoxication and the resulting chaotic lifestyle on women’s choices and priorities (Gazmararian et al 1997, Milligan et al 2002, Downe et al 2009). Many women recognise the potential harm to their fetus and the consequences of any intervention resulting from their pregnancy. This fear can prevent women accessing antenatal care but women may also be isolated from supportive networks as a result of their addiction. Whilst the latter point was not evident in this study, both of the substance misusing women in the study demonstrated avoidant coping strategies. One woman expressed ambivalence, avoiding confirmation of the pregnancy for several months. The other stated that she was frightened when finding out that she was pregnant, suggesting her recognition of the potential consequences of the pregnancy: the required disclosure of her substance misuse, which had resulted in the removal of her previous children. She also suggested that previous negative healthcare experiences, and particularly fear of judgement from her GP, had led her to delay confirmation of the pregnancy and accessing care.
These are common themes in many other US studies relating to substance misuse and antenatal care attendance (Kalmuss and Fennelly 1990, York et al 1996, Gazmararian et al 1997, Mikhail 1999, Napravnik et al 2000, Milligan et al 2002, Lutz 2005). Such women, struggling to cope with difficult personal circumstances and/or lacking the confidence to cope with the complexities of a pregnancy and the involvement of others in their pregnancies, are particularly likely to delay access. However, as this study illustrates, many ‘ordinary’ women also have other challenges, other priorities in their lives, which impact on their ability and willingness to engage with the ‘public property’ of their pregnancy and the care that goes with it.
In some cases the anxiety resulting from pregnancy discovery led to an initial denial and ongoing concealment which continued for a significant proportion of the pregnancy, for two women until well into their third trimester. This secrecy about pregnancy was particularly significant amongst young women in the Sheffield study, reflecting a common theme in other studies (e.g. Leatherman et al 1990, Mackey and Tiller 1998). However, it would be wrong to assume that women concealed their pregnancies completely from those around them (only one woman concealed her pregnancy in the true sense). Most women told other people close to them but concealed their pregnancies from ‘official’ confirmation and involvement, indicative of their fear of the consequences of disclosure. Women were highly selective about who they did tell, choosing friends or the father of the baby initially, people who were removed from their immediate family, followed eventually by ‘layers’ of revealing to those in their social network. In several cases avoidance became postponement, as more people became aware of the pregnancy, a prolonged process resulting in a passive non-acceptance rather than an active rejection of antenatal care, where initial “avoidance seemed easier than engagement” (Callaghan, Buller and Murray 2011: 9 (UK)).
6.3.2 The pregnancy identity

Pregnant women must make many psychological adjustments as part of a transition to motherhood. Though often discussed in the context of postnatal experiences, some authors argue that the process has the potential to start early, at the point at which pregnancy is still unconfirmed, with an initial period of huge adjustment in the first trimester (Carver and Ward 2007). Oakley’s UK-based qualitative research found considerable discrepancy between women’s expectations and the reality of different aspects of motherhood, including pregnancy (2004). The dominant metaphor was ‘shock’. She suggests “a process of emotional recovery is endemic in the normal transition to motherhood” (p266). Mercer argues that the first stage of this transition is a commitment to the pregnancy and becoming a mother: beginning the creation of a maternal identity, a ‘new conception of self’ (2004: 226); something all-encompassing in a woman’s life rather than a role which can be stepped in and out of. Rubin’s US study of maternal adaptation talks about ‘becoming’: a process of ‘taking-on, taking-in, letting-go’ (1967a: 240), considering the latter as part of a process of grieving for a former (non-pregnant) identity.
This process of adjustment and adaptation is influenced by a woman’s social, economic and personal situation, cultural beliefs and knowledge. Successful adaptation is associated with positive pregnancy experiences such as supportive relationships and self-esteem, whereas stress, depression and lack of support all have a negative effect on a woman’s ability to make this commitment, with ongoing consequences throughout pregnancy and after birth (Nichols, Roux and Harris 2007). This process of adaptation is not exclusive to primigravid women. Nichols, Roux and Harris’s (2007) US study identifies the differing characteristics and needs of primigravid and multigravid women antenatally, which are rarely acknowledged, and argue that multigravid women may face as many challenges in this adjustment as primigravid women.
Such pregnancies may not be a positive experience, and the burden of a woman’s pregnancy identity may be felt keenly. Shock and surprise at becoming pregnant was evident amongst many of the women in the Sheffield study. This was reflected in women’s choices around accessing antenatal care, particularly among the postponing (predominantly multiparous) women, as they considered the consequences of another pregnancy, which was often unplanned or unexpected, and the adaptations they must make. Jomeen (2004) argues that pregnancy can be a distressing event that affects a woman’s quality of life, with intense negative feelings of loss. The transition to motherhood is associated with a mixture of emotions, including fear, anxiety, responsibility, discomfort, exhilaration and guilt; a process of adaptation that may be hindered by an idealised society or media view of motherhood which women may not share or may feel unable to achieve (Burke 1985, Winson 2003). The adjustment to motherhood requires women to behave differently, some have argued less selfishly, suggesting again the influence of the ‘public pregnancy’, with its view of a pregnant woman and how she should behave (Bailey 1999). Jomeen (2006) agrees, suggesting that women feel that they are required to act responsibly and comply with convention in order to avoid public criticism, but acknowledges that women do take ownership of their pregnancies and aspire to present themselves as responsible, making the right choices to safeguard their babies. This was evident in the study, though was not an immediate response for some women, as previously discussed.
6.3.2.1 ‘A little bit pregnant’

Rather than an outright rejection of the pregnancy, avoidance in the study reflected a woman’s refusal to consider the pregnancy and its consequences. In contrast postponement reflected a period of ambivalence about and evaluation of the pregnancy, as women considered their choices and priorities, prior to an open acceptance of the pregnancy and initiation of care. Other studies have considered this ‘phase’ of a pregnancy after initial recognition, whether through self-diagnosis or by taking a test, reflected in both avoidance and postponement of care. Peacock et al’s (2001) US qualitative study discusses the idea of being ‘a little bit pregnant’: an in-between, liminal or transitional state, neither pregnant nor ‘unpregnant’, between pregnancy discovery and pregnancy acceptance, when women would make the pregnancy ‘official’ and take action. Pregnancy discovery and pregnancy acceptance form part of the timeline illustrated in figure 6.2. For some women in the Sheffield study, failure to acknowledge their pregnancies by refusing or ignoring a pregnancy test was clearly part of this ‘little bit pregnant’ phase, and suggested an avoidant coping strategy.

This avoidance of pregnancy confirmation suggests women were unwilling or not ready to take full ownership of their pregnancies at that time