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

. Patterson, Freese and Goldenberg’s (1990) qualitative study in Alabama USA talks about a ‘letting it sink in’ phase, lasting from days to months, while women considered whether to continue or terminate the pregnancy, and the process of active or passive delay that ensued. This was clearly evident amongst some of the postponing women in the study, following pregnancy confirmation, and once again reflects their consideration of pregnancy as a social phenomenon, with a public status and consideration of ‘consequences’. Several women identified this ‘needing to think about it’ period and the passage of time that resulted: women struggled with their identity and ownership of their pregnancy, with its associated responsibilities.
6.3.3 Valuing care

6.3.3.1 Prioritising antenatal care

The concept of prioritising antenatal care, particularly amongst vulnerable pregnant women, has been discussed at length by many authors (York et al 1996, Downe et al 2009, Phillippi 2009). Few suggest that women place a low value on antenatal care, however numerous studies, in the UK and elsewhere, have demonstrated that beliefs about the importance of antenatal care are not always predictive of behaviour and do not account significantly for lack of use (Sword 2003 (CAN)). For example, in Chisholm’s (1989) Manchester (UK) study, more than 80% of women who booked late thought antenatal care very important and more than 50% thought early booking important. Similarly, in another (US) study, more than 95% of women receiving inadequate care thought antenatal care very or considerably important; this figure was 75% amongst women receiving no antenatal care at all (Aved et al 1993).
Although lack of knowledge about the value of early care, and others not valuing care were contributing factors in other studies (Harvey and Faber 1993, Nothnagle et al 2000), these factors were not found amongst the women interviewed in Sheffield. Almost all the women demonstrated some knowledge of antenatal care. Most stated that antenatal care was ‘a good thing’. Many had a clear picture of the importance of early antenatal care, some its purpose and positive effects. In Omar, Schiffman and Bauer’s (1998) US study of low-income rural women, whilst all women perceived antenatal care to be important, only half thought that barriers had prevented them from accessing antenatal care, suggesting women perceived their late attendance as an inconvenience or something to be expected, rather than feeling that they had been prevented from accessing care. This suggests that professionals and women define barriers to care quite differently (Sword 1999 (CAN)). This was evident amongst postponing women in the Sheffield study, and reflected the active choice of some women to delay care, from a considered and experienced (rather than uninformed) perspective.
Many women in the study demonstrated their understanding of the convention of attending for antenatal care, using expressions like, “it’s because that’s what everyone does, isn’t it?” and “you need to go earlier to see what, what’s correct.” Other studies found this to be a frequent reason for attending for antenatal care: because it was “the thing to do” or “I knew I was supposed to” (Lia-Hoagberg et al 1990). This was articulated more clearly than an understanding of the value or purpose of antenatal care, suggesting women felt a sense of duty to attend, a wish to accord with a social norm rather than a rational and empirical belief in the importance of antenatal care.



This suggests that most women accept the importance of antenatal care ‘in theory’. For it to be acceptable ‘in practice’ however it needs to be appropriate, a good ‘fit’ to the woman. This echoes Penchansky and Thomas’s (1981) definition of access as the degree of fit between the patient’s characteristics and expectations and the characteristics of providers and services within the healthcare system. All these characteristics can inhibit the initiation and continuation of antenatal care (Sword 1999 (CAN)). Women’s perceptions of convenience, and thus attendance, are influenced by their view of the relevancy of the care to themselves and their lives (Sword 2003 (CAN)), part of the ‘patient-centredness’ identified by Tandon, Parillo and Keefer (2005) as so valued by Hispanic women. Findings from the Sheffield study suggest that women made their own judgement of this ‘fit’/relevance in relation to antenatal care, and their priorities reflected this.
Daniels, Noe and Mayberry (2006) comment, in their focus group study of low-income BME women in Atlanta USA, that some women view antenatal care as important, but not as important as other issues in their day to day lives. Utilisation of antenatal care must be viewed in this context; the complexity of coping or surviving in vulnerable situations, often related to low income and instability. This may overshadow the pregnancy and the need for antenatal care (Mayer 1997, Napravnik et al 2000, Milligan et al 2002, Gaudion and Homeyard 2010 (UK)). Several American authors talk about motivational reasons for inadequate care, with women needing time and energy to deal with a variety of family and personal problems, linked to chronic economic strain, that discourage or take priority over the initiation of care (Leatherman et al 1990, Kalmuss and Fennelly 1990, Lia-Hoagberg et al 1990, Sable et al 1990). However, although most women in the Sheffield study lived in neighbourhoods with high deprivation indices and in low income households, many would not have been considered ‘vulnerable’. Few expressed any practical reasons why they had been unable to access care, suggesting that they were well supported. Rather, they illustrated a different set of priorities, a consideration of convenience and an assessment of the value of early care, linked to location, health and past experience.
This perception of inconvenience has also been noted as a significant factor for non-attendance for antenatal care in other studies (Leatherman et al 1990, Johnson et al 2003, Bloom et al 2004). Sword (2003)(CAN) and Lutz (2005) similarly discuss that women’s access to healthcare and health-seeking behaviour is determined by a perception of value, convenience and priority, a process of what Downe et al (2009) call a ‘weighing up and balancing out’ of the situation, and of the risks and benefits of any action. This echoes Levy’s (1999) (UK) concept of women balancing or ‘maintaining equilibrium’ antenatally. Women’s experiences within the health care system generally may be influential, including the direct and indirect effect of poor experiences, for themselves, their family and friends. Studies from the USA and Canada have identified that some women considered their antenatal appointments to be a routine that did not provide them with any important benefits, or were more of a burden than a benefit (Reitmanova and Gustafson 2008, Sword 2003 (CAN)). Raine et al’s (2010) London-based study found different coping strategies amongst women in responding to poor antenatal communication. Where women perceived a stressful situation was unalterable, when the benefits of engagement were unclear, or where they had been rebuffed in previous encounters, one coping strategy was disengagement, most commonly amongst white women with limited education and non-English speaking women.
Though poor care or communication was not articulated explicitly by any of the women in the Sheffield study, as in other studies antenatal care was identified by many as important but not an immediate priority, something that could be postponed (Lia-Hoagberg et al 1990, Daniels, Noe and Mayberry 2006). Women’s consideration of the relevance and priority of care in their lives is significant. Antenatal care is grounded in a biomedical paradigm that focuses on individual determinants of health, rather than a more holistic, socioecological view of care which acknowledges a more complex range of influences (Sword 1999, Oakley 1992). Sword’s (1999) qualitative study in Ontario, Canada, argues that antenatal care reflects an ideology of practice that gives power and precedence to the knowledge and expertise of health care professionals and precludes consideration of women’s experiential knowledge and shared decision-making. As such it has the potential to be less sensitive and responsive to the needs of low income women particularly, creating an unbalanced relationship which in turn has the potential to alienate them (Oakley 1992). This may be reflected in the low priority given to care by the multiparous women in the study.
6.3.3.2 Pregnancy as wellness

Many studies, from the UK, USA and Canada, have identified that some women consider pregnancy a natural, normal life event, a state of ‘wellness’ rather than a medical condition requiring immediate attention, and would only attend for care if unwell, thus rejecting the convention of early antenatal care (Kalmuss and Fennelly 1990, Lia-Hoagberg et al 1990, Aved et al 1993, Omar, Schiffman and Bauer 1998, Mikhail 1999, Callaghan, Buller and Murray 2011 (UK), Heaman et al 2014 (CAN)). Leatherman et al’s (1990) US study notes that feeling well was a significant reason for delayed attendance amongst older women, suggesting higher parity and greater pregnancy experience and confidence in their bodies. This was borne out in the Sheffield study, with four women, all with previous pregnancy experience, saying that they felt well and that subsequently antenatal care was less important to them, but that they would seek help if problems arose.
For some women booking for antenatal care is an act of engagement with a model of care based on surveillance and testing, an interventionist approach to pregnancy which they may not subscribe to (Carolan and Cassar 2008, Callaghan, Buller and Murray 2011 (UK)). Some studies of BME women have suggested that certain ethnic and religious groups are more likely to share this view; resulting in different patterns of health seeking behaviour and different expectations for healthcare (York 1996, Carolan and Cassar 2008, Reitmanova and Gustafson 2008). Such women may use a different frame of reference to make sense of pregnancy, viewing it as a normal and expected event, and particularly early antenatal care as unimportant. Choté et al’s (2011) study in the Netherlands argues that some (BME) women may feel early care is less relevant given its focus on behaviour change in relation to activities such as smoking and drinking alcohol, which aren’t applicable to them. Another Dutch study (Alderliesten et al 2007) found perceptions amongst ethnic groups were influential on access to care even after several generations.
In some (non-western) cultures a pregnancy doesn’t become real until fetal movements are felt. Dartnall et al’s (2005) UK study found that Muslim women with more traditional beliefs were likely to access care at the time they were due their second ultrasound scan (20-22 weeks gestation) as they were fatalistic and did not see the need for early intervention. The women expressed a strong belief that the course of pregnancy would be decided by God or fate, therefore medical intervention was inappropriate and seen as interference. Similarly, a London-based study identified that women from different cultural communities conceptualise pregnancy in different ways, influencing their engagement with antenatal care (Cresswell et al 2013, Hatherall 2013). The study found some women changed their last menstrual period (LMP) date in order to avoid induction of labour and other interventions; interference in what they saw as the ‘natural’ process of pregnancy. In the Sheffield study three of the four women discussed previously were Muslim and in two cases these were women who said that early screening was not needed and therefore attendance for antenatal care was less important. These and other cases suggest a fatalistic view of pregnancy, and a positivism linked with a feeling of wellbeing, which led to women either not trying to access early care or not challenging delays.
This may also suggest influences beyond religion: an acceptance by the women of their bodies and pregnancies, creating a non-medicalised but positive pregnancy identity. Such women were taking control of their pregnancies, in some cases utilising such positivism as a protective strategy against what they perceived as unnecessary interference. This reflects some of the women’s views from the Bristol (UK) Antenatal Care study of less care as positive, less interference:

“I’m not ill, I’m pregnant. Just let my body get on with it, it knows what it is doing.” (Sanders 2000: 172).

6.3.3.3 Previous pregnancy experience

The influence of previous pregnancies was evident amongst some postponing women, with several women expressing a relaxed, accepting attitude towards their pregnancies and late booking, or who didn’t challenge delay. Authors have identified that some women accept pregnancy as a state of ‘normality’ and familiarity, stemming from previous pregnancy knowledge and experience. The Bristol Antenatal Care Study found women with at least one previous normal pregnancy considered antenatal care less important than primigravid women (Jewell, Sanders and Sharp 2000). A Swedish survey of women’s expectations on the number of antenatal care appointments found that a preference for fewer appointments was associated (amongst other things) with parity, age, obstetric history and previous positive birth experience (Hildingsson, Waldenstrom and Radestad 2002).
Many other studies from the US and UK found that multiparous women, particularly those of high parity, were more likely to book late, or in some cases to not book at all, because they perceived care to be more of a burden than a benefit, with perceived ‘losses’ outweighing ‘gains’ (Chisholm 1989 (UK), Lia-Hoagberg et al 1990, Sable et al 1990, Aved et al 1993, Braveman et al 2000, Hulsey 2001, Nothnagle et al 2000). Daniels, Noe and Mayberry’s (2006) US qualitative study found all women agreeing antenatal care was important, but late initiators were more likely to say it was less important in their current pregnancy, suggesting the influence of previous pregnancy experience. The authors suggest (not entirely positively) that women believed that

“because they had experienced prenatal care in the past they did not need to seek early or any prenatal care” (Daniels, Noe and Mayberry 2006: 193).
Women’s perceptions of convenience and value, and thus attendance, reflect again their view of the relevancy of the care to themselves and their lives (Sword 2003). Women with previously uncomplicated pregnancies are likely to have received routine antenatal care which may have been perceived as less relevant and appropriate in subsequent pregnancies. This may be linked to poor continuity of care, a cornerstone of UK maternity policy. For example, Changing Childbirth (DoH 1993) identified the need for continuity of care within an ongoing relationship with a lead professional, whereas Maternity Matters states that “every woman will be supported by a midwife she knows and trusts throughout her pregnancy” (DoH 2007: 5). However, as Kirkham (2010a) observes, this continuity remains elusive, and the majority of women experience a very fragmented maternity service, with women’s surveys describing a conveyor belt process, rather than receiving care within which a relationship between woman and midwife can flourish.
From a medical, rather than midwifery perspective, Browner and Press’ (1996) study in California (USA) found that multiparous women felt they had received a variety of conflicting and unhelpful advice in previous pregnancies, resulting in ambivalence towards antenatal care. Such women were more likely to act independently, referring back to previous experiences, particularly when these were associated with positive outcomes, and their own knowledge. Women used this ‘embodied knowledge’ and experience as a standard against which to assess the validity of clinical recommendations, rejecting medical recommendations they could not easily incorporate into their ongoing daily life circumstances. This again echoes Levy’s (1999) ‘maintaining equilibrium’, where women dealt with information in order to protect and keep in balance the interests of themselves, their baby, family and others, and ultimately retain control over their pregnancies. Part of this process involved avoiding information if they regarded it to be irrelevant and unhelpful.
Docherty, Bugge and Watterson (2012) argue that whilst access to antenatal care may not necessarily be influenced by the socio-economic background of pregnant women, engagement is. Their Scottish study suggests that this can be defined in terms of less evidence of personal connection to their own care, poorer communication and less opportunity for shared decision making amongst low income women. This reflects the unequal power relationship previously considered, between healthcare provider and pregnant woman, which may hinder the communication of a woman’s needs and influence their beliefs and decisions about what actions to take to enhance their health (Carver, Ward and Talbot 2008). The impact of this relationship has influences beyond the current pregnancy to future healthcare access (and by implication to future pregnancies).
However, in contrast to the studies above, no women in the Sheffield study identified poor experience with previous antenatal care specifically, though one substance misusing woman discussed the judgemental attitudes of her GP, a factor seen in other research (Napravnik et al 2000). This study (and others) suggests rather that women were less motivated to attend where they had a good past experience of pregnancy (Leatherman et al 1990, Mikhail 1999). Roberts et al (1998), in their study of middle-class women in Midwestern USA, found that antenatal care was seen as less important by older, multiparous women, due to their previous positive experience, suggesting that the delay was because women felt care made little difference to the course and the outcome of the pregnancy. There was a suggestion amongst multiparous women in the Sheffield study that they were more relaxed about missing early care, because of their previous pregnancy experience, and that antenatal care was particularly important for first pregnancies, when women had more to learn.
Several multiparous women in the Sheffield study also expressed a trust in their pregnancy knowledge and experience, a suggestion of expertise and an ability to make their own choices. Evidence of this non-participatory approach in pregnancy - women making their own decisions - was also found by O’ Cathain et al (2002), in their study of informed choice in maternity care. They found that multiparous women, but also women from manual occupations and with lower educational attainment (many of the women in this study) were more likely to express a preference for not sharing decision-making with health professionals, but were likely to express that they had made an informed choice antenatally.



Though not specifically related to antenatal care, Dixon-Woods et al’s (2006) idea of ‘candidacy’ suggests that access to healthcare is not simply a question of utilisation but reflects a dynamic process of negotiation, influenced by people engaging in defining their own understanding of what is appropriate medical attention and intervention for themselves. They argue that there are multiple influences on this, including personal characteristics, social context and the macro level organisation of services. The Sheffield study suggests these influences are evident in antenatal care, as some of the pregnant women made these judgements in relation to the timing of antenatal care, in the context of their previous pregnancy experience, their beliefs and their acceptance of pregnancy. The social context includes the experience and influence of other mothers which was also evident in their choices. Many received advice and information, and a number of women in the study had experienced late booking within their families, reflecting (again) the influence of mothers and peers as models for maternal role taking (Rubin 1967b), and the significance of social and cultural norms in relation to late booking.
6.3.3.4 Location of care

Only one of the women interviewed expressed any problems relating to their home circumstances or financial background that had prevented them from accessing care. In contrast, a large number of studies, primarily from the USA but also one from the UK (Dartnall et al 2005), identify practical barriers to access such as distance or transport and the time and cost involved, ‘the ease with which one gets connected to care’ (Bloom et al 2004: 433), as highly significant in influencing access. However, in many of the studies no distinction is made between initial access to care and continuing access, so it is difficult to assess their significance to late booking. Also many of the studies are quantitative, giving the women no opportunity to explain their situation or attitudes further (e.g. Lia-Hoagberg et al 1990, Cook et al 1999, Schaffer 2002, Bloom et al 2004, Johnson et al 2007, Sunil et al 2010).
Travel as a practical barrier to care is not a universal finding however. Chisholm (1989) found a higher proportion of late bookers in Manchester (UK) living near to the hospital, whilst other authors from the USA and Canada suggest that practical barriers, particularly distance and transport, are far less significant than women’s attitudes to care and how they prioritise it (Omar, Schiffman and Bauer 1998, Nothnagle et al 2000, Sutherns and Bourgeault 2008). Similarly, although Dartnall et al (2005) found that changing locations impacted on GP registration and therefore on access (as illustrated by one of the women in the Sheffield study), such practical barriers were primarily linked to ‘mindset’: a lack of understanding of the role and value of the services themselves and subsequent lack of priority.
This concept of mindset is well illustrated by the women who were ‘on the move’ in the study, whose responses are suggestive of a differing set of priorities: a consideration of convenience and the value of early care, linked to location, health and past experience. There is little discussion in the literature of women’s mobility during pregnancy and its impact on access to care, though transient lifestyles were identified previously by Mackey and Tiller (1998) and this was a contributing factor for one woman in the Sheffield study. Callaghan, Buller and Murray’s (2011) London-based qualitative study acknowledged that urban populations are diverse and mobile, and that travel during pregnancy is now common. Late booking was strongly associated with moving during pregnancy in the Sheffield study.
In Callaghan, Buller and Murray’s study the late booking women who had travelled while pregnant all received antenatal care outside the UK, so would not have met the criteria as late bookers in the Sheffield study. In contrast, in Sheffield five women chose not to attend for any care until ‘home’: a place of perceived trust, familiarity and safety. Some women were able, but chose not, to access early care where they were, choosing other priorities in their lives. One woman recounted a negative experience abroad which had influenced her decision not to access care until back home, despite a prolonged period outside of the UK. The women’s stories illustrated again how perceptions of the value and convenience of antenatal care affect women’s attitudes towards its acceptability, in terms of timing, portability and necessity. They also identified the importance women place on a familiar environment for such care; reflecting their desire for home based care which is a good ‘fit’ to their lives: local, familiar and trusted.
6.3.3.5 Taking control, protecting the pregnancy: self-care

The Bristol Antenatal Care Study found both primigravid and multigravid women considered ‘the way you look after yourself in pregnancy’ to have the greatest influence on pregnancy outcomes; suggesting internal control and a lack of association with the belief that antenatal care makes a difference (Jewell, Sanders and Sharp 2000). The authors acknowledge that women do have opinions about their care:

“some women, even at the beginning of their pregnancy, will hold clear views about the type of antenatal care they wish to receive” (Sanders 2000: 173)
or, by implication, care they do not wish to receive. As Browner and Press (1996) identify, women seldom follow medical advice uncritically: they reflect and evaluate, pick and choose, using and discarding advice according to internal and external influences (the ‘weighing up’ considered previously).
In the Sheffield study, where women had other priorities and had made the decision to avoid or postpone antenatal care, they demonstrated differing strategies to deal with their decision. For some women it was simply denial, a refusal to acknowledge publicly their pregnancy, a passive acceptance of delay or ‘hoping for the best’ based on instinct (“I just assumed I’d be all right”). However, others demonstrated a more active, considered approach to their pregnancies, engaging in a process of self-care. Authors have suggested differing views of this process. Sword (2003 (CAN)) suggests it underpins all the decisions a woman makes about her pregnancy:

“taking care of self is the overarching concept used to described the basic consideration inherent in women’s decision making regarding prenatal care use” (p330)

Also, as Peacock et al (2001) observes, pregnant women engage in a wide variety of self-care behaviours, even prior to accessing care. Two women in the Sheffield study expressed a confidence in managing their pregnancy themselves, not needing mainstream antenatal care. They undertook what could be described as ‘DIY antenatal care’, an active process of monitoring the progress of the pregnancy and staying well, as a substitute for conventional care, until they were at an advanced gestation. For these women self-care provided a coping strategy, a way of avoiding or bypassing the ‘social pregnancy’, but for very different reasons. For one woman it formed part of a very private concealment of pregnancy and avoidance of antenatal care. For the other it was openly described as a temporary measure until she was able to access conventional care, while she waited for a ‘point of safety’ in her pregnancy, when the termination her husband wanted her to have was no longer possible.
Peacock et al (2001) and Callaghan, Buller and Murray (2011 (UK)) both discuss other cases where women resisted perceived pressure to have a termination, resulting in their delay to access antenatal care. In all these cases women feared the judgement of others and particularly someone else’s choice being forced onto them, and wished to take control of and ‘protect’ their pregnancies from outside influence. For one of the women mentioned above ‘protecting’ involved creating a safe space away from the threat (her husband) and waiting. As discussed in chapter five, the two women explicitly (and others implicitly) used their experience of pregnancy, both direct and indirect, to make sophisticated assessments of the progress of their pregnancies. This self-reliance was seen as a positive, purposeful thing by the women, who were determined to take control, stay well and informed, and make their own choices about the pregnancy: as identified in previous literature (Omar, Schiffman and Bauer 1998, Roberts et al 1998).
Some authors have presented this self-care in negative terms, as passive non-attendance based on ignorance. Johnson et al (2007) suggest that it is a barrier to care, linked to not valuing antenatal care and an attitude of being able to take care of one’s self, seeking emergency care only if necessary. A traditional perspective of pregnant women ignorantly assuming self-care to be sufficient is given by Mayer (1997), who states that women

“may have correctly considered pregnancy to be a normal and healthy process, but incorrectly concluded that this obviates the necessity of preventative care” (p250)

This study suggests a more positive view, echoing Sword’s qualitative research (2003 (CAN)), who describes this care as a means of self-reliance, part of a strategy for women to take control of their pregnancies, making choices themselves, when they feared this control and choice would be removed. She identifies that women perceived this to be the best choice, given their particular circumstances. In contrast to many other authors, Sword argues that women take an active rather than the assumed passive role in their care, and make choices from an informed, rather than ignorant, perspective.

“In contrast to beliefs about these women as passive non-users of the health care system, the notion of taking care of self positions them as self-determining individuals who make purposeful and rational choices about use of programs and services” (p331)
This positions such women as active participants in their pregnancies (again, reflecting Jomeen’s (2006) view of women taking personal responsibility for their pregnancies), in contrast to Kirkham’s view of pregnant women as ‘consumers’ of maternity services: “still a relatively passive role for life’s most creative act” (Kirkham 2010a: 3).
Similarly, Patterson, Freese and Goldenberg’s (1990) US qualitative study describes this as part of a process of women ‘waiting’, and ‘seeking safe passage’ for their pregnancies, and suggests that “women did what they believed was adequate to promote safe passage” (p30). The concept of ‘ensuring safe passage’ for themselves and their babies during pregnancy is also expressed by Rubin (1984), as an important task in the creation of a woman’s maternal identity. This included gaining knowledge from different sources, self-monitoring, self-care and contingency planning if there was any perceived threat to the pregnancy, with women assuming personal responsibility for their pregnancies and taking an active role. This was particularly evident amongst multiparous women, who decided early care was not needed as they were healthy; avoiding practical difficulties with accessing care and making their assessment based on previous pregnancy experience, despite a fear of being reprimanded. Omar, Schiffman and Bauer (1998) agree, if in a somewhat qualified way, suggesting that multiparous women may have been empowered to determine their own self-care needs during this pregnancy based on past experience, and “may have been able to make their own decisions about when to access ‘the system’” (p246). For the women in Patterson, Freese and Goldenberg’s study this ‘waiting’ was often ended by others (sometimes reluctantly), or if the woman had physical symptoms or needed information and/or reassurance. These reasons were also given by many of the postponing women in the Sheffield study, who expressed considered views about what was appropriate care and when they would seek it. This again reflects women’s rationalisation and normalisation of their pregnancy experience, and their considerations of ‘candidacy’ for antenatal care.
This process of self-care presents women making choices from a considered perspective, associated with the belief that pregnancy is a natural state that does not require early professional intervention. From some women’s perspectives, taking control or charge of the pregnancy may be identified as an active and considered rejection of the ‘status quo’ of antenatal care, a positive rather than negative choice. This thoughtful process of self-determination echoes that seen elsewhere in healthcare research, such as Pound et al’s (2005) notion of ‘resistance’ to medicine taking, with non-compliance not simply a passive failure but the result of active engagement and decision-making by patients, demonstrating ingenuity and energy. Such resistance in pregnancy similarly represents a hidden or concealed process, a modification of the ‘norm’ in response to what Pound et al see as the coercion of traditional approaches (which could include antenatal care). Similarly, Brubaker (2007) observed a process of ‘embracing and resisting’ formal pregnancy care by pregnant teenagers; small assertions of autonomy over aspects of care, part of what Kendall et al (2005) call ‘asserting adulthood’. This concept of women challenging orthodoxy, in choosing to trust their own instincts about maintaining good health in pregnancy, requires further examination as it suggests a link to women’s health beliefs and/or a possible cynicism about the medicalisation of the ‘normal’ process of pregnancy.

6.4 Delayed: barriers to care, accepting delay



Some cases in the Sheffield study have highlighted the lack of a coherent approach between primary, community and secondary care towards the management of early pregnancy. A significant number of women in the study experienced administrative and professional failures. These were sometimes as a result of misdiagnosis of pregnancy or mis-estimation of gestation, or a result of the incorrect scheduling of appointments, leading to and exacerbating other delays. However, there is little evidence of these factors in other studies, and where it exists the authors make no distinction between initial access and subsequent appointments, so it is difficult to assess its significance. York et al (1996) and Hulsey (2001) in the USA acknowledge that the lengthy enrolment process in some publicly funded care led to unavoidable delays in entering care for some women. However, as Callaghan, Buller and Murray (2011) observe, there is little acknowledgement in the UK literature that late booking does not always originate within women’s decisions or indecisions. Their London-based qualitative study identified several women who had been delayed by administrative failure, but made no reference to women’s attitudes to this delay.
The idea that women are prevented from attending for their initial antenatal care is a complex one. Common factors act to prevent women from accessing care, in terms of direct, practical prevention, but also indirectly through an influence on their acceptance of their pregnancy and understanding of antenatal care. Although for six women, professional and system failures were the primary reason for late booking, there were no cases where there were no other contributing factors (see appendix 4.15). Whilst initially appearing to have been prevented from attending for care, many of the ‘delayed’ women expressed other, more subtle opinions relating to their acceptance of the value, timing and portability of antenatal care.
Most significant in this study was women’s acceptance and lack of challenge of delays. On first examination this appeared to be because of a lack of reproductive knowledge, particularly relating to the antenatal care ‘system’ and the appropriate timing of care, and primarily amongst primigravid women. Eleven of the 14 delayed women were primigravidas, two women were non-native English speakers and one multiparous woman had not experienced early care in her first pregnancy. As discussed in chapter five, lack of knowledge and misconceptions about antenatal care and what to expect were evident, and contributed to delayed access. Many US studies identify a limited understanding of the purpose, value and even location of antenatal care (Leatherman et al 1990, Harvey and Faber 1993, Johnson et al 1994, Teagle and Brindis 1998, Mikhail 1999), particularly amongst young women in their first pregnancies.



The Sheffield study, like others, demonstrates that a lack of familiarity with health care services, sometimes linked to difficulties with language, is a significant influence. Whilst not always a primary reason for delayed access, it may exacerbate barriers to care by compounding a lack of knowledge and limiting a woman’s ability to challenge delay (Kalmuss and Fennelly 1990, Schaffer 2002, Dartnall et al 2005 (UK), Tandon, Parillo and Keefer 2005). This has also been identified by several authors in relation to BME women and other marginalised groups (Firdous and Bhopal 1989 (UK), Gazmararian et al 1997, Dartnall et al 2005(UK)), who acknowledge that a poor understanding is linked to a greater likelihood of inadequate care. Language proficiency affects the active and passive acquisition of essential information, including the exchange of experience with other pregnant women (Alderliesten et al 2007).
However, primigravid women’s acceptance of the delays they encountered was also linked to other significant factors, namely their ‘mindset’ and preparedness for pregnancy, their relationship with healthcare professionals and the trust they placed in their professional opinion. The lack of empowerment and passive acceptance of professional opinion forms a significant part of the complex relationship of beliefs and behaviours identified in the study. One woman explained that she had built up a trusting relationship with her midwife in early pregnancy, so did not consider challenging her (incorrect) advice. Lack of knowledge was not a universal characteristic of the delayed women however, as several were well educated about pregnancy and antenatal care, either through experience or reading, particularly the detail of the content of care. Although antenatal care was seen as valuable, life circumstances and personal perceptions of their health and the necessity of care, sometimes as a result of past experience or the views of others, influenced women’s opinions of the timing of care and their acceptance of delay. This suggests that acceptance was as much a significant factor in women’s late attendance as prevention.

6.5 Strengths and limitations of the research
Women’s views are a fundamental part of research into maternity care, and as such researchers must ensure that women’s voices are heard. They should not be thought of as stand-alone extras to ‘hard’ clinical outcomes, but integral, having an impact on such outcomes and playing a key part in their assessment (Jomeen 2006, Green 2012). However, Novick (2009) suggests that despite decades of recommendations for women-centred approaches to antenatal care, women’s experiences of antenatal care are still relatively unexplored. Goldenberg, Patterson and Freese (1992) expressed similar views, in relation to antenatal access:

“it appears that far more emphasis must be placed on understanding the woman’s motivation for seeking care, the psychological characteristics associated with failure to obtain that care, and the actual sequence of events or pathways a woman travels to enrol in care” (p147).
Since the Sheffield research commenced in 2007, there have been several systematic reviews published of the literature around antenatal access and initiation (for example those presented in chapter two), though these are dominated by quantitative research from outside the UK and a focus on antenatal access in general. In addition to the Sheffield study (Haddrill et al 2014), only one other UK-based study has been published recently concerning women’s perceptions of antenatal access, and in particular the initiation of antenatal care: the London-based qualitative study by Callaghan, Buller and Murray (2011). The qualitative findings of another London-based (mixed methods) study remain unpublished (Cresswell et al 2013, Hatherall 2013). There are many similarities between the two published studies, and they share many of the same findings. However, the sample size was larger in the Sheffield study, which only included women booking for care from 20 weeks gestation; in comparison to women booking after 12, 22 and 28 weeks in the London study, but which also included women who had received early care elsewhere.
The Sheffield study has listened to the voices of a group of late booking women, considering their status and their choices in relation to pregnancy; their assessment of risk and the relevance of care. The explicit focus of the research has been the women’s perspective, in contrast to many quantitative studies of late booking which have been driven by the perspectives of professionals (Carver and Ward 2007). Sword (1999) comments on the limitations of such research:

“To date, knowledge about barriers to prenatal care has evolved largely through positivist research approaches and, therefore, is based on what service providers and researchers perceive as important factors… their views may not be congruent with those of women… fails to provide insight into the social context of meanings associated with behaviour” (p1174-5).

A US mixed methods study on non-attendance for antenatal and postnatal appointments found that women had more complicated and emotional reasons behind their missed appointments, such as embarrassment, than those identified on the quantitative survey (Quinn, Detman and Bell-Ellison 2008). The authors argue that women’s reasons for not accessing care are complex and subtle. Cognitive barriers about the perceived value of care may outweigh structural barriers, but reporting structural barriers may be easier or the only option provided in a fixed-choice survey. This emphasises further the strength of qualitative research in relation to healthcare attendance.
Qualitative methods can enrich our knowledge of health and health care and are aligned with the health promotion ideology of empowerment and the emancipatory focus of much feminist research (Sword 1999, Mays and Pope 2000, Willis 2007, Bryman 2008). At the heart is pragmatism. As Strauss and Corbin (1998) argue, the theories that result from inductive methodologies, such as those influenced by grounded theory, can be used not only to explain reality but to provide a framework for action. Sandelowski and Leeman (2012) talk about translating thematic statements into the language of intervention and implementation, to enhance the accessibility and utilisation value of the findings. This was always the intention for this study. Throughout the research there has been a professional consideration (and reconsideration) on my part of the necessity and value of early antenatal care, and of ways of improving access. As a midwife I have a strong belief in the value of antenatal care. I want women to come for care early and regularly during their pregnancies because, like other midwives, I see it as a positive health intervention. Though I acknowledge its limitations, I believe it makes a difference to women’s health and wellbeing, to their pregnancy experience and their preparation for parenthood, whether it is their first or subsequent babies. But I want women to come for care because they value care that is relevant to their lives, not because they feel compelled or threatened to attend by others, or by the need to accord to a social norm. This view has underpinned the research and has driven the suggestions for strategies to reduce late booking which are presented in the following chapter.
The aim of the Sheffield study was to understand the reasons why some women present late for antenatal booking. The intention was to create a study whose findings were believable, and might ultimately contribute to improving early access to antenatal care and outcomes for pregnant women and their babies. The study has used multiple techniques to reflect these aims and to ensure its quality and rigour. These are illustrated in appendix 6.1, which presents a critical appraisal of the Sheffield study, using the CASP Qualitative Research Checklist (CASP 2013). Previously utilised to appraise the evidence in the literature synthesis of chapter two, the intention was to subject this research to the same critical analysis. The techniques are also shown in table 6.5, using Lincoln and Guba’s framework for developing ‘trustworthiness’ in qualitative research, as previously discussed in chapter three (Lincoln and Guba 1985, Guba and Lincoln 1994).
In terms of the study’s credibility, transferability and dependability, a consistent approach has been demonstrated throughout. This is evident in the clear articulation of recognised qualitative methods, the presentation of findings from multiple perspectives and the interpretation of these in relation to previous research. These were developed through a multi-disciplinary process of supervision, independent verification of the data and critical challenge. Additionally, detailed presentation of the findings reflects the important concept of ‘thick description’, as previously discussed in chapter three. The accurate representation of the women’s data, for example using direct quotes and including contextual information, aims to give a sense of women’s ‘whole’ lives and contributes to the study’s confirmability and authenticity. This detail and transparency allows the reader to assess all aspects of the study and creates a vicarious experience of women’s late booking.

Table 6.5 Techniques used in the study to ensure quality
(using Lincoln and Guba’s framework for developing ‘trustworthiness’ in qualitative research - Lincoln and Guba 1985, Guba and Lincoln 1994, Shenton 2004)

		Techniques used in the study
Criteria	Definition	Use of recognised qualitative research methods	Interpretation of the findings, developed through a multi-disciplinary process of supervision and debriefing	Presentation of multiple perspectives and the interpretation of these (data triangulation)	Clear articulation of methods, findings and interpretation, to demonstrate consistency (audit trail)	Detailed presentation of findings and comparisons with previous research, using ‘thick description’	Considerations of reflexivity – promoting honesty and openness	Accurate representation of data, e.g. using direct quotes from women and including contextual information
Credibility	Is the study believable?
Dependability	Could the findings could be replicated with similar participants and context?
Transferability	Could the findings be extrapolated to other settings/groups/contexts?
Confirmability	Does the study give an accurate representation of the data and its interpretation?
Authenticity	Does the study give a fair and honest reflection of the range of women’s lives and experiences?

Such techniques also enable the reader to evaluate the relevance of the findings to other groups or settings. However, this evaluation must acknowledge qualitative research’s recognition of the changing nature of phenomena and participants, and the interpretive and constructivist perspective that understanding is co-created. Therefore the context and findings of each study are unique and are not generalisable in a quantitative sense. Both the quotes and the interpretations of the findings are open to further interpretation by the reader (Jomeen 2006). Such research therefore provides insight, one layer of interpretation, whereby the reader may judge its transferability.