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

6.5.1 The women

The challenges of conducting a study about lack of engagement with antenatal care in a population of women stereotypically seen as ‘hard to reach’, e.g. vulnerable and socially disadvantaged, must be acknowledged. There were many difficulties associated with recruiting women to the study. Women’s reticence, differing priorities, but also the clear opportunities to withdraw from the study, were reflected in the low response rate amongst the women after initial consent to participate. Challenges with recruitment have prevented the ‘member checking’ that could have been valuable for validating the study’s findings, though there are many criticisms of the method (Polit and Beck 2012).
Achieving a truly diverse sample ethnically was not possible, as non-English speaking women were unable to participate due to the lack of interpreting provision. The views of the very small number of women in Sheffield each year who did not receive any antenatal care at all were also excluded, as these women declined to participate. This would have added another dimension to the results. However, recruitment took place over 22 months during which snowballing methods and active engagement with key health and social care practitioners were undertaken. This, in combination with some women’s reluctance to participate, lengthened the recruitment phase and has inevitably influenced the findings. However, the overall diversity, size and exclusivity of the sample, within the context of qualitative research, suggest a rigorous and largely successful process.
The focus of this study has been the diversity of views of late booking women across the social spectrum, in comparison to most previous studies which have targeted low income or vulnerable women from specific communities. As table 5.1.1 illustrates, the women in the study were diverse in terms of age (from 15 to 37 years), parity (zero to four) and socioeconomic status; including occupation (students, unwaged and those in a range of jobs, including service and professional occupations), educational attainment (from secondary only to university graduates) and the deprivation ranking of their home address. This may be considered a strength or a weakness. Gestation at hospital booking, rather than the initial community-based appointment, was chosen to examine whether external as well as personal factors were influential. This has contributed to the diversity of the sample, including those for whom pregnancy discovery was delayed, those who initiated care later and those who were delayed by ‘the system’, and has provided a range of perspectives and experiences not usually recorded. There have been many (unexpected) overlapping views across the sample. Many of the women would have been considered low risk antenatally, had they not booked late, and therefore arguably are of less concern to maternity policy makers. The study has not focused on pregnancy outcomes. As discussed in the introduction, Downe et al (2009) suggest that these ‘low risk’ women might be expected to maintain a normal pregnancy, regardless of the number of antenatal visits. However, all the late booking women missed the opportunities provided in early pregnancy for screening and/or support. This has the potential to influence women indirectly; as a minimum it may be linked to reduced breastfeeding and poorer psychological status, and difficulties with newborn attachment.
6.5.2 The interviews

One major strength of the study was interviewing women antenatally, shortly after their first booking appointment, in contrast to 35 of the 47 primary research studies included in the synthesis which interviewed women postnatally or both antenatally and postnatally, in some cases several years after the birth. As Novick (2009) observes, women are unlikely to criticise their antenatal care postnatally, after the safe arrival of their baby; also women’s recollections of early pregnancy will change over time.
The study’s flexible and iterative methods of data collection and analysis were informed by the inductive approach of grounded theory, and were, in many situations, effective at generating rich data about attitudes towards antenatal care. This process continued, as previously discussed, to a point of data saturation. The individual interview method aimed to minimise power imbalances in interviews, and the location of interviews was also influential in this respect, encouraging women to talk openly and honestly about their experiences. This was reflected in the findings. Women interviewed in their homes, particularly those who had not realised they were pregnant, were generally open and happy to talk in detail and at length about not accessing care. Similarly, women who had experienced professional or system failures were angry or frustrated and keen to tell their story.
However, there was a need to know not just what the women thought and did, but also why, that was not always fully explored, due to a lack of depth in some of the interviews (Green 2012). Recognising the complexity of women’s views and allowing them to be expressed completely was challenging, given many women’s reticence and my inexperience as an interviewer. This lack of experience was particularly evident when interviewing women who had postponed or avoided care. A poor exploration of the influence of previous pregnancies and antenatal care, amongst multiparous women, is a particular limitation to the study. It is also inevitable that my own background and position, as a midwife, was influential. There are challenges with the relationship between any researcher and participant, but arguably even more so between health professional and ‘client’, as some women would have perceived the relationship. Hennings, Williams and Haque (1996) also argue that there is an assumption that a female researcher has an automatic affiliation with female participants by virtue of their shared gender, but that this may be the only characteristic shared. These influences, combined with the interview environment and its timing, came to the fore in hospital-based interviews. Women interviewed in clinic, often the women who had concealed their pregnancies, were reluctant to talk about non-access, being quite closed and defensive in their responses. This suggests that they felt that they would be judged and/or criticised by me as a midwife, or by the healthcare ‘establishment’ in general, for making the wrong choices (Kirkham 2010a, Jomeen 2012).

The use of field notes taken at the time of (and immediately following) the interviews, was underdeveloped, in part due to my inexperience with qualitative methods. Such notes should represent the interviewer’s “efforts to record information and also to synthesise and understand the data” (Polit and Beck 2012: 548) but were largely descriptive, rather than analytical, and lacked detail: the ‘thick description’ previously mentioned. The notes were, with hindsight, of limited value. Note taking could have been used more effectively to complement the interview data and to support the inductive process of thematic analysis, providing a greater contribution to the more conceptual and analytical memos and diagrams that were created subsequently.

6.5.3 Reflexive considerations

As discussed previously, the perspective of the researcher shapes all research. My background, and the multidisciplinary influences of the supervisory team, have been influential. However, as Malterud (2001b) comments, "Preconceptions are not the same as bias, unless the researcher fails to mention them" (p484). Considerations of reflexivity are evident in the methods used, the presentation of the findings and the interpretation of these, and are a significant influence on the study’s authenticity and credibility. I have attempted to acknowledge both aspects of reflexivity (as suggested by Schwandt 2007), and provide an honest interpretation of the findings, by

1. acknowledging my part in the phenomenon of late booking and its Sheffield context;

2. self-reflecting on my own biases, preferences and involvement in the research, and theoretical inclinations , throughout the study.
I recognise that my background as a midwife in Sheffield, albeit not one involved in the clinical care of the women interviewed, has played an integral part in the construction of the findings from this study. I have attempted to establish a relationship of openness, trust and mutual understanding with the women in the study, whilst being honest about my role and the ‘distance’ between myself and the participants. I have never obscured my status and, as previously discussed, this has had both positive and negative effects on my relationship with the women interviewed. It may have influenced women’s responses and their need to present themselves as the ‘responsible pregnant woman’ previously discussed.

I have tried to be aware of my prejudices and how they might be influential. Certainly my view of late booking at the beginning of the research was very different to many of the women interviewed. This grew into a deeper understanding of women’s priorities and choices as the study progressed; reflexive thinking acknowledges that the potential influence works in both directions (Lambert, Jomeen and McSherry 2010). However, my intention has always been to ensure, as far as possible, that the study’s findings reflect the experiences and perceptions of the participants, rather than my own characteristics and opinions. Overall, the research has sought to focus on listening to women and critical thinking beyond the accepted conventions about antenatal care attendance (Smythe 2011), whilst remaining sensitive to its context as health services research. As discussed in chapter three, I have reflected both on the status of the women in the study and the choices they made, but also on the necessity and value of early antenatal care from a professional perspective. These factors, alongside the methodological and theoretical openness, a consideration of the influence of the social setting, and an awareness of the wider context of the research evident in the thesis, allow the reader to judge its trustworthiness and potentially its value in enhancing practice (Green and Thorogood 2014).
6.6 Conclusions

The findings of this study, considered alongside previous research into late booking, suggest that the timing of initial access to antenatal care is determined by a spectrum of choices, from acceptance through a more passive non-acceptance to an active rejection of the pregnancy and/or the need for antenatal care. Cognitive, emotional and personal factors and environmental influences are all interacting determinants, operating within different domains and at multiple levels (Sword 1999). Chaotic lifestyles, lack of knowledge and economic deprivation all influence women’s perceptions of their healthcare needs and priorities. The themes from this study suggest a different emphasis however, across the social spectrum. Whilst vulnerable groups are strongly represented in this cohort, women do not always fit a socio-cultural stereotype of a ‘late booker’. Rather, many women illustrated a different set of priorities regarding antenatal care, relating to its relevance, convenience and familiarity. They used their previous pregnancy experience and embodied knowledge, and good health, and take an active rather than passive role in their pregnancies to ensure wellbeing. There was also greater emphasis on the lack of a pregnancy ‘mindset’ relating to the expectation of becoming pregnant, which influenced women’s acceptance of their personal pregnancies, and the creation of a woman’s pregnancy identity as part of her ‘social pregnancy’. All these factors are linked to women accepting delay, even when this originates from professional or administrative failures.
Inevitably, comparisons with other research, particularly from outside the UK, need to be undertaken with caution. Distinct, whilst overlapping, factors will influence antenatal care initiation and continuation, though these are not differentiated in some studies. The overwhelming majority of research conducted into antenatal attendance is from the USA (83% of the primary research studies in the synthesis in chapter two), where there are significant differences in the organisation of healthcare. The influence of models of care based around privately funded rather than universal antenatal care provision has been significant, with some studies demonstrating a considerable financial element to women’s non-attendance (Philippi 2009). Additionally, a recent comparison of USA and UK low-risk antenatal guidance found only 56% of quality indicators were the same, suggesting differences in practice and professional norms (Bollini and Quack-Lötscher 2013). This is likely to be reflected in women’s attitudes and patterns of attendance. The medical focus of maternity care, and the lack of midwife-led care in the USA and in some European countries could also be influential. This is only mentioned generally in other research, in the context of women, usually BME women, preferring female carers during pregnancy.
However, despite differences in care provision between the USA and UK, Bollini and Quack-Lötscher (2013) acknowledge that antenatal guidelines (and others from Europe and Australia, as discussed in chapter one) have the same recommendation for early booking, ideally before ten weeks gestation. Several US studies have surveyed women in receipt of free antenatal care (Gazmararian et al 1997, York et al 1999, Braveman et al 2000, Nothnagle et al 2000) to exclude financial barriers, finding negative attitudes towards unintended pregnancies a common theme. Delvaux et al’s (2001) study in ten European countries found convenience issues and cultural barriers, alongside unintended pregnancies and women feeling that medical care was unnecessary, rather than the direct cost of care, were most significant. This suggests that differences in health service structures and care provision between countries may be a less significant influence on late booking than at first appearance.
The women’s reflections on their late booking have emerged as an additional area of interest from the study data. For example, the perception amongst some women that delayed access was a positive thing, with an impatience for the pregnancy to be over as soon as possible, has not previously been identified. These findings reveal another layer of attitudes and behaviours influencing access, further pieces in the late booking ‘jigsaw’, which merit further consideration. Ultimately, booking for antenatal care is an act of engagement with the NHS maternity system, an approach to pregnancy and a model of care which women may or may not understand, may embrace or accept as convention only, or may even not subscribe to. Care must be responsive to such a range of acceptance. Women place importance on feeling accepted when attending for appointments, however acceptance works on both sides (Carolan and Cassar 2008). Professionals need to accept women’s embodied knowledge and experience and use this to individualise care, whether physical, psychological or educational. In turn, women need to be enabled to recognise the value and relevance of such care to their pregnancies.
In The Woman in the Body (1989), Emily Martin considers the complex interaction of the biological and the social components of women’s health, and the need for an integrated understanding of the relationship between them. She gives the example of the baking of a cake, the contribution of the ingredients together rather than individually and the processes that transform them. Whilst the factors contributing to late booking can be identified individually it is the consideration of their interaction and integration that holds the key to improved access to early antenatal care. Chapter seven considers this interaction and integration and how the findings of the study may influence future maternity care policies and practice, alongside suggestions for future research around the subject of late booking.

Chapter 7: Recommendations to reduce late booking and for further research
7.1 Introduction



The aims of this thesis are pragmatic; namely, to try to understand delayed access to antenatal care from the woman’s perspective, and ultimately to contribute to improvements in early access to antenatal care and outcomes for pregnant women and their babies, by encouraging changes in practice and policy. Reflecting these aims, chapter five has presented the findings of a qualitative study undertaken in Sheffield to ascertain the perceptions of late booking women. Chapter six has considered these findings and discussed them in relation to existing research around pregnancy, antenatal access and attitudes towards care. To conclude the thesis, chapter seven will consider strategies to reduce late booking for antenatal care, and possible directions for further research around the subject.
Antenatal care originates from models developed in Europe in the early decades of the 20^th century (Oakley 1982). It has been argued that the content of antenatal care is more ritualistic than rational and the evidence for its benefits is far from clear, particularly for low risk women (Enkin et al 2000, Dowswell et al 2010). Late initiation of antenatal care is associated with poor maternal, fetal and neonatal outcomes, but with many complicating factors, as discussed in chapter one. However, at its simplest, contact with a midwife early in pregnancy has the potential to give women more time to make informed choices about their care, and to ensure they can take advantage of all the support and screening available. Evidence suggests that this will improve the likelihood of women receiving appropriate care and achieving better health, emotional and psychological outcomes (Shribman 2007, National Childbirth Trust (NCT)/RCM/ RCOG 2012).
For healthy, low risk women this support can be as significant as the prevention of pregnancy complications, through health education and promotion and lifestyle advice, reducing the risk of conditions such as antenatal and/or postnatal depression and increasing the likelihood of breastfeeding, with its concomitant health benefits. Research has also found longer term benefits, because the experience families have during pregnancy and postnatally influences their long-term health, wellbeing and their use of health services in general (NHS Commissioning Board 2012, Cresswell et al 2013). Women who have positive experiences with antenatal care are more likely to be socialised into the ‘system’ of family health and health surveillance, for example attending baby and child clinics and accessing preventative services such as contraception, immunisations and developmental assessments (Tandon, Parillo and Keefer 2005, Quinn, Detman and Bell-Ellison 2008). For young women and women from outside the UK this may be particularly important, as pregnancy may be the first time they access regular healthcare.
The pragmatic aim of the Sheffield study (and this thesis) follows ethical principles for research, which argue that researchers should not take sides but rather ask what potential contribution they can make to solutions (Green and Thorogood 2014). As other authors have identified, there is a need for culturally sensitive, patient-centred and appropriate interventions to improve early and consistent access to antenatal care (Cresswell 2013). However, determining the dimensions and detail of such interventions is challenging. As Jomeen (2012) observes, pregnant women are not a homogenous group; they are individual, complex and multi-dimensional. Access to care is a dynamic process, involving the interplay between a woman, healthcare professionals and the setting for care (Phillippi and Roman 2013). As discussed in the previous chapter, the timing of initial access to antenatal care is determined by a spectrum of choices, from acceptance through to a more passive non-acceptance and at the extreme an active rejection of the pregnancy and/or the need for antenatal care. This suggests a linear process, however the reality is often less structured, a combined ‘web’ of these choices bound up (in some cases) with organisational and practical barriers to care.
This reflects the multiple interrelated influences on women’s acceptance of their personal and public pregnancies, and their decision to access early antenatal care. An interaction of psychological, social and demographic factors must be negotiated prior to a woman’s first antenatal appointment (Downe et al 2009, Philippi 2009). As this research and previous studies have identified, logistical/practical barriers during pregnancy appear to play a relatively limited role in the late initiation of care (Bloom et al 2004). Rather, the findings suggest that late booking is linked to reproductive knowledge and pregnancy expectation, anxieties about the consequences of pregnancy and considerations of the relevance and priority of antenatal care. Understanding the complexity of this decision-making process and the priorities women set during pregnancy is essential, in order to consider any interventions to improve access to antenatal care (Sunil et al 2010).
There is a widespread recognition of the need for an integrated ‘life course’ approach to optimising women’s health; an approach which maximises collaborative opportunities and ‘joined up’ thinking (Willems van Dijk, Anderko and Stetzer 2010, RCOG 2011). One of the RCOG’s stated steps to achieving this is

“removing financial and healthcare provider barriers to seamless integration of services across the interconnected phases of a woman’s life including contraception, preconception, antenatal and postnatal stages” (RCOG 2011: 6)
The Marmot Review (Marmot et al 2010) shares this recognition of the need for action across the life-course, both antenatally and postnatally, to reduce adverse outcomes of pregnancy and infancy. As the Sheffield study has also shown, the way in which women decide what they want from their antenatal care, and the choices they make, are not straightforward. They are influenced by many factors such as past experience, personal commitments, family influence and the care setting (Hirst et al 2003). Improving early booking and birth outcomes (and thus reducing infant mortality) therefore requires a comprehensive focus on all of the “social, environmental, biological, and behavioural determinants of health” (Willems van Dijk, Anderko and Stetzer 2010: 99). As suggested above, solutions need to be tailored to different situations, with multiple approaches from different directions. This again has been acknowledged by the RCOG in its consideration of women’s lifelong health:

Changing health behaviour… requires long-term, multifaceted strategies involving cross-sectoral agencies and recognition that a ‘one size fits all’ approach is unlikely to succeed.” (RCOG 2011: 4)



Antenatal guidance focuses around providing women with care appropriate for their gestation, rather than encouraging them to attend in the first place. There is an underlying assumption that women will attend (NCCWCH 2008, RCOG 2008). Any care provided at a woman’s initial attendance is therefore an influence on whether she, or other pregnant women she knows, will prioritise such care in future pregnancies. The complexity of the challenge concerning late booking is reflected in the focus not on solutions but on targets and monitoring, as evident in NICE guidance and local strategies for reducing infant mortality, with their recommendations to establish regular reporting systems and ‘achieve’ levels of early booking (NCCWCH 2010, Greig and Burrows 2012). Arguably this is only part of the solution.
This study has identified three overlapping themes amongst late booking women: those who did not know that they were pregnant (not knowing), those who knew but chose to avoid or postpone care (knowing), and those who were delayed by professional and administrative failures (delayed). Lack of pregnancy intention or expectation was an overarching factor amongst all three groups of women. Recommendations to reduce late booking reflect these themes, the pragmatic Health Services Research focus to the study and my professional expertise as a midwife. Three interacting recommendations are proposed, resulting from the consideration of existing policies and previous research, in addition to the findings of the Sheffield study. These aim to consider, and influence, both women’s personal and public (social) pregnancies. They reflect general priorities identified by NICE for women with complex social factors, namely improvements in

• 
  service organisation,
  
• 
  care provision,
  
• 
  training for healthcare staff,
  
• 
  information and support for women, and
  
• 
  woman-centred care (NCCWCH 2010).
  

The recommendations are intended to work concurrently and collectively, and be integrated across education, health and social care services. Whilst the focus of these proposals is improving initial access to antenatal care, there are many suggestions which apply to care throughout pregnancy and postnatally too, given the potential influences on both current and future pregnancies. The three recommendations are:

1. 
   To address unintended pregnancies: developing strategies for improving reproductive knowledge (including contraception, the recognition of pregnancy signs and symptoms, and the value of early antenatal care) amongst women, their families and peers;
   
2. 
   To facilitate easy access to care: streamlining and clarifying processes for access to early antenatal care; and
   
3. 
   To provide woman-centred antenatal care: care which women perceive as relevant and valuable, and are willing to prioritise. This entails the provision of individualised and flexible care which reflects women’s needs during pregnancy.
   

These are discussed in detail in the following section.
7.2 Three recommendations to reduce late booking
7.2.1 1. Addressing unintended pregnancies

The recommendation to address unintended pregnancies considers ways of improving women’s reproductive health literacy, including knowledge of pregnancy prevention and planning, but also a woman’s recognition of pregnancy and the value of early antenatal care. Such health literacy has the potential to influence a woman’s pregnancy mindset, related to her intention and expectations of becoming pregnant, but also her attitude towards accessing care. As discussed in the previous chapter, lack of pregnancy planning and expectation are the most common factors related to the late initiation of antenatal care. Research from the USA suggests that an estimated 49% of pregnancies are unintended (defined as mistimed, unplanned or unwanted) (Finer and Zolna 2011). Links between unintended pregnancy and negative maternal and child health outcomes have been identified; consequently reducing unintended pregnancies has been adopted as a national goal in the Healthy People 2020 campaign (Grindlay and Grossman 2013). Similarly, figures of 40-50% in the UK have been cited (CMACE 2011, RCOG 2011), and “preventing unplanned pregnancies” identified as a challenge for clinical commissioners (NHS Commissioning Board 2012: 12). In the Sheffield study the proportion was even higher, with 17 of the 27 women stating that they had not planned to become pregnant.
There are some difficulties with the concept of pregnancy planning, as there is considerable variation in the definitions of a planned pregnancy. Some authors have identified that pregnancy planning is not part of how women view their pregnancies, is not used by the majority of women and is resisted by some. As Barrett and Wellings (2002) note, pregnancy planning is more than just stopping contraception, but linked to agreements and wider preparations. Kendall et al (2005) argue that becoming pregnant ‘accidentally’ enables a woman and her partner to avoid the decision of whether to deliberately enter parenthood, and may be a conscious choice. The authors also consider a ‘planned pregnancy’ to be a middle class concept, foreign to many women, primarily because it assumes women are the locus of control for such decisions, but also because of lack of reproductive knowledge, economic disadvantage and social or cultural norms. The language of any health messages needs to reflect this focus on pregnancy intention rather than planning.
Many authors consider reducing barriers to effective family planning to be an integral part of any solution to unintended pregnancies (Braveman et al 2000). Contraceptive use, like late booking, is multi-faceted, with many factors affecting women’s preferences and their ability to use contraception or to postpone a pregnancy. As the Sheffield study illustrates, women “present a complex story to support their childbearing decisions” (Kendall et al 2005: 310) reflecting multiple circumstances and desires. Again, a more holistic view of a woman’s reproductive health, through her life course, and reproductive health targeting, needs to be adopted to reflect this complexity. A key recommendation in the most recent UK maternal mortality reports is for pre-conceptual discussion/education as an integral part of routine maternity services, for women with pre-existing medical conditions, but ideally for all women planning a pregnancy (CMACE 2011, Knight et al 2014). However, the 2011 report acknowledges that given the large proportion of unintended pregnancies there is a need for opportunistic reproductive health reviews and education, and contraceptive counselling in community settings.
As the Sheffield study suggests, for a small number of (potentially the most vulnerable) women preventative factors may influence their acceptance and decision-making in relation to pregnancy. Lack of reproductive knowledge could be part of this. Teenage pregnancy rates in England, though falling, remain the highest in Western Europe (Dugan 2014). Some women, particularly young women, may have little knowledge and experience of formal health care, and limited knowledge about sexuality and pregnancy, prior to becoming pregnant (Brubaker 2007). To address this therefore requires educational interventions prior to conception as well as in early pregnancy.
Such women need access to flexible reproductive health services and information. Most important is the dissemination in primary care of clear and concise health promotion and education messages about reproductive health, including the limitations of contraceptive methods. However the existence of lay hindrance and a lack of active engagement in care seen in this study suggest a need for improved promotion of the value and relevance of early antenatal care generally in the population, not simply among women who might become pregnant. This reflects the influence of a woman’s social network on her pregnancy, as previously discussed. It necessitates adopting a broader approach, across health, social care and education settings. This would include (where appropriate) key messages for pregnancy preparation, the signs and symptoms of early pregnancy, access to early antenatal care and the models of care available to women, stressing the importance of early booking (RCOG 2002). In combination with the wider use of pregnancy testing kits, in all settings, this may facilitate earlier recognition of pregnancy and access to care. The RCOG (2011) has also acknowledged the significance of peer influences on women’s health behaviours: “Behaviour change is more likely if it is part of greater health literacy involving exchange of information between peers, rather than from the top down.” (p4). Reaching others is key to addressing the social and cultural norms of late booking that were evident amongst some women in the study.
NICE antenatal guidance (NCCWCH 2010), particularly aimed at women from outside the UK, recommends that women should be provided with information about pregnancy and antenatal services, including how to find and use them, in a variety of formats, settings and languages. Information about all aspects of reproductive health needs to be aimed not only at women across the childbearing spectrum but also their families, partners and peers, with different messages tailored to different groups and communities. There is a role for community-based information and advice campaigns about early pregnancy symptoms and care, particularly targeting areas with higher than average late booking. Early access to maternity services in Sheffield has improved following a targeted communications campaign informed by a health equity audit (NHS Sheffield 2010) and influenced by the findings of this study (Greig and Burrows 2012). This echoes RCOG guidance (2008), that campaigns and materials should be targeted towards women in groups and communities who under-use maternity services or who are at greater risk of poor outcomes. Such information needs to use a variety of methods, locations and both low and high technologies to reach new audiences, to ensure health services are responsive to all women’s needs (Gaudion, Godfrey and Homeyard 2009, RCOG 2011).
Formal education has a part to play in this reproductive health literacy. The government’s Sex and Relationship Education Guidance (Department for Education and Employment 2000) for schools identifies that the key task for schools is, through appropriate information and effective advice on contraception and on delaying sexual activity, to reduce the incidence of unwanted pregnancies, particularly teenage pregnancies (Long 2014). There have been criticisms of inadequate teaching in a large number of schools however, particularly those not following the National Curriculum, and comments from health campaigners that better teaching around consent, relationships and sexual health would contribute to safer and healthier young people (Burns 2014). In relation to pregnancy the guidance mentions addressing “the consequences of one’s actions in relation to sexual activity and parenthood” (p10), providing young people with information about how they can access local sources of advice, and the benefit of using other young people, such as teenage mothers, as peer educators. With a change of emphasis all of these could be employed, alongside preventative strategies, to provide key messages around early pregnancy recognition and the purpose and accessibility of antenatal care previously mentioned.
Highlighting the value of early care is important for multiparous women too. For such women, an improved emphasis on their six or eight-week postnatal appointments, particularly for those women at risk of or who have experienced poor pregnancy outcomes, such as giving birth prematurely or to a low birthweight baby, or who have booked late previously, may be effective. Such appointments are currently under-valued and poorly attended, again as women weigh up the benefits of attending, in terms of time, inconvenience and the potential costs involved (Quinn, Detman and Bell-Ellison 2008). They have the potential to highlight the value and relevance of early antenatal care for subsequent pregnancies, and offer opportunistic reproductive health reviews and education. The RCOG (2011) has recognised the need for such a joined-up approach to reproductive healthcare, which could have had a significant impact on many of the women in the late booking study:

“A life course approach implies the need for greater integration of services across different sectors, both horizontally and vertically… For example, the traditional separation of contraceptive services and antenatal services hinders delivery of effective preconception care and postnatal contraception, both key to achieving control of fertility and healthy pregnancies and children. Through these services, women have multiple encounters with nurses, midwives, general practitioners and obstetricians who are well placed to deliver consistent health messages and more holistic care. Although about 40% of pregnancies are unplanned, contraceptive consultations can provide an important opportunity for discussion of preconception issues” (p 5)
This might require taking such appointments out to the women, in the home or community setting, perhaps linked to the use of lay health workers. These have recently been identified in a Cochrane review (Glenton et al 2013) “as a different and sometimes preferred type of health worker” (p2), with a positive role in the development of services that recipients perceive as relevant, and in improving access to maternal and child healthcare. All these strategies have the potential to improve health literacy and women’s mindset around pregnancy and associated care. They may also contribute to enabling women to challenge misdiagnosis and delays in their care; a significant factor in the Sheffield study.