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

Addressing unintended pregnancies
Recommendations for maternity care commissioners and providers:

• Development of education campaigns around recognising pregnancy and the value of early antenatal care, aimed at all members of the community, to be located in GP practices, children’s centres, libraries, community centres, secondary schools and colleges. Use of a range of languages and formats, developed collaboratively with local groups from BME communities.

• Developing links with third sector organisations involved in sexual health, pregnancy and parenting, particularly those aimed at young people, such as Brook and Best Beginnings. This could include the development of mobile phone Apps relating to contraception, pre-pregnancy and early pregnancy health, with potential links to the national 1001 Critical Days campaign (Best Beginnings 2015) or global WHO affiliated 1000 Days campaign (1000 Days 2015).

• Prioritising of pre-conceptual discussions with GPs, and opportunistic counselling around contraception and pre-conception health in primary care.

• Formalising of postnatal follow-up for all women, but particularly those who have experienced complex pregnancies, poor outcomes or previous late booking – strengthening the handover from midwife to health visitor, practice nurse and GP.

• Trialling of lay health workers to work with postnatal women in relation to maternal and child health issues (again as part of 1001 Critical Days campaign), particularly reproductive health (Glenton et al 2013).



7.2.2. 2. Facilitating easier access to early antenatal care

Facilitation is a key (external) aspect of the access process: optimising a woman’s ability to enter and maintain antenatal care. It has been argued by others that improvements to the clinical environment are integral to such facilitation (Phillippi and Roman 2013). Though the physical environment for care had little influence on women’s late booking in the Sheffield study (being more linked to USA studies of continuing care), broader influences on the clinical environment, in terms of deficiencies in the information offered and referral procedures, were evident influences. Improving the clinical environment, in its broadest sense, also connects to strategies for improving community-based information and advice on pregnancy and contraception, as suggested in recommendation one.
There is significant guidance in the UK aimed at facilitating access to early antenatal care. As mentioned in the previous section, NICE antenatal guidance (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. This echoes one of the RCOG’s Standards for Maternity Care (2008) which identifies that

“Maternity services should be proactive in engaging all women, particularly women from disadvantaged and minority groups and communities, early in their pregnancy … Antenatal care should be readily and easily accessible to all women and the option for all women to access a midwife as the first point of contact should be widely publicised” (p14)

Direct access to maternity care, and to midwives in particular, has been championed as beneficial in improving early access. This is evident in the NHS Vision and Strategy: an Approach in Midwifery Care (2012) which aspires to make midwives the first point of contact for pregnant women within ‘accessible maternity services’, with direct access to maternity services and booking by 12 weeks gestation. It has been reflected in many local initiatives. Sheffield’s Early Access to Maternity Care target includes the need to ‘establish and promote timely referral into maternity services’ (Greig and Burrows 2012). A pregnancy helpline/textline has been established, influenced by this research, as part of the community-based information and advice campaign about early pregnancy symptoms and care. Others schemes include fast-track booking in the West Midlands, linked to free pregnancy testing in pharmacies (DoH 2007b), NHS Bradford and Airedale’s Direct Access to a Midwife campaign (Bradford Teaching Hospitals 2011), and the establishment of central booking lines across Scotland to facilitate early access to antenatal care. Such schemes have been linked not only to improved access but also to an improvement in ‘health behaviours’: reduced smoking and substance misuse, and increased breastfeeding rates (RCM 2014: 8). This is in contrast however to research from the USA. A review of 10 years of national pregnancy survey data found mandated direct access to maternity care had not resulted in improvements in maternal health behaviours or infant health outcomes (Durrance and Hankins 2011). The authors recommend a focus on alternative policies.
In addition, the improved management of early antenatal care, a more ‘joined up’ approach which was identified as missing by several women in the Sheffield study, is required. Improved communication and co-ordination between community midwives, family doctors and reproductive and sexual health services, but also health and social care services that are outside of the NHS, could help to ensure the transfer of appropriate information, and the referral and follow up of women in early pregnancy. This could also minimise system and professional failures, but also provide the essential information and advice women need to encourage them to challenge any delays. Automatic pregnancy testing in primary care for women with unexplained symptoms could help to facilitate early access to antenatal care in some situations. It would have prevented the misdiagnosis and delay experienced by several women in the Sheffield study. The NICE pathway on pregnancy and complex social factors (NICE 2014) offers guidance for ‘enhanced care delivery’, and recommends that at the first contact between a pregnant woman and any healthcare professional, the need for antenatal care should be discussed. If the woman is continuing with the pregnancy a booking appointment in the first trimester should be offered, ideally before 10 weeks. New technologies are being employed to improve referral procedures and facilitate this joined up approach to early care, including the use in Sheffield of electronic referral systems and the prioritising of scheduling of booking appointments by gestation rather than receipt.
Facilitating easier access to early antenatal care
Recommendations for:

Local Authority public health/health promotion and NHS care providers:

• Explore best practice in terms of development of direct access to antenatal booking schemes, related to pregnancy health education and health promotion activities. To complement existing access routes through primary care services. Continued development of a range of formats, including phone and online services, for women of all ages and communities.
Maternity care commissioners and providers:

• Continued improvement of referral procedures within NHS, but also streamlining procedures and improving pregnancy confirmation, information giving and transfer when pregnant women present outside of maternity services or primary care. For example, pregnant women presenting to social care, Accident and Emergency or walk-in centres, sexual health and pregnancy/abortion services such as 3^rd sector organisations such as British Pregnancy Advisory Service (BPAS) and Marie Stopes UK.




7.2.3. 3. Providing woman-centred antenatal care

Such practical proposals, focusing on education and easier access, are perhaps only part of the answer to the challenge of late booking. Any discussion around improving access to antenatal care needs to consider the care itself, its quality and focus. There needs to be some acknowledgement of the potential influence, direct and indirect, that the content and delivery of care has on attitudes and behaviours in relation to antenatal booking. This consideration also reflects my background: as a midwife I am concerned with the care women receive, and whether it meets their needs, not only in physical but also psychosocial terms. Such care needs to be truly woman-centred, a phrase widely used in maternity care but which, like informed choice, risks becoming a theoretical description or ideal, rather than the reality of care.
Phillippi and Roman’s (2013) theory of antenatal care access argues that motivation must come first, as it is the most cited reason that women fail to begin prenatal care: “a woman’s drive for care must be present to begin the access process” (p511). This motivation is reflected in a woman’s acceptance of her (personal) pregnancy and the need for antenatal care (her public pregnancy), which in turn is reflected in her engagement with antenatal services. For women to attend for antenatal care, it must be perceived as relevant and valuable to their lives and pregnancies. As discussed in the previous chapter, bridging the gap between perceptions of the importance of antenatal care in theory, and its acceptability in practice, requires care which is a good ‘fit’ to the woman. Early pregnancy is acknowledged as a time when many women have a particular need for information and reassurance (Sanders 2000). However, for low risk, particularly multiparous, women, the benefits of early antenatal care may not be immediately obvious, and subsequently not a priority. This was evident in the Sheffield study. As mentioned previously, by the time they see a midwife or doctor, women have already overcome the majority of common barriers to antenatal care (Downe et al 2009, Philippi 2009).
The challenge therefore, to improve both engagement and potentially outcomes, is both direct and indirect: to create responsive maternity care which influences women in current and future pregnancies, but also changes general perceptions about the purpose and value of antenatal care amongst women and those around them. This necessitates providing care which matches women’s lives and expectations. It requires the reconceptualisation of antenatal care, to make care relevant to all women from all backgrounds, particularly young primiparous women but also multiparous women and women whose experience of healthcare comes from outside the NHS (RCOG 2002). As Kirkham (2004) suggests, women need to be at the heart of such changes:

“If we are to develop better ways of taking decisions and women are to be involved in their childbearing on their terms, profound change is called for in the organisation and resourcing of maternity services” (p 287).
Raine et al’s (2010) London study of antenatal communication discusses the need to “encourage empathetic interactions that promote constructive provider-user relationships, and encourage women to engage effectively and access the care they need” (p590), but this is arguably easy to say, hard to do.
The process begins with acknowledging that blaming women is unhelpful. An undercurrent of opinion that women who don’t access care are ignorant and need to change, a paternalistic view favouring ‘expert’ opinion and western models of care, still remains (Mayer 1997, Johnson et al 2007, Carolan and Cassar 2010). This has the potential to distract from the real issues around late booking, as Braveman et al (1993) comment:

“A widespread and convenient belief has emerged that places the blame for poor prenatal care on irresponsible behaviour by pregnant women… blaming the women themselves diverts attention and resources away from effective solutions that would simultaneously address financial, systems and personal obstacles to receiving high quality care” (p1289)

As the Sheffield study found, asking women questions that were perceived as judgmental and blaming, such as “why did you book so late?” resulted in defensive, closed responses. As the interviews progressed this question became modified to “tell me about your experience of finding out you were pregnant” and “what was it that made it difficult for you to book for antenatal care?”, opening lines of communication. And as Bloom et al (2004) identify, opening up communication begins the process of involving women in finding solutions to late booking.
So what might this woman-centred care look like? Antenatal care that

• 
  provides individualised and flexible care
  
• 
  is focused on listening to women (like this research)
  
• 
  provides psychological as well as physical care
  
• 
  treats women as active partners in their care, and
  
• 
  facilitates real choice and autonomy for women
  

is likely to be effective and accepted care that women are prepared to prioritise, to attend early and regularly for throughout pregnancy, and to recommend to friends and family. It is care that is likely to have a positive influence on women’s decision making and access in current and future pregnancies. These qualities are explored in the following sections.
7.2.3.1 What does ‘woman-centred’ mean in the context of antenatal care?

Surveys of women’s attitudes towards antenatal care inevitably focus on the women who do attend; often white, educated and articulate women, rather than those who do not. Authors have acknowledged the challenges of reaching ‘hard to reach groups’, such as teenagers, low income and BME women (Hirst et al 2003). But there is an acknowledgement that there are some fundamental commonalities in what women want: to understand and be understood and respected, to be able to express their wishes and choices. Any solutions therefore start with the aim, as in this study, of understanding women’s views of pregnancy and antenatal care, and their needs, and placing them at the centre of care. The NHS Vision and Strategy: an Approach in Midwifery Care (2012) identifies key priorities around woman-centred care, including working in partnership with women, their partners and families and developing social models of care with women at the centre of the experience.
In recent history women’s needs in pregnancy have been defined by health professionals, within the context of a biomedical model (Carver, Ward and Talbot 2008). In the 1920s the primary focus of antenatal care was considered to be the surveillance and supervision of women’s health (Oakley 1982); arguably little has changed since then. Antenatal care has been described as primarily “a way for women to integrate into the medical/obstetric care system” (Feijen-de Jong et al 2011: 904), and a “process of medical socialization” (Browner and Press 1996: 144). Pregnancy may thus be viewed as a medical ‘problem’ needing ‘expert’ attention: relying on such experts to define experiences that historically women have understood better themselves. Kirkham (2010a) argues that despite reports from the 1990s concluding that a medical model of care should no longer drive maternity services, the proliferation of monitoring and surveillance in maternity care, in a risk conscious, medicalised society, defines women as needing medical procedures to have a ‘normal’ pregnancy, and makes an assumption that normality has to be continually proved. This has the potential to target women’s insecurities and anxieties about their bodies and their ability to have a normal pregnancy, resulting in fear and contributing to the convention of attending for care. Recent research on women’s emotional journey through pregnancy indicates that the first trimester is one of the most anxious times for women (NCT/RCM/RCOG 2012). Women are required to be responsible pregnant women/‘mothers-to-be’ and behave appropriately: the public pressure to do this is another powerful influence (Edwards 2004, Jomeen 2012).
It is argued that current models of antenatal care are still dominated by health professionals and ‘experts’ views of need, and focus particularly on physical aspects of health, even if these offer neither improved outcomes nor satisfaction: “the needs of pregnant women, as expressed by the women themselves, have received little attention in the provision of health care programs during pregnancy” (Carver and Ward 2007: 98). As such women’s experiences and subjective knowledge, and their resulting needs, may fail to be incorporated into the antenatal care system (Carver, Ward and Talbot 2008). Kent (2000) argues that many midwives support ways of working and advising women that incorporate this biomedical model of pregnancy and birth. Consequently they may need further encouragement to facilitate woman-centred care and choices, particularly amongst the most disadvantaged, whose lives (and pregnancies) may be viewed as more ‘problematic’ (Brubaker 2007). This is borne out in analysis of the findings from the 2010 National Maternity Survey, which highlights the need for a change in the culture and attitudes of health professionals towards women from lower socio-economic groups particularly (Lindquist et al 2014).
As discussed in chapter three, trying to understand the lifeworld of late booking women necessitates acknowledging the unique context and individual perspectives that led to the delayed initiation of care. In order to respond to women, to engage and inform rather than judge and stigmatise, midwives need to begin with a realistic view of women’s circumstances and life experiences (Radcliffe 2011). This research contributes to providing such a view of late booking women, which may be used to inform midwifery practice. As discussed in the previous chapter, the research was most effective when women were interviewed at home. Such an approach takes a holistic perspective, seeing individuals within their social environment and demonstrates how the research agenda can be shaped by the researched as well as the researcher, as partners and equals (Hennings, Williams and Haque 1996). There is a need to reflect this influence of context and equity if the goal of holistic, woman-centred maternity care is to be achieved. For example, information provided and its format, women’s background and experiences, the people around them and the timing and location of any encounter, are all significant components of individualised care (Green 2012). This care needs to be built around the premise that antenatal care makes a positive and welcome addition to women’s pregnancies, and is care that women want to come for, rather than feeling coerced or frightened into attending.
7.2.3.2 Providing individualised and flexible care

“quite simply, clinicians should ask women directly about their own needs and preferences, and modify care accordingly” (Novick 2009: 235).

If all women are to receive optimal care during pregnancy, antenatal care attendance needs to be viewed not simply as convention, but as valuable and relevant to individual women. Many women in the Sheffield study weighed up the value and relevance of antenatal care in relation to their personal circumstances, deciding what was best for them. They favoured care in a familiar, personal setting. Considerations of priority were influential for all women across the social, educational and cultural spectrum, not just vulnerable and low-income women. Relevance and acceptability stem, in part, from care which is individualised, tailored to each woman, and flexible enough to meet their needs (Clement et al 1996, RCOG 2002). Effective midwifery care requires a balance of this individualisation with credible evidence-based clinical guidelines (Viccars 2009). The differing characteristics and needs of primigravid and multigravid women antenatally, evident in this study, suggest the need for tailored care beyond the physical components (Nichols, Roux and Harris (2007).
Official guidance identifies that antenatal care should be sensitive to the needs of individual women and the local community (RCOG 2008, NICE 2014). However, as Kirkham (2004) suggests, many policies, procedures and guidelines for evidence-based care are derived from randomised controlled trials, and apply to the ‘average’ childbearing woman. Rather, there is a need to recognise women as individuals; to respect their need for control of their situation and to nurture individuality to improve outcomes. Jomeen argues that care should be flexible and individualised, not rigid or fixed in a way which imbues women with the need to aspire to some “blanket criteria of normality” (2006: e199): the convention of antenatal access previously considered. Sandall, in her recent report on continuity of midwifery care for the RCM (2014), identifies that personalising women’s care contributes to building better relationships between women and midwives. A midwifery outreach scheme in Lambeth and Southwark, London, reflects this, noting that “reductions in the number of unbooked women show what can be done through provision of responsive individualised services” (DoH 2007b: 80).
Additionally, there are suggestions that a good relationship between a woman and her midwife could reduce the need for care. Clement et al’s (1996) Bristol Antenatal Care study found women satisfied with reduced schedules of antenatal care were more likely to have had a supportive caregiver (a midwife presumably) and were less likely to be depressed in pregnancy. This suggests individualised/personalised care has benefits for all concerned. What is required is to provide midwives with the resources to offer women the individualised and relevant support they need during pregnancy, not simply screening (which women might not want) and physical assessments. Individualised care can only be provided where there is continuity of care and carer; a key recommendation from the recent UK study examining utilisation of maternity care and outcomes for women from low socio-economic groups (Lindquist et al 2014). The benefits of such continuity are widely recognised; for example the Cochrane systematic review of midwife-led continuity models of care identified several benefits for mothers and babies, and no adverse effects when compared with models of medical-led care and shared care (Sandall et al 2013). The authors conclude that most women should be offered such care. However, such approaches require time, appropriate midwifery caseloads and facilities.
7.2.3.3 Focused on listening

“it is important that we listen to the needs of women across the stages of pregnancy and that the ‘voice’ of pregnant women be as influential as that of ‘experts’ in informing policy… and the provision of care which meets individual women’s needs” (Carver, Ward and Talbot 2008: 77)

Understanding women’s lives and meeting their needs requires sensitivity and flexibility, and the ability to listen (Levy 1999). Page (2006) argues that one of the fundamental steps to sensitivity in evidence-based practice is “finding out what is important to the woman and her family” (p360). As Gaudion and Homeyard have observed in their research with disadvantaged women:

“It is essential to begin with the woman’s view of the world, not the professionals… finding out what the woman’s individual needs are and working with her to make a holistic plan” (2010: 157)

The value of listening to women’s opinions about their healthcare is evident in strategies such as the Friends and Family test, already used for antenatal services: “This kind of feedback is vital in transforming NHS services and supporting patient choice” (NHS England 2014). Women’s opinions about their care have great potential for influencing their own future care decisions, but also those of others. NICE’s Pathway on Pregnancy and Complex Social Factors (NICE 2014) and RCOG guidance on reducing maternal mortality (2002) suggest that involving women in their antenatal care is key to improving service organisation and encouraging women to access antenatal services. They suggest this is to be achieved by ensuring women are asked about their satisfaction with the services provided and using this information to guide service development, but also involving women in determining and meeting local needs, engaging representatives of vulnerable groups in the planning of services. Both strategies have the potential to influence future access, however listening to women’s views needs to begin during rather than after pregnancy.
Pregnant women gather their experience and knowledge of maternity care in different ways. This may be limited, or framed by social influences, and contrasts with healthcare practitioners’ lengthy education and socialisation into the practice and values of their profession. Consequently, midwives have a different view of pregnancy and risk to women. This has the potential to create an imbalance in expertise and power, which can hinder the midwife focusing on the individual voice and needs of each woman. Such a relationship may be centred around one way communication, resulting in care which is not individualised or relevant (Kirkham 2004). Docherty et al’s (2012) study of antenatal engagement found poor perceptions of care amongst low income women, including a perception that care was less personalised and an imbalanced relationship where midwives did not assess women’s prior knowledge and directed their antenatal decisions. Edwards (2004), in her study of women’s choices around homebirth, observed that many women found their care to be lacking in flexibility and depth, never really scratching the surface.
A woman-centred approach requires an acknowledgement of women’s understanding and priorities; it is not simply about knowledge (or lack of it). Women make pragmatic decisions. Reviews of women’s views on antenatal care, including the comprehensive national surveys conducted by the NPEU, suggest that key aspects of care valued by women include convenience (Redshaw et al 2007). ‘Need’, like risk and safety, is subjective and socially constructed. Kirkham and Stapleton (2004) describe the focus in midwifery practice of a routinised process of ‘checking not listening’ and argue that if midwives are to learn about women’s knowledge, values and preferences they must start by listening: “when women are listened to, they voice many ways of seeing maternity care and many definitions of safety” (p142).
Edwards (2008a,b) has similarly argued that pregnant women have a much wider view of caring and safety than healthcare professionals, with family and relationships at its centre, and which involves the continuing physical and mental wellbeing of their whole family, in the present and future. As such, ‘safety’ is both relative and limited, and “may be defined differently depending on one’s beliefs, values and circumstances” (Edwards 2008b: 19). She also talks about the emergence of a ‘telling not listening’ culture, steering women to make the ‘correct’ choices, and the need to be willing to listen and keep listening (Edwards 2004). This reflects RCOG guidelines aimed at reducing maternal mortality, which identify the need to overcome dismissive staff attitudes and enhance the status of listening to all women (RCOG 2002). The report, also echoed by Raine et al (2010), recommends exploring ways to provide all women with the opportunity to discuss their experiences, with local training programmes for midwives and obstetricians in 'listening skills', including ‘active listening’.
Such active listening, and greater emphasis on the personalisation of care, may help to eliminate any lack of depth and equality. There is a need to strike a balance within antenatal care between the two perspectives: the midwives’ expert knowledge (with its professional boundaries) and women’s knowledge of their own needs (Carver, Ward and Talbot 2008). This acceptance and compromise on both sides is significant in the provision of care which has relevance and value for pregnant women. This balance of views is necessary across midwifery. This study has not focused particularly on women from outside the UK or for whom English was not their first language, though these were included. Language proficiency affects the acquisition of healthcare information directly and indirectly, although integration into a culture relates to more than language proficiency. The Sheffield study and other research suggests that differing attitudes, particularly towards health surveillance and testing, cultural differences and the different organisation of healthcare in a woman’s home country are likely to be significant reasons for late booking. Any effective interventions to encourage minority groups to engage with maternity services must reflect such differences as part of this process of acceptance and compromise (Cresswell et al 2013).
Carolan and Cassar’s (2008) study of immigrant women in Australia found a gradual ‘trajectory of adjustment’ towards pregnancy and the priority given to it; to valuing antenatal care. They note that “women assimilated continuous pregnancy care into their understanding of how things should be during pregnancy” (p195). This suggests a somewhat paternalistic view of the ‘right’ way to manage a pregnancy, i.e. the Western model of care, and that women were expected to change. However, the authors do acknowledge women’s struggle to conform to Australian expectations, but also the reaching of compromises, and the co-existence of old and new beliefs. They argue that acceptance works on both sides: professionals accepting women’s embodied knowledge and experience, women accepting the value and relevance of care. This needs to be reflected in antenatal provision.
7.2.3.4 Targeted care

Targeting may form part of the process of individualising care. The US Department of Health and Human Services have previously estimated that up to 80% of women at high risk of having a low birthweight baby could be identified at their initial antenatal appointment and, by implication, offered individualised care and support (Roberts et al 1998). Docherty et al argue that the first trimester may be an important period in terms of initiating and sustaining engagement and that the early identification of those women at risk of non-engagement may facilitate “the development of a more equitable antenatal service” (2012: 126). Antenatal guidelines identify that women who fail to attend should be actively followed up (RCOG 2002, NCCWCH 2010), however targeting women prior to booking is a greater challenge.
Evaluations of targeted, non-standard models of antenatal care, seem to suggest they offer some benefits to women at increased risk of poor pregnancy outcomes, both in the short and long term. Willems van Dijk, Anderko and Stetzer (2010) reviewed data from more than 10,000 low income women at high risk of poor pregnancy outcomes, who received Prenatal Care Coordination (PNCC). PNCC is a widely available service in the USA supporting women who receive Medicaid to access antenatal care and other health, education and social care services (such as nutrition and smoking cessation) through outreach and advocacy. They found women who received such tailored care, based on a holistic view of their needs, an ongoing relationship and bespoke interventions, were at significantly reduced risk of poor birth outcomes, including low birth weight and prematurity. The authors argue that such care is cost effective but needs to be part of wider family healthcare; that targeted high-intensity antenatal care for women at risk

“should be delivered within a comprehensive, broad-based system of care for families and young children to ensure the greatest long-term outcomes for creating a healthy population” (Willems van Dijk, Anderko and Stetzer 2010: 107).
A systematic review of 36 tailored antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women found several interventions, all from the USA, including increased frequency of care, group antenatal care, improved continuity and health education (including maternal care coordination), which seemed to indicate beneficial effects (Hollowell et al 2011). However the authors consider that it is unclear whether the findings could be generalised to other disadvantaged populations or healthcare systems. They conclude that there is insufficient evidence of an adequate quality to suggest that interventions involving alternative models of organising or delivering antenatal care are effective at reducing infant mortality and preterm birth, and recommend further research and ‘robust evaluation’.
Allen et al’s systematic review of models of maternity care for adolescents found “growing evidence that the model of maternity care can make a significant difference to those at risk” (2012: 62), with tailored care resulting in improved childbirth outcomes. The most established programme of support for such women is the Family Nurse Partnership (FNP). In existence for 30 years in the USA and 7 years in the UK, and underpinned by an extensive evidence base, it offers prolonged, targeted, individualised information and support for pregnant young women (aged under 19 years) who are at a high risk of poor life chances. It aims to recruit the majority of young women before 17 weeks gestation, and has demonstrated improved health, social and educational outcomes in the short, medium and long term. The scheme is currently being extended in England (NHS FNP 2014).
As discussed in the introduction, women with reduced or delayed antenatal care have poorer birth outcomes, particularly in terms of preterm birth, but the focus of previous research has been largely on the quantity or timing of antenatal care, rather than its content in relation to timing. Recent Belgian research suggests a minimum ‘appropriate’ level of care, in terms of 3 key antenatal interventions (blood pressure, ultrasound and blood sampling) through pregnancy, has the potential for a significant reduction in preterm birth (Beeckman et al 2012). Part of any flexibility in antenatal care could enable women at low risk to receive such a minimal level of physical care and intervention. Although this scheme still recommends booking by 13 weeks gestation, this ‘low key’ approach could be attractive to low risk women, though whether this is defined as in the NICE guidance as a ‘healthy woman with an uncomplicated singleton pregnancy’ (NCCWCH 2008) or in some other way, requires further consideration.
So targeting care may make sense, both at the very beginning and throughout pregnancy. All types of individualised care, perhaps making use of new technologies to facilitate interactions between pregnant women and their healthcare providers, offer the potential for increased relevance and value (Raine et al 2010). However, such care relates to women who have already booked for antenatal care; it is arguably more difficult to reach women prior to booking. The challenge is to get the targeted care to women in early pregnancy so that it can have most benefit and contribute to positive experiences and outcomes. These will in turn influence future pregnancies, for women, their peers and families, creating models of care that women are prepared to prioritise. As discussed in section 7.2.1, it requires broad education and promotion across health, social care and education settings, and joined up thinking and opportunistic contraceptive and preconception care, to address both current and future pregnancies.
7.2.3.5 Providing psychological as well as physical care

“the provision of sympathetic listening support through continuity of care, which is what women have been requiring whenever anyone has thought to ask them, is a more effective way to promote their health and that of their babies than most of the medical interventions carried out in the name of ‘antenatal care’ (Oakley 1992: 327)

As the Sheffield study has illustrated, social and psychological support is integral to initial access to antenatal care. Schemes such as the FNP and PNCC (and Oakley’s Social Support and Motherhood study quoted above (Oakley 1992)) suggest that such support, through advocacy and relationship building during pregnancy, leads to improved outcomes, as much as physical care. This reflects both lay and professional influences. Furber et al (2009) discuss how antenatal depression, like late booking, is associated with preterm birth and low birth weight babies. This correlation may be worthy of further investigation, especially given this growing evidence of the benefits of individualised antenatal care which offers holistic and sustained psychological support for women.
Midwifery care should form part of this support. The NHS Vision and Strategy: an Approach in Midwifery Care (NHS 2012) identifies providing ‘holistic, responsive and compassionate’ midwifery care as a priority. Numerous authors and antenatal guidance discuss the need to offer improved psychosocial as well as physical care: an empathetic, sensitive and non-judgemental approach that builds a relationship and provides support for the psychological period of adjustment to motherhood (Clement et al 1996, Docherty et al 2012, NICE 2014). Such an approach acknowledges the significance of the ‘social pregnancy’ and the recognition that birth is a collective social enterprise (Kirkham 2010b). However, the emphasis on physical care, for example in the NICE antenatal guidelines (NCCWCH 2008), reflects the medical dominance of pregnancy with its risk management approach. Current midwifery remains focused on the physical (arguably easier) aspects of care; a process frequently of form filling and box ticking, which is arguably disempowering and de-individualising (Stephens 2004). This process, for low risk women at least, has the potential to ignore or sideline more important psychological elements of antenatal care, which are messy and harder to quantify.
Booking has been identified as linked primarily to antenatal screening (Rowe et al 2008), but there is little discussion about women who decline screening, and far less emphasis on the other roles for early booking, such as support and health education/promotion. Many existing measures focus on the quantity of antenatal care women receive, but do not measure the quality of such care. This is perhaps not surprising, given the challenges of such measurement. Feijen-de Jong et al’s (2011) systematic review of late and/or inadequate use of antenatal care identifies the need to examine both the content and quality of prenatal services. As the previous section describes, evidence that enhanced, ‘patient-centred’ care can lead to improved birth outcomes is increasing. Tandon, Parillo and Keefer’s (2005) study of Hispanic women suggests patient-centredness in a maternity context stems from what is communicated and how, women’s relationships with healthcare practitioners and the provision of culturally and linguistically sensitive care. This presents challenges for healthcare providers capturing and coding tasks for payment however, as antenatal care becomes defined as a set of tasks and tariffs into which ‘relationship’ doesn’t fit (Kirkham 2010a).
Choté et al’s (2011) Dutch study examining ethnic differences amongst late booking women, suggests that some, particularly BME women, may feel that early care is less relevant to them, given its current focus on screening and behaviour change in relation to activities such as smoking and drinking alcohol. Despite visions and strategies, in the present risk and financial model of antenatal care there may be little left for women (and midwives) beyond the physical aspects of care and the behaviour change messages. Any reconceptualisation of antenatal care must therefore address the continuing challenge (amongst others) of marrying official policies and clinical guidelines with the complexity of social and emotional care (Kirkham 2004).
7.2.3.6 Women as active partners in care

Marmot’s report on the promotion of health equity identifies the need to encourage a partnership approach to healthcare; working together to empower the most disadvantaged and to provide individualised care (Marmot et al 2008). Research suggests this partnership is valued by those using healthcare too. Entwistle et al’s (2012) synthesis of 77 studies of patients’ experiences of health care delivery found that patients wish to feel respected, contribute to their care and experience reciprocity. Alongside the provision of improved information for women about the pattern and purpose of pregnancy care, there is a need for recognition that women can be experts in their own pregnancies and can take an active role in their care. Effective antenatal care “needs to meet their expectations and support them to be in control of their childbirth experience” (Viccars 2009: 265). Sandall’s recent report for the RCM (2014) talks about optimal maternity care supporting “women’s own innate capacities” (p3), Docherty et al (2012) about using strategies such as shared decision making and the recognition of prior knowledge. Involving women more actively in their care requires women to take more control and for midwives to relinquish some control, whilst maintaining a partnership. In order to develop and sustain engagement, health professionals need to recognise all women’s prior knowledge and experience, balancing women’s wishes with organisational and professional requirements (Kirkham 2010b). Arguably the most vulnerable women, such as teenagers, need this partnership and reciprocity, and degree of decision making power, to reduce stigma as much, if not more, than other women (Brubaker 2007).
Many of the knowing women in the Sheffield study assumed such an active and thoughtful role. Kirkham (2010a) argues that childbearing women have become relatively passive ‘consumers’ of maternity services, but could be active and equal participants. It is difficult to identify those women wishing less care (Clement et al 1996, RCOG 2002), however shifting the balance of control antenatally may be feasible, even if it requires thinking ‘outside the box’. Influential health consultancy McKinsey voiced a controversial suggestion in 2012 that the majority of antenatal care could be delivered by women themselves (Dowler 2012). Though the RCM’s response was that the McKinsey view was simplistic, treating maternity care like a production line, the principle of self-care merits further consideration, particularly given that nearly 50% of women are classified as low risk, even at the end of pregnancy (Sandall 2014). As Patterson, Freese and Goldenberg (1990) suggest, for low risk women in particular,

“it seems appropriate to begin to think about what aspects of prenatal care might be transferred to women to manage themselves” (p31).

Such self-care is found elsewhere in the NHS. The Expert Patients Programme was established in 2002 by the Department of Health to put patients with chronic conditions at the centre of their health care, teaching ‘self-management’ and monitoring (ORCIC 2013). Such schemes have recognised the benefits of self-management, giving patients some control over their health, both in physical and psychological terms, and the resulting economic benefits. Although pregnancy is not a chronic condition, there are many circumstances where women take control of aspects of their antenatal care. This study and others have acknowledged that the majority of women do take responsibility for their pregnancies, for seeking ‘safe passage’ for themselves and their babies, taking steps to protect the pregnancy, undertaking self-care in the form of monitoring and lifestyle changes, and accessing care at a chosen point. Ultimately the majority of late booking women want to be seen to be ‘doing the right thing’ and do take ownership of their pregnancies and responsibility for their babies, though this may not be an immediate reaction to pregnancy discovery, as women struggle with their pregnancy identity.
This expertise and personal responsibility, whether it includes women declining care, should come from an informed perspective and a realistic view of what antenatal care entails. This builds upon women’s health literacy, which begins with good communication and the provision of relevant educational information across families and communities, as discussed in section 7.2.1 (Docherty et al 2012). O’ Cathain et al’s (2002) view of non-participative decision making by pregnant women is that if decisions were made from a position of power and understanding then they should be respected and followed. If such decisions stem from a position of resignation or ignorance this needs tackling educationally. However, sensitivity and flexibility are needed to meet women’s needs. Health professionals, with their differing views of needs and risk, may be guilty of judging women as passive and ignorant rather than making informed decisions to delay access. Women shouldn’t be demonised for not wanting early care or screening, which may be the case when women are referred to social care as a result of late booking. Self-care (as opposed to no care) deserves recognition and respect, in the context of individualised and holistic care; care which tries to balance both women’s and midwives’ needs. However, as Beeckman et al (2012) suggest, this partnership and dialogue around a minimum effective level of care should begin ideally in early pregnancy. Such an approach goes hand in hand with improvements in health literacy and access.
7.2.3.7 Facilitating real choice and autonomy

The concept of informed choice has become a mantra in maternity care. Sandall’s report for the RCM (2014) identifies that high quality maternity care is “women and family centred, which involves facilitating informed decision making” (p3). The Changing Childbirth (DoH 1993) and Maternity Matters (DoH 2007) reports both explicitly state that women should be the focus of maternity care, with an emphasis on providing choice, easy access and continuity of care. Such reports and the NICE guidance for antenatal care that has followed them argue that the views, beliefs and values of women should be sought and respected at all times (NCCWCH 2008). The suggestion is however that informed choice is something that women can only make with professional guidance: “having discussed matters fully with the healthcare professionals involved” (NCCWCH 2008: 6).
There are arguments that despite this ‘discourse of choice’ it remains merely a maternity buzzword, with a lack of evidence to suggest that choice is a reality for many women accessing maternity care (Jomeen 2006, Carver, Ward and Talbot 2008). Kirkham (2010) argues that choice has become a big issue in maternity care but that the service provider controls the menu of ‘choices’: a series of predefined options. With the powerful professional concept of the ‘right choice’, options are limited for many women. She suggests that any autonomous action, arguably some of the late initiation of care seen in this study, is seen as a deviation from the pathway laid down by the ‘experts’. Kirkham and Stapleton (2004) previously argued that what women exhibit is ‘informed compliance’ rather than informed choice, perhaps reflected in women accepting the convention of antenatal care rather than choosing to attend because they valued its contribution to their pregnancy. Many late booking women in the Sheffield study were highly aware of the convention and expectation of early care and most expressed feelings of guilt and remorse. This reflects women feeling the need to be perceived as responsible pregnant women, fearful of making the ‘wrong’ choice and being labelled as bad mothers or problematic for choosing a different path, or declining care (Anderson 2004, Jomeen 2006, 2012).
Choice is a messy and complicated process, subject to many influences. As O’ Cathain (2004) comments, perhaps the most striking difference between maternity care and other settings is the sheer number of decisions that need to be made. As consumers and recipients of care, pregnant women are caught in the middle between a medical model of risk and safety, and a midwifery model of normality (Jomeen 2012). Edwards identifies that choice “unravels rather rapidly into a series of complex processes, rather than a thin, linear, unproblematic ‘shopping list’’ (2004: 4); an interaction of interests, concerns and constraints. Attendance for antenatal care is predominantly women balancing these priorities and choices - in terms of benefits, risks and consequences - as measured by themselves; and maintaining control. This is evident in the thoughtful, rather than passive, process of ‘weighing up and balancing out’ of Downe et al (2009), and Levy’s (1999) ‘maintaining equilibrium’ with its tightrope balancing metaphor. As Novick comments:

“some women may perform something similar to a cost-benefit analysis… may decide that the benefits of receiving prenatal care do not outweigh the expenditure of time and resources required to obtain care. These women, who may sometimes be viewed within the health care system as noncompliant or passive nonusers of care, may in fact be making rational choices” (2009: 233).

Facilitating informed choice itself is complex, with information and education (associated with the concept of health literacy perhaps) seemingly relatively ineffective compared to context and social influences (O’ Cathain 2004). Midwives need the sensitivity to acknowledge these influences and to have a good understanding of the choices women make. They need the skills and knowledge to provide women with real rather than theoretical alternatives to prevalent models of care if women are to attend and engage with care that they perceive has relevance and value; care that they are willing to prioritise (Edwards 2004, Levy 2004). Choice should be “less about presenting a predetermined menu and more about providing opportunities which enhance women’s autonomy potential as they engage with decisions” (Edwards 2004: 23).