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

Providing woman-centred antenatal care
Recommendations for commissioners of maternity research:

Understanding what works

• Evidence uncertainties remain about effective antenatal care programmes, particularly for socially disadvantaged and vulnerable women in the UK. Further robust evaluation is required (Hollowell et al 2011, NICE 2011).

• Evidence suggests the benefits of continuity models of care (Sandall et al 2013) and the wider health benefits of investing in antenatal care. However, there needs to be greater evaluation of the long term impact of models of care and antenatal interventions; for example broader health status, access to healthcare generally and in subsequent pregnancies, as well as short term morbidity and mortality.
Understanding what women want

• To commission studies of women and their families’ views about antenatal care, in terms of what they want from their care, perceptions of the value and relevance of such care, in terms of meeting both physical and psychological needs. This needs to be across the socio-demographic spectrum and amongst both nulliparous and multiparous women, seeking beyond the broad interpersonal questions about interactions with healthcare professionals assessed in questionnaires such as the NPEU’s National Maternity Survey (Redshaw and Henderson 2015).

• Such ‘conversations’ may involve engagement with community-based organisations working with women and families, also midwives’ perspectives.
Recommendations for commissioners and providers of maternity care:

Refocusing care - providing choice and continuity

• To use research findings to drive the development of high quality, individualised care; care that women are willing to prioritise. Such care could be based around the default concept of pregnancy as wellness and the status of women as ‘active partners’ in their pregnancies; where women are well informed and well supported in their choices. This might include offering minimal patterns of care for low risk, multiparous women, innovations in targeted and shared care, and alternative choices such as group antenatal care.

• Antenatal guidelines also need to acknowledge the full range of potential benefits of attending for antenatal care; recognising the influence of psychological, emotional and social support during pregnancy, alongside physical assessments of wellbeing, and the time required for such holistic care.

• Continuity is at the heart of providing such woman-centred care; flexible care based on women’s needs. There needs to be sustained development and evaluation of such models of care, in particular for the most vulnerable women and families. These could be targeted around geographical areas with poor access and engagement with healthcare, or towards women with socio-demographic, physical or psychological risk factors for poor pregnancy outcomes, or towards all nulliparous women.

• Models of care need to provide midwives with manageable caseloads based around risk and need, providing care which is truly integrated between midwives, GPs, health visitors, family and social support services and 3rd sector organisations. Such models could incorporate the use of lay health workers (Glenton et al 2013).
7.2.3.8 Conclusions

Creating a model of antenatal care which encourages women to book early presents particular challenges, as women are attending for the first time, not returning for subsequent care. Initial attendance is influenced by women’s acceptance of their personal and public pregnancies, which are in turn shaped by their knowledge of pregnancy and antenatal care, but also prior experiences, direct and indirect, and external influences. As some of the women in the Sheffield study demonstrate, accessing care is not simply about knowing that it exists and its purpose, but considerations of its value and priority, its timing and portability. This relates to where care fits into women’s lives, for example the convenience and familiarity of the home setting, the relationship with previous pregnancies and perceptions of screening. Encouraging women to book early is therefore not simply about telling women the risks associated with non-attendance or making attendance a convention: fear and obligation are not good foundations for engagement. Health promotion and education messages about the purpose and benefits of antenatal care need to co-exist with care that women feel belongs to them, that they are encouraged to be actively involved in and that is tailored to their needs and experience. It is this combination of high quality information and advice around conception and early pregnancy, with easily accessible and individualised antenatal care, that is likely to be most effective at reducing late booking.
7.2.4 Financial incentives

The role of financial incentives to improve access to antenatal care deserves brief consideration. A systematic review of the effectiveness of financial incentive interventions for encouraging healthy behaviour change, such as smoking cessation and attendance for screening (excluding antenatal screening), found that they were effective for encouraging healthy behaviour change, both in the short term, and to a lesser extent, in the longer term (Giles et al 2104). The authors argue that financial incentives may be a useful addition to the behavioural change toolkit and should be considered across the spectrum of healthy behaviours, of which antenatal attendance could be considered part. A recently published Scottish RCT has demonstrated the successful application of financial incentives for smoking cessation in pregnancy, with nearly three times as many women in the incentives group quitting (Tappin et al 2015).
NOurishing Start for Health (NOSH) is a National Prevention Research Initiative funded project exploring the potential of offering women financial support to breastfeed, in order to improve breastfeeding initiation and duration in areas with low breastfeeding rates. The project authors acknowledge that the impact of financial incentives for women on breastfeeding is a relatively unexplored area, but cite effective schemes in North America (University of Sheffield 2014a). A pilot study in 2013-14, designed by researchers and local healthcare professionals to complement existing breastfeeding support, tested the feasibility of the incentive scheme (University of Sheffield 2014b). Satisfaction with the scheme was high among both mothers and health-care staff participating in the scheme, which saw a modest increase in women breastfeeding at 8 weeks postnatal. A large scale randomised controlled trial testing the effectiveness of the scheme is now planned (Relton et al 2014).
Regulation limits the type and value of incentives that can be offered to women receiving Medicaid in the USA. However, a study in Las Vegas by Rosenthal et al (2009) found that an incentive of $100 given to 1436 women of low socioeconomic status, to initiate antenatal care in the first trimester and maintain regular visits, led to an increase in the uptake of early care from 14% to 76%. The incentive also contributed to a reduction in neonatal admissions and spending on paediatric health in baby’s first year, but had no influence on birth weight. Smaller incentives have shown less success in influencing women’s behaviour however (Laken and Ager 1995).
Several European countries, including France, Finland, Hungary and Luxembourg, have offered women financial incentives for the early initiation of antenatal care (McQuide, Delvaux and Buekens 1998). As mentioned previously, a country comparable to the UK in terms of its universal accessibility and encouragement of antenatal care, Finland’s incentive is in the form of the Maternity Package. This parcel of newborn essentials, packaged in a box which doubles as a cot, is given to all pregnant women who attend for antenatal care before five months gestation. Part of Finnish culture, the package has been in existence for more than 75 years and its provision has accompanied a dramatic fall in Finland’s infant mortality to one of the lowest levels in the world (Lee 2013). The difference between this and pregnancy incentives currently available in the UK is its universal availability, part of the engraining of early access to antenatal care into the culture, at a time when universal benefits such as Child Benefit and the Health in Pregnancy Grant (previously given to all pregnant women) in the UK have been removed or reduced.
It is likely that such incentives would have an influence on women’s short term behaviours and perceptions of the priority of attending for antenatal care, but perhaps not on their perceptions of its relevance or value. However, in combination with the provision of high quality, individualised care, it could have longer term influences, for example on subsequent pregnancies. The universality (like Finland) of an incentive would ensure maximum effect. However, targeting towards the groups identified in chapter one as most likely to book late and experience adverse outcomes may be most cost effective. As with the NOSH or Scottish smoking cessation studies, perhaps attaching financial incentives to key targets, such as the minimum antenatal care interventions identified by Beeckman et al (2012) in section 7.2.3.4, may be worthy of further exploration.

7.3 Future research
As chapter one has identified, and this study has confirmed, late booking women are a diverse group. Such a diversity of backgrounds is reflected in the range of experience conveyed by the women, and the interacting influences on women’s acceptance of their personal and public pregnancies presented in chapters five and six. This diversity needs to be reflected both in solutions but also in future research, requiring the ‘layered approach’ to the complexities of the topic suggested by Lavender et al‘s (2007) systematic review of access to antenatal care. As Feijen-de Jong et al’s (2011) systematic review of late and/or inadequate use of antenatal care also identifies, further research, both quantitative and qualitative, is needed to ‘disentangle’ the mechanisms associated with poor antenatal care usage (and, by implication, with poor pregnancy outcomes). Part of this disentangling requires the examination of influences on both early antenatal booking and ongoing access to care throughout pregnancy. Both contribute to maternal and neonatal health and wellbeing.
Though not exclusively, social and economic disadvantage were common themes throughout the group of women interviewed in the Sheffield study. It is likely that, given the poorer outcomes associated with such disadvantage discussed in chapter one, targeting such women by ‘pursuing work with known disadvantaged groups’ (Lavender et al 2007: 6) may be the most effective strategy for future research around late booking, and likely to have most impact. The NICE guideline for pregnant women with complex social factors (NCCWCH 2010) has identified three key research priorities relating to antenatal access, and pertinent to late booking. These are explored below, in relation to the findings from the study.
1. Training for healthcare staff

Evidence presented in the NICE guideline suggests that women facing complex social problems are deterred from attending antenatal appointments, including booking appointments, because of the perceived negative attitude of healthcare staff. Though a common theme in the literature synthesis this was not evident amongst the women in the Sheffield study. Lindquist et al’s (2014) recent analysis of UK maternity survey data found pregnant women living in the poorest areas not only less likely to book early but also significantly less likely to report that they were ‘able to see a health professional as early as desired’ (p5). Though somewhat ambiguous, this suggests external barriers to early care that were only briefly identified in this part of the Sheffield study, related to difficulties with appointments and the negative perceptions of healthcare staff, as mentioned by NICE. Staff attitudes and behaviours are integral to providing antenatal care that women perceive as relevant and valuable. The subject is being explored in the other part of the study, looking at health and social care practitioner perceptions of late booking, which may be influential in developing further research.
2. The effect of early booking on maternal and neonatal outcomes

As chapter one has discussed, pregnant women experiencing social and economic disadvantage are known to book later, on average, than other women, and to experience poorer maternal and neonatal outcomes, but the evidence linking the two factors is limited. As NICE comment about facilitating early booking:

“It seems likely that facilitating early booking for these women is even more important than for the general population of pregnant women. There is, however, no current evidence that putting measures in place to allow this to happen improves pregnancy outcomes for women with complex social factors and their babies.” (NCCWCH 2010: 11).

Further research is therefore needed to evaluate the impact of improving early access to antenatal care, for vulnerable groups in particular, and may include both quantitative and qualitative components.
3. Different models of service provision and interventions

Evaluation of the effectiveness of interventions to address late booking and poor antenatal attendance is also required. The examination of different models of antenatal care reflects the need for further research and ‘robust evaluation’ around tailored antenatal care programmes, to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women, as identified by Hollowell et al (2011) in their systematic review. NICE identify that, for example in relation to substance misusing women,

“It seems likely that making it easier for these women to attend antenatal appointments and providing tailored care will improve outcomes, but at present it is not clear how this should be done” (NCCWCH 2010: 13).

Further research is needed to develop and examine the effectiveness of targeted care and antenatal (and/or postnatal) interventions, to discover which are most effective at encouraging early and regular attendance. Such interventions could apply to both initial access to antenatal care, as discussed earlier in the chapter, and subsequent care, and could include financial incentives. NICE suggests that it is unclear what models of service provision exist in the UK and how these models compare, both with each other and with standard care, in terms of outcomes. It needs to be determined what data should be collected, and how, as well as how it is shared, in order to assess the quality of and allow comparisons between different models of care.
Comparisons of maternal and neonatal outcomes between women, for example those receiving standard or targeted care, could be made using quantitative techniques. However, it is also essential to ensure that women’s voices don’t get lost along the way. Further qualitative research is needed to examine women’s experiences of different models of service provision or antenatal interventions, especially considering their potential influence on women’s current and future decision making around antenatal care. The University of East London’s Institute for Health and Human Development is currently undertaking National Institute for Health Research funded research evaluating a complex intervention package to improve equity of access amongst low income and particularly BME women in East London, using both qualitative and quantitative methods (Hatherall 2014, personal communication). The intervention aims to address the multiple barriers identified by previous research regarding perceptions of the purpose, value and nature of antenatal care, and factors within maternity service organisation, which may delay the early initiation of antenatal care in diverse communities (Hatherall 2013).
The characteristics and perceptions of late booking women

However, there are other aspects to late booking which merit further exploration. The themes identified in the Sheffield study challenge over–simplistic perspectives concerning the reasons why women present late, such as socio-demographic adversity, concealed pregnancy and denial, and the view of late bookers as passive and ignorant. The study participants included many ‘low risk’ women, who may be forgotten in a story of late booking which focuses wholly on vulnerability and deprivation. As mentioned previously, potentially all late booking women will be disadvantaged by the reduced care they receive antenatally. It may be that these low risk women represent a larger group than previously identified. If stereotypical categorisation is to be challenged this requires further study, in a larger scale cohort study, comparing late and early booking women, in terms of outcomes, but also maternal characteristics and perceptions of care. The unique and distinct differences between primigravid and multigravid women in the study suggest that both research and interventions tailored to each are required (Nichols, Roux and Harris 2007). The influence of women’s experience in previous pregnancies was underexplored in this study and may be highly influential on the choices women make antenatally.
Women’s views of the value and convention of antenatal care are significant, and further exploration of the influences on women’s perceptions of care necessary. Women’s reflections on their pregnancies and their own late booking, perceiving it in both positive and negative ways, have emerged as an additional area of interest from the data. The study suggests that the likelihood of repeated late booking is associated with women’s direct and indirect experiences of late booking, and that there are social and cultural norms in relation to pregnancy and antenatal access, and differing views of risk amongst groups of women. This deserves further examination, in particular women’s perceptions of time and risk in relation to pregnancy, and their prioritising of antenatal care. Women’s opinions on solutions to late booking will also form an important part of any future research, as this important subject was omitted from the Sheffield study.
This study has also identified aspects of reproductive knowledge and beliefs relating to contraception, and particularly contraceptive failure and the likelihood of conceiving, which need further exploration. Hindering and facilitating factors relating to lay and professional involvement have also been identified. These require further investigation and analysis, in terms of what makes women present for pregnancy care both initially and regularly, and the relationship between pregnant women, those around them and the health and social care professionals who care for them. The study suggests that it is not only women’s views but those of peers, families and professionals, that are influential and worthy of further examination. Multiple methodologies are required to contribute to a greater understanding of the multi-faceted nature of late booking.
7.4 Conclusions
Antenatal care in the UK is a well-established programme of health screening, health education and support, and offers many benefits to pregnant women and their families. Sandall (2014), in her RCM report into continuity in midwifery care, identifies that both the model of care and the place of birth are important influences on a range of outcomes for mothers and babies. Heaman et al‘s (2014) Canadian study agrees, suggesting that

“prenatal care can contribute to a decrease in maternal and perinatal morbidity and mortality by screening for potential risks, treating medical conditions, and helping women address behavioural factors that contribute to poor outcomes” (p817)

Such a description provides compelling reasons for promoting timely and regular antenatal care. However, it ignores the other significant aspect of care that, at its best, antenatal care offers psychological, social and emotional support for women during pregnancy and beyond, with direct and indirect benefits which are harder to quantify. Arguably, this aspect of care is as valued by women as the physical checks that confirm their pregnancies are progressing normally. It is a fundamental part of individualised care which has relevance for women, their friends and families; care which women are willing to prioritise.
There is an underlying assumption that pregnant women will recognise the benefits and attend for early care, however a small but significant number of women do not attend early, many with risk factors for poor pregnancy outcomes. The Sheffield study has contributed to a greater understanding of this late booking, and to the debate around strategies to improve early access to antenatal care and outcomes for pregnant women and their babies. Evidence from this study and others, both qualitative and quantitative, suggests that antenatal care initiation behaviour is extremely complex, and is influenced by the interaction of cognitive, emotional, social and environmental factors. A woman’s mindset and particularly her acceptance of her personal pregnancy, the social consequences of the pregnancy and the need for antenatal care (her public pregnancy), are reflected in her relationship with antenatal services. This study shows that there are common themes, such as unintended pregnancy, and prevalent groups who book late. However, it also highlights a different perspective on late booking, one rarely seen in previous studies. This demonstrates that women across the social spectrum exhibit thoughtful and purposeful engagement with their pregnancies, outside of mainstream maternity care, also comparable attitudes and priorities relating to the relevance and value of such care. Consequently, stereotypical definitions of ‘late bookers’ are unhelpful. Solutions to late booking and poor antenatal engagement must attempt to balance such commonalities with the evident complexity and diversity of women’s experiences. They must also acknowledge that acceptance works on both sides.
Any approach to improving maternal health equity, in terms of access and outcomes, requires co-ordinated action. Reducing late booking necessitates reaching out to places where women access all forms of education, health and social care, using a range of methods and media, but also reaching out to women personally. The three recommendations from this study acknowledge this. Ultimately women, their friends and families, need to be better informed about all aspects of reproductive health. Antenatal care needs to be readily accessible but also relevant to women’s lives and needs. To do this, such care needs to be flexible and focused on the individual, with more emphasis on a woman’s choice, and with psychological support having parity with physical assessment. It is this combination which will promote the provision of timely, but also effective, antenatal care for all women.