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

Appendix 2.3 illustrates the application of these quality criteria for all the included studies. In accordance with the guidance of both of these authors, and other authors of Critical Interpretive Syntheses, I decided that a low threshold of quality was appropriate, particularly amongst studies from the UK, in order to maximise relevance and the conceptual contribution of the evidence to theory generation.
The final synthesis contained 54 studies: 14 qualitative, 19 quantitative, 14 mixed method, and seven systematic review, analysis or synthesis of literature. Five studies which contained both women’s and practitioners’ views (interviewed separately) were included. Thirty nine (83%) of the 47 primary research studies included in the synthesis were from the USA, four from the UK, two from Canada, one from Europe and one from New Zealand. The studies dated from between 1987 and 2014. A chronological list of the included studies, by study type, is presented in table 2.2.3.

T able 2.2.3 Summary of studies included in the synthesis, by type and chronology

	included studies	publication	year	country	study type	Sample size and characteristics
Qualitative
1	Patterson ET, Freese MP, Goldenberg RL. Seeking safe passage: utilizing health care during pregnancy.	IMAGE: Journal of Nursing Scholarship	1990	USA	Qualitative grounded theory study.	27 antenatal and postnatal women, who had accessed care during 1^st/2^nd/3^rd trimester or not at all. Interviewed at prenatal clinics or on postnatal hospital wards, about pregnancy discovery and prenatal care.
2	Merchant V. Maternity services: antenatal care. The needs and experiences of some women living in two deprived areas of Lancaster.	Journal of Advances in Health and Nursing Care	1993	UK	Qualitative focus group study.	18 women from Lancaster, interviewed during pregnancy and postnatally over an 18 month period; also an unspecified number of professionals from health promotion/ education, health visiting, midwifery, nurse management, academics and students.
3	Johnson Jl, Primas PJ and Coe MK. Factors that prevent women of low socioeconomic status from seeking prenatal care.	Journal of the American Academy of Nurse Practitioners	1994	USA	Qualitative Semi-structured interviews.	15 low income postnatal women who had received no prenatal care.
4	Gazmararian JA, Schwartz KS, Amacker LB and Powell CL. Barriers to prenatal care mong Medicaid managed care enrolees: patient and provider perceptions.	HMO Practice	1997	USA	Qualitative Focus group study.	6 focus groups with random selection of 42 enrolled women in 3 groups: recently pregnant, currently pregnant, no children (‘contemplators’). 4 focus groups with 22 providers in professional groups: doctors, nurse practitioners, nurses and medical assistants.
5	Mackey MC and Tiller CM. Adolescents’ description and management of pregnancy and preterm labour.	Journal of Obstetric, Gynecologic and Neonatal Nursing	1998	USA	Qualitative interview study.	13 pregnant adolescents (14-19yrs) admitted to two obstetric antenatal units because of threatened preterm labour, interviewed in hospital and at home.
6	Peacock NR, Kelley MA, Carpenter C, Davis M, Burnett G, Chavez N, Aranda V and members of the Chicago Social Networks project. Pregnancy discovery and acceptance among low-income primiparous women: a multicultural exploration.	Maternal and Child Health Journal	2001	USA	Qualitative focus group study.	Purposive sample of 87 low-income postnatal women (birth in previous 12 months) from 4 cultural groups, in 8 community-based focus groups.
7	Milligan R, Wingrove BK, Richards L, Rodan M, Monroe-Lord L, Jackson V, Hatcher B, Harris C, Henderson C and Johnson AA. Perceptions about prenatal care: views of urban vulnerable groups.	BMC Public Health	2002	USA	Qualitative, focus group study.	169 women and men in 18 focus groups: homeless women, substance-misusing women, male partners of these women, and members of a community with high infant mortality and poverty indices and low incidence of adequate prenatal care; including pregnant and postnatal women.
8	Sword W. Prenatal care among women of low income; a matter of “taking care of self”.	Qualitative Health Research	2003	Canada	Qualitative, grounded theory study.	26 low-income women who were pregnant or had given birth in previous 2 years, from two areas of Ontario, interviewed in community settings.
9	Dartnall L, Ganguly N and Batterham J. Access to Maternity Services Research Report.	Department of Health report	2005	UK	Qualitative study.	14 one-to-one in depth interviews with representatives from intermediary organisations, 28 one-to-one and 9 mini group interviews with pregnant women or those who had given birth in previous 18 months, from target audience.
10	Lutz KF. Abused pregnant women’s interactions with health care providers during the childbearing year.	Journal of Obstetric, Gynecologic and Neonatal Nursing	2005	USA	Qualitative, grounded theory study.	Convenience sample of 12 pregnant women who had disclosed abuse during pregnancy.
11	Daniels P, Noe GF, Mayberry R. Barriers to prenatal care among black women of low socioeconomic status.	American Journal of Health Behavior	2006	USA	Qualitative, focus group study.	32 women who were currently pregnant or had attended particular prenatal clinics in the past 2 years, divided into 5 focus groups of either early, late initiation of prenatal care, or a mixture of both.
12	Callaghan M, Buller AM and Murray SF. Understanding ‘late bookers’ and their social circumstances.	British Journal of Midwifery	2011	UK	Qualitative, semi-structured interviews.	Non-random purposive sample of 20 ‘late booking’ pregnant/recently delivered postnatal women who booked after 12,22 or 28 weeks gestation in South-east London.
13	Roberts SCM and Pies C. Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care.	Maternal and Child Health Journal	2011	USA	Qualitative, interview and focus group study.	Racially/ethnically diverse sample of 38 low-income women pregnant or had given birth in previous 2 years and using drugs and alcohol, in one California county. 20 individual interviews and 2 focus groups.
14	Nepal VP, Banerjee D and Perry M. Prenatal Care Barriers in an Inner-city Neighborhood of Houston, Texas.	Journal of Primary Care & Community Health	2011	USA	Qualitative focus group study.	32 women aged 17-30 years with pregnancy experience in previous 5 years. From an underserved and predominantly African American inner-city neighbourhood in Houston, Texas. 5 focus group discussions around prenatal care experience held in community settings plus a brief survey.
Quantitative
15	Leatherman J, Blackburn D and Davidhizar R. How postpartum women explain their lack of obtaining adequate prenatal care.	Journal of Advanced Nursing	1990	USA	Quantitative: structured interviews.	Convenience sample of 44 newly delivered postnatal women identified as receiving inadequate care, including those with no care until 3^rd trimester.
16	Kinsman SB and Slap GB. Barriers to adolescent prenatal care.	Journal of Adolescent Health	1992	USA	Quantitative: structured interviews.	101 postnatal women aged <17 yrs, interviewed within 48 hours of birth at one urban hospital.
17	Reis J, Mills-Thomas B, Robinson D and Anderson V. An inner-city community’s perspective on infant mortality and prenatal care.	Public Health Nursing	1992	USA	Quantitative study with structured questionnaire	Convenience sample of 380 black adults – 231 women, 149 men – from inner-city Chicago neighbourhood, including 72% parents and 5% pregnant women.
18	Cartwright PS, McLaughlin FJ, Martinez AM, Caul DE, Hogan IG, Reed GW and Swafford MS. Teenager’s perceptions of barriers to prenatal care.	Southern Medical Journal	1993	USA	Quantitative: structured interview study.	184 newly delivered postnatal women aged 17 or younger, interviewed in hospital.
19	Sable MR and Wilkinson DS. Pregnancy intentions, pregnancy attitudes and the use of prenatal care in Missouri.	Maternal and Child Health Journal	1998	USA	Quantitative: subsample from larger study of postnatal women.	2378 women completing either 1) a postal questionnaire sent 3 months postpartum, 2) face-to-face interviews or 3) self-completed questionnaires, both on the postnatal wards of 5 hospitals.
20	Cook CAL, Selig KL, Wedhe BJ and Gohn-Baube EA. Access barriers and the use of prenatal care by low-income, inner-city women.	Social Work	1999	USA	Quantitative: cross-sectional descriptive study.	Convenience sample of 115 low-income newly delivered women on postnatal ward of a large urban hospital.
21	Fuller CA and Gallagher R. perceived benefits and barriers of prenatal care in low income women	Journal of the American Academy of Nurse Practitioners	1999	USA	Quantitative: cross-sectional descriptive study.	Convenience sample of 100 pregnant low-income women, interviewed at the initial prenatal appointment.
22	Mikhail BI and Curry MA. Perceived impediments to prenatal care among low-income women.	Western Journal of Nursing Research	1999	USA	Quantitative: structured interview study.	Convenience sample of 126 African American women who had given birth in preceding 12 months.
23	Braveman P, Marchi K, Egerter S, Pearl M and Neuhaus J. Barriers to timely prenatal care among women with insurance: the importance of pre-pregnancy factors.	Obstetrics and Gynecology	2000	USA	Quantitative: subsample of larger cross-sectional postpartum study.	3071 low-income postnatal English and Spanish speaking women, interviewed during hospital stay.
24	Beckmann CA, Burford T and Witt J. Perceived barriers to prenatal care services.	MCN, the American Journal of Maternal/ Child Nursing	2000	USA	Quantitative study: Descriptive correlational study.	110 pregnant women who sought prenatal care after 20 weeks gestation, at prenatal clinics.
25	Nothnagle M, Marchi K, Egerter S and Braveman P. Risk factors for late or no prenatal care following medicaid expansions in California.	Maternal and Child Health Journal	2000	USA	Quantitative study.	6364 low-income postnatal women interviewed during their hospital stay in 19 large California hospitals.
26	Delvaux T, Buekens P, Godin I, Boutsen M and the study group on barriers and incentives to prenatal care in Europe. Barriers to prenatal care in Europe.	American Journal of Preventative Medicine	2001	Europe	Quantitative: Case control study: structured interviews.	1238 recently delivered postnatal women with inadequate care, compared with 1280 control women, interviewed in hospital or by telephone.
27	Chandler D. Late entry into prenatal care in a rural setting.	Journal of Midwifery and Women’s Health	2002	USA	Quantitative survey study.	176 pregnant women, in 5^th-9^th month of pregnancy, attending for prenatal care at 4 obstetric/ nurse-midwifery practices in a rural county of California.
28	Johnson AA, Nabil El-Khorazaty MN, Hatcher BJ, Wingrove BK, Milligan R, Harris C and Richards L. Determinants of late prenatal care initiation by African American women in Washington DC.	Maternal and Child Health Journal	2003	USA	Quantitative: Structured interviews.	303 pregnant African American women interviewed at their first prenatal care visit, in a range of prenatal care clinics for low-income women.
29	Bloom KC, Bednarzyk MS, Devitt DL, Renault RA, Teaman V and van Loock DM. Barriers to prenatal care for homeless pregnant women	Journal of Obstetric, Gynecologic and Neonatal Nursing	2004	USA	Quantitative: Descriptive survey with written questionnaire	Convenience sample of 41 homeless pregnant women and 6 women who had given birth in previous 6 months whilst homeless, recruited through homeless agencies.
30	Johnson AA, Hatcher BJ, Nabil El-Khorazaty MN, Milligan R, Bhaskar B, Rodan MF, Richards L,Wingrove BK and Laryea HA. Determinants of inadequate prenatal care utilization by African American women.	Journal for Health Care for the Poor and Underserved	2007	USA	Quantitative: Structured interviews with postnatal women.	Convenience sample of 246 urban African American newly delivered postnatal women, in 5 Washington DC hospitals, classified as having adequate or inadequate care (Kotelchuck index).
31	Schempf AH, Strobino DM. Drug use and limited prenatal care: an examination of responsible barriers.	American Journal of Obstetrics and Gynecology	2009	USA	Quantitative retrospective cohort study.	812 low-income recently delivered postnatal women in one hospital.
32	Sunil TS, Spears WD, Hook L, Castillo J and Torres C. Initiation of and barriers to prenatal care use among low-income women in San Antonio, Texas	Maternal and Child Health Journal	2010	USA	Quantitative survey.	444 low-income 3^rd trimester pregnant/postnatal women (birth within previous 6 weeks) interviewed at public health clinics.
33	Heaman MI, Moffatt M, Elliott L, Sword W, Helewa ME, Morris H, Gregory P, Tjaden L & Cook C. Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case control study	BMC Pregnancy and Childbirth	2014	Canada	Quantitative case control study.	Study of newly delivered women in 2 hospitals in Canadian city. Structured questionnaires with postnatal women, comparing those receiving adequate (n = 406) and inadequate antenatal care (n = 202), matched by neighbourhood.
Mixed methods
34	Poland ML, Ager JW and Olsen JM. Barriers to receiving adequate prenatal care.	American Journal of Obstetrics and Gynecology	1987	USA	Mixed methods study: structured interviews and review of medical notes.	Interviews with 111 recently delivered postnatal women who had received varying amounts of prenatal care, in one hospital in Detroit.
35	Chisholm DK. Factors Associated with late booking for antenatal care in Central Manchester.	Public Health	1989	UK	Mixed methods cohort study with structured questionnaire	960 pregnant women in Central Manchester.
36	Lia-Hoagberg B, Rode P, Skovholt CJ, Oberg CN, Berg C, Mullett S and Choi T. Barriers and Motivators to prenatal care among low-income women.	Social Science and Medicine	1990	USA	Mixed methods interview study, with closed and open-ended sections.	211 newly delivered women from areas with high poverty levels interviewed in 5 hospitals.
37	Kalmuss D and Fennelly K. Barriers to prenatal care among low-income women in New York City.	Family Planning perspectives	1990	USA	Mixed methods questionnaire study.	496 postnatal low-income women, interviewed in selected hospitals, including those who received no prenatal care.
38	Sable MR, Stockbauer JW, Schramm WF and Land GH. 1990. Differentiating the barriers to adequate prenatal care in Missouri, 1987-88.	Public Health Reports	1990	USA	Mixed methods case-control interview study.	Interviews with 1484 newly delivered women on postnatal wards of 11 hospitals with higher than average inadequate prenatal care rates.
39	Aved BM, Irwin MM, Cummings LS and Findeisen N. Barriers to prenatal care for low-income women.	Western Journal of Medicine	1993	USA	Mixed methods study: patient interview survey and focus group discussion.	69 recently delivered postnatal women who had received inadequate/no prenatal care, interviewed in 8 Californian hospitals. 7 obstetric doctors from same area.
40	Harvey SM and Faber KS. Obstacles to prenatal care following implementation of a community-based program to reduce financial barriers.	Family Planning Perspectives	1993	USA	Mixed methods study: structured interviews.	Postnatal interviews with newly delivered 236 women receiving inadequate care (including those initiating care in the 3^rd trimester) and 246 women receiving adequate care, interviewed in hospital or at home.
41	Omar MA, Schiffman RF and Bauer P. Recipient and provider perspectives of barriers to rural prenatal care.	Journal of Community Health Nursing	1998	USA	Mixed methods study using descriptive survey and focus groups.	61 pregnant women in 3^rd trimester with at least 3 prenatal visits, recruited from prenatal clinics and childbirth education classes. Completed checklist at clinic or home. 15 providers of prenatal care in rural county. Focus group questions based on checklist given to women.
42	Roberts RO, Yawn BP, Wickes SL, Field CS, Garretson M and Jacobsen SJ. Barriers to prenatal care: factors associated with late initiation of care in a middle-class midwestern community.	The Journal of Family Practice	1998	USA	Mixed methods study with structured questionnaire	813 pregnant women from two major clinics in Minnesota during a 6 month period, at their first prenatal appointment.
43	Teagle SE and Brindis CD. Perceptions of motivators and barriers to public prenatal care among first time and follow-up adolescent patients and their providers.	Maternal and Child Health Journal	1998	USA	Mixed methods interview study.	250 consecutive pregnant adolescents from 5 prenatal clinics in one county of Arkansas, plus a convenience sample of 16 health providers working at the same clinics.
44	York R, Grant C, Tulman L, Rothman RH, Chalk L and Perlman D. The impact of personal problems on accessing prenatal care in low-income urban African American women.	Journal of Perinatology	1999	USA	Mixed methods study: questionnaire and semi-structured interviews	Postnatal data collection from 297 newly delivered African American women of low socioeconomic status, classified into 4 levels of prenatal care, from one hospital.
45	Napravnik S, Royce R, Walter E and Lim W. HIV-1 infected women and prenatal care utilization: barriers and facilitators.	AIDS Patient care and STDs	2000	USA	Mixed methods interview study.	Convenience sample of 3 women who had given birth whilst HIV positive and had received inadequate prenatal care (Kotelchuck index).
46	Houston Department of Health and Human Services. Women of Worth: factors relating to prenatal care among women of Greater Fifth Ward: a qualitative and quantitative project.	HDHHS, 2009, Houston, Texas.	2009	USA	Mixed methods: focus groups and structured questionnaire	5 focus group interviews with 24 pregnant/ postnatal women with a child aged less than 2 years, from one ward of Houston, in community settings.
47	Corbett S, Chelimo C and Okesene-Gafa K, Barriers to early initiation of antenatal care in a multi-ethnic sample in South Auckland, New Zealand.	The New Zealand Medical Journal	2014	New Zealand	Mixed methods study with structured questionnaire, containing some open ended content	826 women (including 137 late booking women) after 37 weeks gestation or less than 6 weeks postnatal, completing a questionnaire about antenatal care at appointments or home.
Literature reviews/analyses/syntheses
48	Perez-Woods RC. Barriers to the use of prenatal care: critical analysis of the literature.	Journal of Perinatology	1990	USA	Critical analysis of literature relating to beginning and remaining in prenatal care.	45 papers published between 1966 and 1987.
49	York R, Grant C, Gibeau A, Beecham J and Kessler J. A review of problems of universal access to prenatal care.	Nursing Clinics of North America	1996	USA	Review of literature on prenatal care utilisation.	32 USA papers reviewed.
50	Lavender T, Downe S, Finnlayson K and Walsh D. Access to antenatal care: a systematic review – Report. Downe S, Finlayson K, Walsh D and Lavender T. ‘Weighing up and balancing out’: a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries.	University of Central Lancashire. British Journal of Obstetrics and Gynaecology	2007 2009	USA, UK and Canada USA, UK and Canada	Structured review of qualitative and quantitative literature on access to antenatal care in developed countries. Synthesis of qualitative studies from developed countries.	7 quantitative papers (outcome and demographics only) from USA, UK, Ireland and France; 8 qualitative papers from USA, UK and Canada. 8 qualitative papers from USA, UK and Canada.
51	Philippi JC. Women’s perceptions of access to prenatal care in the United States: a literature review.	Journal of Midwifery and Women’s Health	2009	USA	Review of US literature on women’s perceptions of access to prenatal care within the United States.	42 papers, including 19 with direct surveys of women.
52	National Collaborating Centre for Women’s and Children’s Health. NICE Clinical Guideline CG110 - Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors.	Royal College of Obstetricians and Gynaecologists, London.	2010	UK/USA/ Europe/ Australia/Canada	Literature reviews as part of National Institute of Health and Clinical excellence (NICE) guideline.	64 papers from UK/USA/ Europe/ Australia/ Canada: Migrant women: 28 papers Substance misusing women: 10 papers Young women: 10 papers Abused women: 16 papers
53	Hollowell J, Oakley L, Vigurs C, Barnett-Page E, Kavanagh J and Oliver S. Increasing early initiation of antenatal care by Black and Minority Ethnic women in the United Kingdom: a systematic review and mixed methods synthesis of women’s views and the literature on intervention effectiveness: Final Report.	National Perinatal Epidemiology Unit, Oxford.	2012	UK	Mixed methods review and thematic analysis.	72 studies of disadvantaged and vulnerable groups of women in the UK, with a subsequent focus on 36 papers relating to BME women for the thematic analysis and 21 papers for the synthesis.
54	Boerleider AW, Wiegers TA, Mannien J, Francke Al and Deville WLJM. Factors affecting the use of prenatal care by non-western women in industrialised western countries: a systematic review	BMC Pregnancy and Childbirth	2013	Europe/ Canada/ Australia	Systematic review of literature on non-western women’s experience in industrialised countries.	Synthesis of 16 articles from Europe, Australia and Canada - 12 qualitative, 3 quantitative and 1 mixed-method.

2.2.4 Data extraction

Dixon-Woods et al (2006a,b) identify that all types of synthesis involve some summary of data and some interpretation, and that formal data extraction procedures such as proformas may be helpful but are not essential, and that their role in the synthesis of qualitative research requires formal evaluation. Like Flemming (2010), following a detailed reading and re-reading of the papers, and identifying recurring themes, I have created a proforma detailing the content of the included studies (appendix 2.4). This consists of:

Author, title, source, year of publication

Country of publication

Aim of study

Participants and setting

Key themes in relation to delayed/no access to antenatal care, using phrases presented by the women and the researchers.