Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill
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I have used qualitative data analysis methods to extract and summarise the key themes from each study, creating titles based on the themes and quotes presented in the results and discussion sections of the included studies (Pope, Mays and Popay 2007, Talseth and Gilje 2011). 2.2.5 Conducting the interpretive synthesis The interpretive synthesis is concerned with generating concepts with maximum explanatory value, incorporating themes identified in primary studies into a more subsuming theoretical structure and potentially identifying concepts not found in the original studies, to help explain phenomena (Dixon-Woods et al 2005). The process and product are conceptual, aiming to move beyond the summarisation and aggregation of data (though this is part of the process of interpretation and synthesis) to produce a more insightful and generalisable way of understanding a phenomenon. The process of synthesis therefore follows the following (simplified) sequence: subthemes 1st/2nd/3rd order argument/ core concept (theory/explanation) A ‘lines of argument’ (LOA) synthesis builds a general interpretation grounded in the findings of separate studies, with the most powerful themes recurring in the data identified by constant comparisons between accounts. Dixon-Woods et al (2005) suggest that a LOA synthesis enables a higher order analysis to be achieved, and is more appropriate for a large body of evidence, rather than the ‘reciprocal translational analysis’ (RTA, the extent to which concepts are translatable into each other) suggested by Noblitt and Hare (1988), which can dampen rather than promote the interpretive process. The synthesis method draws many influences from primary qualitative research: themes from original research become data, with the findings coded into themes and subthemes, which are then refined into constructs. These constructs can be generated initially with a low level of theoretical abstraction, for example through a taxonomy, then a more interpretive, sophisticated analysis to create concepts and theories (Dixon-Woods et al 2006a, Flemming 2010). The idea of first, second and third/synthetic order constructs reflect the interplay of emic and etic perspectives fundamental to qualitative research (Holloway and Wheeler 2010). They can be summarised as follows:
Talseth and Gilje (2011) talk about the spiral and unfolding/enfolding manner of this process: relating, translating, interweaving and synthesising of the subthemes and themes into constructs and concepts, through a dialectical and reflective process: “the text began to illuminate an understanding…” (p1665). This develops into a synthesising argument, which integrates themes from across the studies into a coherent theoretical framework: a network of constructs, combining both synthetic constructs developing through the process and the second order constructs already reported in the research and exploring the relationships between them (Dixon-Woods et al 2005,2006a, Heaton, Corden and Parker 2012). The aim of the synthesis process is to provide ‘critical’ and ‘authorial’ voices: examining the context in which knowledge is produced, acknowledging reflexivity, questioning assumptions and lines of argument (Barnett-Page and Thomas 2009). The latter requires use of an element of Noblitt and Hare’s refutational synthesis to identify, characterise and explain contradictions, as part of the generation of the synthesising argument. Authors of CIS accept that because of the creative, interpretive processes involved, full transparency and reproducibility are not possible, but aim to generate a plausible, well justified, critically informed and meaningful theory (Dixon-Woods et al 2006a, Annandale et al 2007). To develop the synthesis I have created a taxonomy of first, second and ‘synthetic’ constructs from the proforma detailing the content of the included studies (appendix 2.4). These included the original views and beliefs presented by the women, in their own words (1st order), themes identified by the researchers (2nd order) and 17 synthetic constructs (3rd order) developed through an in-depth comparison of the studies, relating to structural and practical, personal and motivational barriers to early antenatal care. I have focused throughout on themes relating to the initiation of antenatal care rather than continuing care, though this is not explicit in all studies. I subsequently developed a line of argument synthesis to ‘thread’ this network of constructs together, exploring the relationships between the constructs, the context of the themes and considering any contradictory or overlapping elements. This created the synthesising argument or core concept, an overarching interpretation of the findings (Heaton, Corden and Parker 2012). 2.3 Findings The summary of the constructs relating to late booking from the evidence is presented in table 2.3.1. This represents the views of the women (1st order), the interpretations of the authors of the 54 selected studies (2nd order), the integration of these into 17 ‘synthetic’ constructs (3rd order) and the resulting line of argument synthesis. Table 2.3.2 identifies the numerical occurrence of these constructs in the literature. The synthesis identifies acceptance of personal and public pregnancies as the core concept relating to late booking for antenatal care, which is explored in two parts in the following section. First there is acceptance of the ‘personal’ pregnancy, which considers the influence of mindset in the recognition and acceptance of pregnancy. This acceptance is influenced by knowledge of pregnancy symptoms, pregnancy planning and desire, psychological factors associated with the recognition of pregnancy and the support of a woman’s immediate social network. Second, acceptance of the ‘public’ pregnancy considers women’s assessment of the social consequences of pregnancy, and the relevance and priority of antenatal care. This acceptance is influenced, amongst other things, by past experience, both positive and negative, beliefs about pregnancy and a consideration of life priorities. These two strands of acceptance are considered in relation to the selected studies, with those studies where the themes were represented most strongly referenced in the text. Brief comments are made, where relevant, of practitioner views in relation to the themes, from the five included studies of both perspectives. Table 2.3.1: Constructs and concepts relating to late booking from the literature: women’s perceptions and beliefs
Table 2.3.2: Occurrence of synthetic constructs relating to late booking in the literature: women’s perceptions and beliefs
2.3.1 Acceptance of the personal pregnancy: the pregnancy mindset 2.3.1.1 “I didn’t know I was pregnant” - knowledge of/recognition of pregnancy Poor knowledge and late recognition of the signs and symptoms of pregnancy contributed to delayed initiation of antenatal care in 25 studies, particularly those with a focus on younger women (Kinsman and Slap 1992, Cartwright et al 1993, Mackey and Tiller 1998), though one review identified this as young women not wanting to recognise the pregnancy (NCCWCH 2010). For some women this late recognition was due to the masking of pregnancy symptoms by irregular periods or psychological conditions such as stress and anxiety (Lia-Hoagberg et al 1990). For others it was because the expectation and perceived risk of becoming pregnant was low (Peacock et al 2001, Nepal, Bannerjee and Perry 2011). Such women were not in a pregnancy mindset. One author identified the inability of women to place all their symptoms into a ‘meaningful whole’ and recognise the pregnancy, as a result of this lack of mindset (Peacock et al 2001). Other authors identified women’s poor knowledge of the symptoms of pregnancy, in some cases as a result of a lack of experience of pregnancy amongst their peers (Kinsman and Slap 1992, Delvaux et al 2001, Daniels, Noe and Mayberry 2006). This was reiterated by one group of healthcare practitioners as a lack of education and knowledge about pregnancy (Gazmararian et al 1997). Early pregnancy awareness was not always associated with early initiation however (Braveman et al 2000). Further delay in confirming the pregnancy followed a ‘letting it sink in’ phase of pregnancy; an in-between phase, sometimes lengthy, where women considered their options before making their pregnancy official by attending for care: being ‘a little bit pregnant’ (Patterson, Freese and Goldenberg 1990, Peacock et al 2001). 2.3.1.2 “I can’t do nothing but stick with it” - pregnancy intention, desire Thirty three studies linked the late recognition of pregnancy and initiation of care to lack of pregnancy planning, with many identifying unexpected or mistimed pregnancies (Chisholm 1989, Braveman et al 2000, Daniels, Noe and Mayberry 2006, Heaman et al 2014). This resulted in feelings of ambivalence and negative attitudes, with some women struggling to accept the pregnancy and others going so far as to state that the pregnancy was unwanted (Poland, Ager and Olsen 1987, Kinsman and Slap 1992, Mackey and Tiller 1998, Napravnik et al 2000). In some cases women hoped to miscarry, in others women considered having a termination but were unable to go through with it, for time, financial or personal reasons (Sable et al 1990, Johnson et al 2003, 2007, York et al 1999). 2.3.1.3 “Not thinking straight” - emotional and psychological factors A wide range of negative emotional and psychological issues were presented in the studies. This was the most common theme, identified in 33 studies as influencing the acceptance of pregnancy and access to care. Many women experienced depression, anxiety and stress, as a result of an unplanned or unexpected pregnancy or because of difficult life circumstances, often linked to poverty, social isolation and lack of power (Aved et al 1993, Cook et al 1999, Chandler 2002, Heaman et al 2014). Women experienced a range of emotions from ambivalence and indifference towards the pregnancy, to guilt and regret, embarrassment and the stigma of an unplanned pregnancy (Downe et al 2009, Houston Department of Health and Human Services (HDHHS) 2009, NCCWCH 2010). Many women described feeling angry and shocked, and unprepared for pregnancy (Mackey and Tiller 1998). Fear was widely expressed, particularly fear of the ‘consequences’ of pregnancy, whether this was the response of others, the necessary disclosure of risk taking behaviours or the need for official intervention in their lives (Lavender et al 2007). Fear of discovery of substance misuse in particular was highlighted by two groups of practitioners (Aved et al 1993, Gazmararian et al 1997), depression and the consequences of teenage pregnancy by another (Teagle and Brindis 1998). In some cases women acknowledged that these emotions led to the denial and resulting concealment of their pregnancies (Sable and Wilkinson 1998, Dartnall et al 2005, Daniels, Noe and Mayberry 2006). 2.3.1.4 “Didn’t want to be bothered with me” - social support for pregnancy Eighteen studies identified the pivotal role of social support in the recognition and acceptance of pregnancy, whether from a woman’s partner, family or social network (Poland, Ager and Olsen 1987, Johnson et al 1994, Peacock et al 2001, HDHHS 2009). As previously mentioned, the fear of a negative reaction to the pregnancy from the father of the baby, family members or others close to them was highly influential (Milligan et al 2002). In some cases this resulted in women not wanting to accept nor share their pregnancies (Daniels, Noe and Mayberry 2006). One author discusses the notion of ‘temporarily limited’ support from a woman’s social network, as a result of lack of approval of a pregnancy (HDHHS 2009), that is available before pregnancy and postnatally, but not at the critical point of pregnancy acceptance. 2.3.2 Acceptance of the public pregnancy: social consequences, antenatal care relevance and priority 2.3.2.1 “Nothing in it for me” – the necessity of antenatal care The consideration of priorities and the weighing up of the benefits and risks of attending for antenatal care by pregnant women were documented in many studies. They identified that some women did not value care, viewing it as unimportant or unnecessary for a number of reasons, which impacted on their motivation to attend (Poland, Ager and Olsen 1987, Kinsman and Slap 1992, Harvey and Faber 1993). Women whose perception of prenatal care was that it was ‘less than very important’ were more likely to initiate care late, if at all (Roberts et al 1998). Some women explained that friends and family supported them, and therefore formal care was less important (Johnson et al 2003,2007, Heaman et al 2014). For other women it was the need to guard their private lives (and personal pregnancies), linked to the consequences of disclosure, that led them to conclude that the risks of attending outweighed the benefits (Lutz 2005). Women not valuing early care was identified by several practitioners as a significant influence on the initiation of care (Aved et al 1993, Gazmararian et al 1997, Omar, Schiffman and Bauer 1998). 2.3.2.2 “Knew what should be done” - previous experience Negative perceptions of antenatal care were often presented by women with previous pregnancy experience. Eleven studies identified women using their previous positive pregnancy experience, both in terms of uncomplicated pregnancies and successful births, to assess their wellbeing and pregnancy priorities (Poland, Ager and Olsen 1987, Leatherman, Blackburn and Davidhizar 1990, Delvaux et al 2001, Daniels, Noe and Mayberry 2006). Some expressed a cynicism towards medical involvement in their pregnancies, stating that doctors were not needed for a healthy pregnancy or that they could not prevent some pregnancy problems (Schempf and Strobino 2009). 2.3.2.3 “I feel fine” - feeling well Pregnancy was viewed by some women as a natural state rather than a condition requiring medical involvement. If the women felt well and had no medical problems then they saw no reason to attend, particularly during early pregnancy (Aved et al 1993, Philippi 2009). Women made contingency plans to access care in an emergency, but did not value preventative or routine antenatal care (Lia-Hoagberg et al 1990, Patterson, Freese and Goldenberg 1990), a point noted by practitioners in one study (Gazmararian et al 1997). This was particularly the case for multiparous women, especially those who were required to pay for care. 2.3.2.4 “Not up to going for care” - psychological and physical factors In addition to psychological wellbeing, which was a significant influence on women’s initial acceptance of pregnancy, a small number of studies identified physical factors such as feeling unwell and fatigue as influencing women’s ability to attend for care. These symptoms were typical of those related to normal pregnancy, but were also the result of, and influential on, continuing stress, anxiety and depression related to difficult life circumstances and, as previously discussed, an unplanned or unwanted pregnancy (Harvey and Faber 1993, Johnson et al 1994, Cook et al 1999). 2.3.2.5 “I can do this on my own” - self-care, self-reliance Seven studies identified women taking responsibility for their care (‘taking care of self’) as they perceived this to be the best choice for their circumstances (Poland, Ager and Olsen 1987, Sword 2003, Heaman et al 2014). This was described by one author as women taking an active role in their care, enough to promote ‘safe passage’ of their pregnancy, rather than simply a passive avoidance of care (Patterson, Freese and Goldenberg 1990). For some this was a temporary measure, part of being ‘a little bit pregnant’, prior to accessing formal, public care (Peacock et al 2001). For others it was a way of achieving at least some control over their pregnancies, when they felt they had little control otherwise (Merchant 1993, Sword 2003). 2.3.2.6 “Out of my hands” - fate, acceptance Three studies focusing on women from BME communities highlighted cultural and religious influences in relation to women seeking antenatal care, particularly the role of fatalism and an acceptance of pregnancy. As such women were less interested in the screening offered in early pregnancy so were more likely to delay initiation of care (Dartnall et al 2005, Hollowell et al 2012, Boerleider et al 2013). Heaman et al’s (2014) study with a large number of indigenous Canadian women also suggested a reliance on self-care was part of this acceptance of pregnancy, as a normal state of health. 2.3.2.7 “Not very important to those close” - social support for antenatal care Alongside the large number of studies identifying the pivotal role of social support in the acceptance of pregnancy, ten studies identified the influence of a woman’s social network in accessing antenatal care. Women were highly influenced by the knowledge, beliefs and attitudes relating to pregnancy and healthcare access (both positive and negative) of those around them; the cultural and social norms of their families and communities. Others lacked the social support and advice needed to access care or relied on others to accompany them (Daniels, Noe and Mayberry 2006, Hollowell et al 2012). Both of these experiences had the potential to influence women’s knowledge of antenatal care and whether it was valued and prioritised (Leatherman, Blackburn and Davidhizar 1990, Perez-Woods 1990, Mikhail and Curry 1999, Nothnagle et al 2000). 2.3.2.8 “Need time, energy to deal with other problems” - other priorities in life Twenty three studies highlight the influence of other priorities in a pregnant woman’s life on her attendance for antenatal care. ‘Overwhelming life situations’ (York et al 1996) were identified by women and practitioners: personal problems and those of family and their social network, responsibilities that occupied their time, and other concerns in their lives which were a more important focus than healthcare (Gazmararian et al 1997, Dartnall et al 2005, HDHHS 2009, Heaman et al 2014). These, again, often related to complex, challenging and/or chaotic life circumstances as a result of poverty, and frequently lifestyle or health behaviour issues such as drug use (York et al 1999, Napravnik et al 2000, Milligan et al 2002, Callaghan et al 2011). In the most extreme situations immediate survival concerns inevitably took precedent (Lavender et al 2007), however for women from all backgrounds attendance reflected a consideration of life priorities. 2.3.2.9 “No means” - practical/site related/system factors Practical and convenience issues were identified by the majority of studies (38), particularly in relation to transport, distance, childcare and scheduling of appointments, including three studies of practitioners’ views (Gazmararian et al 1997, Omar, Schiffman and Bauer 1998, Teagle and Brindis 1998). At first sight some of these appear to be unrelated to the initiation of care, however they were discussed in studies whose focus was late booking, often by multiparous women, as influential (Omar, Schiffman and Bauer 1998, Beckman, Burford and Witt 2000, Sunil et al 2010). Moving during pregnancy was also identified as a practical barrier to care (Chisholm 1989, Callaghan et al 2011, Corbett, Chelimo and Okesene-Gafa 2014). However practical considerations were only part of women’s consideration of convenience and priority. In one UK study poor women living close to the maternity hospital were more likely to book late for antenatal care than more affluent women living further away (Merchant 1993), in another administrative failures leading to delay went unchallenged (Callaghan et al 2011). The issues of practicality and convenience again reflected women’s assessment of their priorities and their commitment to receiving antenatal care. 2.3.2.10 “The cost of getting care is too high” - financial issues, economic hardship In some US studies, particularly quantitative studies, the inability to afford antenatal care and insurance problems were presented as barriers to initial access (Philippi 2009). However the cost of attending for antenatal care was frequently discussed by women, including those eligible for free care, in the context of the increased economic burden of pregnancy rather than the cost of the healthcare per se. For example the cost of attending for care in terms of transport costs and time off work reflected another part of women’s assessment of priority (Reis et al 1992, Beckman, Burford and Witt 2000, Lavender et al 2007). This economic burden was also frequently linked to unplanned pregnancy and lack of familial support (HDHHS 2009). 2.3.2.11 “I already knew I was pregnant” - knowledge of antenatal care, the 'system' Nineteen studies illustrated a poor knowledge and lack of understanding amongst some women about the content and value of early antenatal care, maternity care in general and access to it (Leatherman, Blackburn and Davidhizar 1990, Johnson et al 1994, Mikhail and Curry 1999). One group of practitioners shared this view (Gazmararian et al 1997). Some authors suggested this was a result of poor literacy and comprehension, due in some cases to language and communication barriers, others that it was the result of poor advice from others or social isolation (Dartnall et al 2005, HDHHS 2009, NCCWCH 2010). Without this knowledge and understanding women were unable to accept the need to attend for antenatal care and to prioritise it in their lives. 2.3.2.12 “Like you’re a piece of meat” - previous healthcare experience, dislike of care Twenty six studies identified women’s poor experience with health services generally and negative antenatal care experiences as influential (York et al 1999, Daniels, Noe and Mayberry 2006, Callaghan et al 2011), though only one group of practitioners recognised this (Teagle and Brindis 1998). In the context of late booking these were expressed as direct experiences in previous pregnancies and indirect experiences from friends and family. Some women perceived a lack of relevance and poor organisation of care, for example with scheduling problems, communication difficulties and lengthy, poor quality appointments (Merchant 1993, Sword 2003). Others had negative attitudes towards healthcare practitioners, having experienced cultural ignorance and insensitivity, and articulated a lack of trust and confidence in them (Milligan et al 2002, Schempf and Strobino 2009, NCCWCH 2010). Women identified a lack of power and control in their experiences, which had a negative influence on their perceptions of the value and priority of care (Teagle and Brindis 1998, Hollowell et al 2012). For some this negative perception extended to a fear of specific procedures or examinations which led to women avoiding antenatal care. 2.3.2.13 “Cultural and religious differences” - cultural factors Eight studies of BME women identified cultural factors as influencing their acceptance of antenatal care (Delvaux et al 2001, Dartnall et al 2005, NCCWCH 2010, Boerleider et al 2013). These were expressed in relation to direct healthcare experiences, for example the interaction with male healthcare staff, and the cultural norms relating to pregnancy, which were in conflict with the idea of attending for early care. The latter included consideration of pregnancy as private rather than a public experience to be shared with others, preferring care and support from within their own community, and differing experiences of healthcare in their country of origin (Hollowell et al 2012). 2.3.3 Discussion Despite the huge diversity of women, in socio-demographic terms, and settings for the included studies, a simple argument has developed from the synthesis. For women to initiate antenatal care they must first recognise, then accept, their pregnancies, then accept the relevance and priority of antenatal care. This suggests the existence of two pregnancies: the intimate, ‘personal’ pregnancy of the woman (and possibly her immediate social network) and the ‘public’ pregnancy with its accepted norm of antenatal care attendance and its ‘social consequences’ (Peacock et al 2001, Daniels, Noe and Mayberry 2006, Lavender et al 2007). Late booking may result from the non-acceptance of either or both of these. In terms of pregnancy recognition, the view of practitioners was one of primarily young, poorly educated women who lacked the knowledge and experience of pregnancy needed to identify that they were pregnant. This was borne out in a number of studies, particularly those with quantitative and demographic elements. However a more complex picture of pregnancy non-acceptance emerged overall, linked to lack of pregnancy planning and expectation and the influence of negative emotional and psychological factors, a result of these often unplanned and sometimes undesired pregnancies, and frequently combined with difficult life circumstances. The vigilance and support of a woman’s social network for the pregnancy, and the timing of this support, was also highly influential on a woman’s acceptance of her pregnancy. The influence of a positive pregnancy ‘mindset’ is suggested, both for the woman and those around her, in terms of recognition of signs and symptoms and acceptance of the personal pregnancy, the first part of a woman’s pregnancy journey. Where this mindset is absent, ambivalence and fear of the consequences of pregnancy mean that delayed acceptance of pregnancy is more likely. Mindset influences women’s consideration of time and the choices available to them, when accepting their pregnancies and traversing the boundary between the personal and public pregnancy, with the result being further delay in accessing antenatal care. Once women have accepted their private, personal pregnancies there is a consideration of the public pregnancy and its social consequences; part of the creation of a ‘social pregnancy identity’ (Campbell et al 1995). Downe et al (2009) identify women’s consideration of their priorities, and a weighing up of the benefits and risks of attending for antenatal care, as a factor in ongoing care, rather than initiation (“weighing up and balancing out”). But the studies suggest it is also an important consideration for women at the beginning of their pregnancy journeys, particularly the majority of women studied who had complex and challenging life circumstances. Practitioners expressed many of the same perceptions of late booking as the women. However, unsurprisingly perhaps, whilst many women didn’t perceive barriers to care or gave practical reasons for late or non-attendance, this was expressed by practitioners in labelling, negative terms. Women were seen as non-compliant, clinic ‘defaulters’, lacking the knowledge and understanding of the purpose and value of early care, which prevented them from prioritising care (Aved et al 1993, Merchant 1993, Gazmararian et al 1997). The women’s views suggested a different perspective. Some multiparous women made judgements about the relevance and priority of antenatal care in the context of their previous positive pregnancy experience and physical wellbeing, linked to views of pregnancy as a state of ‘wellness’ as opposed to a medical condition. Religious or cultural views of pregnancy were also influential for some BME women, in terms of the need for care. Fear of the consequences of a public pregnancy and the interventions of others in this also influenced a woman’s perceptions of control and whether she prioritised care. A natural extension of all these views was reflected in ‘self-care’: women taking control of their care, sometimes temporarily, as part of an ongoing consideration of priorities. As with acceptance of the pregnancy, women’s psychological and physical wellbeing influence their judgements in relation to the priority of antenatal care, as well as their physical ability to attend. A woman’s social network and the social and cultural norms of its members can also be highly influential on her perceptions of the relevance and priority of antenatal care. All these factors however have the potential to influence a woman’s understanding and acceptance of antenatal care. Women’s acceptance of the priority of care is also linked to negative healthcare experiences and poor relationships with healthcare staff. These are widespread experiences, both direct and indirect, among many women in the studies, and they have a profound influence on the value placed on antenatal care and women’s desire to attend. The overwhelming majority of research in the synthesis is from the USA (83% of the primary research studies), where there are significant differences in the organisation of healthcare. However, few women rejected the detailed content or format of antenatal care, but some rejected the overall relevance of the care: findings that cross national boundaries. Lavender et al’s (2007) systematic review of access to antenatal care acknowledges that many of the identified barriers to antenatal care in other countries, particularly the USA, may be pertinent to the UK, despite different models of healthcare provision. Financial barriers reflect at first sight the strong US bias to the research, though in many studies women were eligible for free care. They also reflect the large number of studies with a quantitative, socio-demographic focus: statements such as ‘the cost of getting care is too high’ were found in only three qualitative studies. However closer examination of economic and practical issues suggest that women’s views across the diversity of studies reflect a recognition of the full consequences of a pregnancy, including the costs, both personal and financial, direct and indirect, associated with attending for care. Again, past experience of antenatal care, particularly negative, influences women in early pregnancy. For many women from low-income backgrounds (the majority of studies), women with often complex lives and multiple commitments to their time and energy, cost and convenience represent significant considerations. Women in such circumstances demonstrate pragmatic decision making when prioritising their lives, accepting that antenatal care is not top of their priority list. The issue of prevention suggests a contradiction to the theory of acceptance. A small number of studies, relating to BME women and particularly those recently arrived in a western country, have identified that there may be particular circumstances where preventative factors influence or even outweigh women’s acceptance of their need for care (Hollowell et al 2012, Boerleider et al 2013). For example, poor knowledge of antenatal care and ‘the system’ of care is associated with social isolation and misinformation, however there could be some circumstances where it results from language or comprehension difficulties. There may be a small number of women who are prevented from attending for care by practical issues such as financial restrictions or through administrative failures, if these are unchallenged. However the evidence suggests that even amongst these specific groups this is only part of the picture, and that knowledge and cultural factors, as well as practical considerations, influence women’s acceptance of the value of attending for antenatal care. 2.4.3.1 Limitations of the CIS method The critical element of the CIS method requires a consideration of the nature of assumptions made in the studies. Different factors may influence antenatal care initiation and continuation, though any one factor may influence both (Leatherman et al 1990). Few of the studies sampled make a clear distinction between these factors, rather it is more a question of emphasis, a potential weakness in the review. The differing constructions of ‘late booking’ inevitably influence findings, with wide variation in the definition of late. Arguably women booking at 13 weeks gestation are likely to demonstrate differing attitudes towards their care than a woman booking at, say, 28 weeks. In addition, the inclusion of women who were unbooked in some studies represents another dimension of opinions, an extreme view of antenatal non-attendance perhaps, but one which was included to add further depth and completeness to the review. The findings also reflect the diversity of women, contexts and the methods used. The range of ages (from 12 to 45) and backgrounds illustrate the full spectrum of life experience. Women interviewed postnatally, immediately after the safe arrival of their babies or several years later, will have a very different view of pregnancy challenges than those interviewed antenatally. Women interviewed in hospitals or clinics are likely to present themselves differently to women at home. Likewise, women singled out as ‘late bookers’ are likely to respond differently to women in more general surveys of antenatal access or participation. The breadth and detail of the findings reflects the nature of the interviews and the freedom of choice women were given to respond. This ranged from the flexible interview guides of grounded theory studies (e.g. Sword 2003) to largely demographic data collection questions with a short list of possible barriers to antenatal care (e.g. Delvaux et al 2001) to complex questionnaires with more than 100 questions relating to health beliefs, barriers to care, pregnancy intention and support (e.g. Cartwright et al 1993, Fuller and Gallagher 1999). Even a well-constructed questionnaire has its limitations however, as Chandler (2002) illustrates: “we have little idea what was in the respondents’ minds when they said that they had ‘felt a great deal of stress’ at the time they found out they were pregnant” (p33). Several mixed method studies restrict their presentation of findings to demographic data and the fixed choice responses given by women, suggesting a preference for ‘hard’ quantitative elements to justify the validity of their findings (Kalmuss and Fennelly 1990, Teagle and Brindis 1998, Corbett, Chelimo and Okesene-Gafa 2014). Though the studies of women’s and practitioners’ views add another layer to the discussion, the comparison of such views is complicated by the different methods used to ascertain them, for example fixed or restricted choice questionnaires versus open focus group discussions. In addition, few researchers consider the influence of reflexivity. The age of included studies is likely have some influence on the findings. However, although referral procedures and the location of care may have changed, the content of early antenatal care has changed little (in the UK at least) in the last 20 years. This is illustrated by Merchant’s 1993 description of the booking appointment, which (as now) included history taking, Body Mass Index (BMI) calculation, blood pressure and urinalysis, the offer of antenatal screening tests and ultrasound assessment of gestation. There are limitations to any literature review, and inevitable summarising and subjectivity, however systematic the approach. Quality issues may weaken the nature of constructs emerging from the studies and subsequently their synthesis, however the CIS approach acknowledges the integral interpretation of both credibility and contribution (Flemming 2010, Annandale et al 2007). It embraces the authorial voice, using accepted qualitative research methods and a creative approach, to produce not simply a summary but a more conceptual reinterpretation of the evidence. In this case the somewhat limited voices of the women presented in quantitative studies contrast with the richness, and arguably the honesty, of the qualitative research. However all these studies have a contribution to make, forming an essential part of the evidence around late booking and contributing to the insight and usefulness of the synthesis. Similarly, incorporating other literature reviews and analyses adds to the body of knowledge, reflecting another layer of thinking about delayed access to antenatal care and helping to achieve a theoretical saturation on the subject. 2.4 Conclusions, aims and objectives for the study CIS offers one approach to synthesis, one that is both systematic and iterative, and explicitly oriented to theory generation. This interpretive review of a large and methodologically diverse body of evidence around perceptions and beliefs towards late booking for antenatal care, identifies that antenatal care participation behaviour is extremely complex. However, an overarching theme develops, namely the acceptance of two pregnancies: personal and public. The personal pregnancy acknowledges that initial recognition and acceptance of pregnancy is the start of the pregnancy journey, and is influenced by knowledge, expectation and social support. The public pregnancy recognises that acceptance of the relevance and priority of antenatal care influences initial access to such care, the next step on the journey. This acceptance is shaped by a complex balancing of the positives and negatives of being pregnant, by a consideration of past, present and future factors: for some women late booking is a positive choice rather than a passive disengagement. The limited views of practitioners concur with many of those of the women, but universally express disapproval for late booking. The review illustrates the limitations, in both breadth and depth, of research around late booking for antenatal care, as opposed to access to antenatal care generally. There is a lack of recent research about antenatal care initiation, a lack of UK based research and particularly research which is not London based. There is also a predominance of quantitative approaches. The findings, alongside the evidence presented in chapter one, demonstrate the need for further qualitative research around late booking. A Health Services Research project was developed in Sheffield. The aim of the project was to understand the reasons why some women present late for antenatal booking; to contribute to an improvement in early access to antenatal care and ultimately to outcomes for pregnant women and their babies. To achieve this aim the project had two objectives: 1. To interview pregnant women booking late for antenatal care in Sheffield: - to explore barriers to their early initiation of antenatal care; - to explore their understanding of the importance of early antenatal care;
- to explore their perceptions of the barriers to antenatal care; - to explore ways that antenatal access may be improved for ‘hard to reach’ pregnant women. The focus, for the purpose of this thesis, is on the perspectives of the women. This study was the part of the larger project which I led as research midwife, including recruitment, data collection and analysis. Findings from initial reviews of the literature and from the studies and publications in chapter one were used to refine the research question for the study, and to inform study processes such as the development of the interview guide and sampling. The following chapters, three and four, detail this refinement and the methodological considerations and qualitative methods underpinning the study. The interpretive synthesis itself was conducted subsequently, and separate to the data analysis for the Sheffield study. The intention was to maintain the originality of both the synthesis and the findings from the study, to avoid the imposition of a priori themes and ideas. These two parts are brought together later in the thesis, in the discussion and recommendations chapters. Chapter 3. The methodology for the study 3.1 Determining the research methodology 3.1.1 Why qualitative research? Yüklə 0,62 Mb. Dostları ilə paylaş:
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