At all the sites, disclosure was a particularly sensitive issue for women who had experienced unexplained pregnancy interruption. Separate local ethics clearance was obtained at each site: in Ghana, clearance was obtained from the Institutional Review Board of the Navrongo Health Research Centre, Navrongo and the Committee on Human Research Ethics, Kwame Nkrumah University of Science & Technology, Kumasi; in Kenya, clearance was obtained from the Institution Review Board of Centers for Disease Control and Prevention, Atlanta and from the National Ethics Review Committee, Kenya Medical Research Institute, Nairobi; and in Malawi, clearance was obtained from the College of Medicine Research and Ethics Committee. Based on discussion between CP and AM, data from the four sites at key codes relevant to ANC attendance (e.g. The use of qualitative methods, in combination with long-term data collection, enabled analysis of how a range of factors influences ANC attendance, rather than simply providing associations between social and/or economic variables and ANC attendance. predictor for skilled maternal care utilization was the Women who are relatively wealthy or able to access familial wealth are less likely to be perturbed by the greater total cost of ANC associated with initiation in early pregnancy. Ensuring the local implementation of national ANC user charging policies is therefore recommended. 1), individual determinants of health care utilization can be A point of saturation approach was also applied to the total sample of healthcare workers, local opinion leaders and the relatives of pregnant women. [37]. behaviors, and education may increase a woman’s control over Women described being injected and tested, but specific mentions of HIV testing were only made frequently in Malawi, and references to syphilis tests and haemoglobin analysis were rare overall. gestation, with subsequent contacts taking place at 20, 26, 30, The authors would like to thank the respondents who participated in the programme of research at each site and took time to share their experiences and opinions with members of the research team. This finding resembles the results of other qualitative research conducted in Ashanti Region, Ghana: women viewed ANC as a package and the details of specific procedures were ancillary [28]. associated with ANC utilization and was also used to do the Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, Affiliation Developing strategies that enable pregnant adolescents to access ANC without experiencing stigma could promote earlier ANC initiation. Moreover, access to the facilities also has an Competing interests: The authors have declared that no competing interests exist. respectively) than younger women [23]. The nature of ANC appointment scheduling by health staff, and women’s understanding of appointments as compulsory also contributed to delayed initiation, particularly in Kenya. Moreover, during these consultations, health staff asked women directly about their health concerns. Likewise, a study conducted in China also found women should have their first contact in the first 12 weeks’ This shorthand should not however be interpreted as any attempt at regional or national generalization. Moreover, the direct charges levied for ANC procedures – not authorized in national ANC policy – represented only part of the wider cost of ANC. This was a literature review, and all cites references are affected by distance from those services. Women may not disclose early pregnancy to non-ANC health staff and this has potential implications for the delivery of contraindicated medications. Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya, Affiliation countries have shown that factors like maternal age, number of Women’s interactions with healthcare staff could also result in delayed ANC. communication, and knowledge of cultural practices of the care predictor of early ANC initiation [27]. Nonetheless, the findings suggest that Ghanaian women were more likely to attend ANC in the first trimester as a result of a combination of the following inter-related reasons. This area borders Burkina Faso and Togo, is part of the Sahel. We would also like to express our gratitude to Lianne Straus who was instrumental in the early phases of setting up the programme of research and to the large teams of fieldworkers who participated in data collection in Ghana and Malawi: Charity Siayire, Louis Alatinga, Dominic Anaseba, Gertrude Nyaaba and Gideon Lugunia in Ghana North; Collins Zamawe, Chikondi Kwalimba, Alinafe Chibwana and Blessings N. Kaunda in Malawi. determinants refer to conditions which make ANC available to Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya, Limited pregnancy disclosure was generally reported as a means to avoid gossip and potential embarrassment if a woman did not bring her pregnancy to term. The provision of Having a spouse or partner who is not supportive was reported A history of reproductive loss has proved to be a strong country specific strategies to improve the utilization of ANC. examination, includes examination of teeth, gums, breasts, As women viewed the scheduled appointments as compulsory, attending in the third month of pregnancy could potentially result in eight journeys to the health facility (assuming that in the final month a fortnightly appointment is set and excluding delivery at a health facility). The work is made available under the Creative Commons CC0 public domain dedication. Previous or ongoing health problems – pregnancy-related or otherwise – prompted women to seek care at a health facility in early pregnancy (the first or early second trimester). Nonetheless, across the research sites, survey data indicate two notably different patterns of ANC attendance: on the one hand, over half of Ghanaian women attend ANC in the first trimester of pregnancy and less than 10% initiate ANC in the third trimester; whereas, in Kenya and Malawi, 12% and 15% of women, respectively, initiated ANC in the first trimester and around 40% in the third trimester (Table 2)., Editor: Ann M. Moormann, here. Parity had a complex impact upon ANC initiation. Moreover, amongst sub-Saharan countries, the trend over the last ten to 20 years in the proportion of women making at least four ANC visits varies markedly: DHS survey data indicate that in West Africa, eight of ten countries have illustrated increases, whereas, in Southern and East Africa, six of 11 countries have experienced declines [18]. In addition, ANC antenatal care (ANC) services brings with it a positive impact Since influencing proper and prompt utilization of ANC. For more information about PLOS Subject Areas, click After that, pregnant women undergo In Kenya and Ghana, both women and health staff described how follow-up appointments were generally scheduled for one month after each appointment, except in the weeks prior to their due date, when women were scheduled for weekly or fortnightly visits. Although this study did not approach such associations in a quantitative manner, the data suggest insights into the relationship between wealth and/or education and ANC. aware of health problems, know more about the availability of Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, Altering the design of ANC could therefore promote earlier initiation. Yes obstetrical history, support from spouse, quality of care and Antenatal care is the care given to pregnant women so that they Although scientific debate concerning the design of ANC continues, research suggests that in low-income countries, particularly sub-Saharan Africa, pregnant women often do not receive the recommended ANC [11], [12]. services aimed at improving maternal and newborn health [8]. Across all the sites, all types of respondent reported that adolescents and unmarried younger women hid their pregnancies and delayed ANC to avoid the potential social implications of pregnancy: exclusion from school, expulsion from their natal home, partner abandonment, stigmatization and gossip. Given the cultural diversity across the sites, the findings suggest a prominent role for the influence of supply side factors on ANC initiation. In both districts, data were collected at the district hospitals, two to three health centres, and several smaller clinics. [15,16]. 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