In this study we found that the percentages of mothers entering antenatal care late was higher in non-Dutch than in Dutch mothers, with the exception of Surinamese-Hindustani. These percentages were especially high among Moroccan and Antillean mothers. As a consequence, mothers with a non-Dutch background are less likely to receive timely health educational advice or benefit from screening opportunities.
Additionally, we found that these ethnic differences diminished, but remained significant, in three of the six ethnic groups after taking into account many factors that can influence the entry into antenatal care. However, the differences between Turkish and Cape Verdean women versus the Dutch women could be fully explained by the explanatory variables included in the analysis. Differences in design notwithstanding, differences between Turkish and Dutch women also disappeared in the multivariate analysis in the study by Alderliesten [9
]. The initially large difference between the Moroccan group and the Dutch group remained statistically significant in our study but nevertheless diminished considerably. In this study we focused on the explanation of ethnic differences in the timing of entry into antenatal care, and not of ethnic differences in the number of contacts, because the latter did not occur in our study population.
A probable explanation for the difference between Dutch women and two non-Dutch groups (Moroccan and Turkish women) could be found in the behavioral factors. For example, women who adapt their behavior positively early in pregnancy—by abstaining from alcohol and tobacco use—entered antenatal care earlier than those already behaving healthy before the pregnancy. However, the observed differences between Dutch women and two non-Dutch groups (Turks and Moroccans) appeared to a large extent to exist because of the behavioral adaptation of the Dutch women. Neither Turkish nor Moroccan women usually drink alcohol, which is related to their religion, as most of them are Islamic. In addition, few Moroccan women smoke, unlike Turkish women, who were more likely to smoke than women in other groups, also during pregnancy. Furthermore, the causal sequence is questionable, as it could be the case that these women adapted their behavior after they were advised to do so by the midwives during early pregnancy. Unfortunately, we do not know whether the behavioral adaptation during pregnancy took place as a response to such advice. If it did, our hypothesis—that women who are not directed towards healthy behavior regarding pregnancy will also not be inclined to enter antenatal care early in pregnancy—cannot be confirmed. Further examination of this point is necessary.
Regarding folic acid use, women who never used it during pregnancy entered antenatal care late. A similar trend (not significant) was visible for those who used it late in pregnancy, compared to women who used it either before pregnancy or as soon as they knew that they were pregnant. These results suggest an underlying adverse behavioral pattern including both late entry and adverse health behavior. Because this seems to be at least partly the case, health education cannot be left only to the midwives. The continuation of smoking during pregnancy by Turkish mothers also points in that direction.
Although we expected that poorer perceived health would prompt early antenatal care use, our study did not confirm this; nor did it explain differences in antenatal care entry between Dutch and non-Dutch women. Adjustment for more objective risk factors (e.g.: the presence of chronic conditions, such as diabetes, and complications in previous pregnancies) could only have been partly useful, because especially multiparae women then directly enter secondary care. However, future research should take into account more specific subjective health assessments directly related to pregnancy that could affect time of entry (e.g.: nausea and vomiting).
Enabling factors explained part of the differences between Dutch and non-Dutch women, but not the majority—except in Turkish women. We only included educational level and not other indicators of socio-economic position, such as occupational level and income level. We decided to focus on education because it reflects the more general concept of enabling factors better than other indicators. Indeed, educational level reflects not only financial resources, which are less relevant in a system without financial barriers, but also general health knowledge and health literacy. It should be mentioned that there is no consensus on whether having a paid job and educational level should be considered as either enabling or as predisposing factors. We decided to consider them as enabling factors, because they facilitate access to information. In this respect, we acknowledge one of the limitations of this study. Although ethnic minorities without a legal status are nevertheless formally entitled to antenatal care, in practice it is unlikely that many of them were included in the Generation R study, because they would be afraid of recognition by official authorities.
The classical predisposing variables were not significantly associated with early/late entry into antenatal care. This is in contradiction with most previous studies. Nevertheless, in our study the associations between parity and time of entry, and between planned character of the pregnancy and time of entry, were as expected but without being significant. It is important to note that we assessed the influence of these factors after adjustment for all other explanatory variables, whereas most previous studies took into account fewer explanatory variables. Indeed, our inclusion of more explanatory variables than most previous studies represents an important strength of this study over previous studies. Nevertheless, we could not include a number of attitudinal characteristics such as the degree to which women recognize the importance of early antenatal care. It might be possible that migrant women value antenatal care less than Dutch women. This might be the consequence of lack of familiarity with antenatal care in the country of origin, but also with lack of access to information due to problems with understanding the Dutch language. It could therefore be interesting to investigate differences in timing of entry between non-Dutch women born outside the Netherlands (1st generation) and those born in the Netherlands (2nd generation).
An advantage of our study was the possibility to distinguish between Surinamese-Creole and Surinamese-Hindustani women, two distinctly different groups that have different origins, one with an African background, and the other with an Asian background. Our study found large differences in delay in antenatal care use between these two groups: Surinamese–Hindustani did not differ significantly from Dutch women, but Surinamese–Creoles did.
Our results should be interpreted with some caution because of some limitations in our study. Besides the ones already mentioned above, one should also acknowledge the following. First, we did not include all midwife practices participating in the larger Generation R study. We excluded three midwife practices, since they did not use electronic antenatal charts. There was no indication that the ethnic composition of these practices was different from the participating practices (analyses not shown). Secondly, we excluded mothers from the analysis whose ethnic background was unknown. We analyzed whether the timing of their entry into antenatal care was different from the women included in this study, and found that this was not the case (analyses not shown). Thirdly, we defined late antenatal care entry as entry after 14 weeks of pregnancy. This was based on the recommendations for basic antenatal care developed by the Dutch Society of Obstetrics and Gynecology (NVOG) at the time of the data collection. The recommendations by the NVOG are based more on professional agreement than on scientific evidence, and currently it is often advised to seek antenatal care earlier in pregnancy, and even before pregnancy [39
]. Finally, it is likely that migrant groups with a higher socio-economic position were overrepresented in the Generation R Study, as enrolment of migrant women was more difficult due to language and cultural barriers. Since a higher socio-economic position is associated with earlier entry into antenatal care, it is probable that the ethnic differences found in this study represent an underestimation of true differences.
In conclusion, although we could explain part of the ethnic differences in the timing of entry into antenatal care, differences between Dutch women and women in some migrant groups remained statistically significant. One possible explanation might be that migrant women are not well informed about how obstetric care is organized in the Netherlands and that this lack of knowledge leads to delay in antenatal care entry. In particular, the role of midwives may be unknown, and women might prefer to consult their general practitioner early in pregnancy. However, at least in Rotterdam (where this study took place), a visit to the general practitioner is not likely to be the first step in antenatal care, since women are advised to consult a midwife first. We did not examine differences in generational status (1st and 2nd generation migrants) and language factors as indicators of cultural distance, as our main aim was to explain differences between non-Dutch and Dutch women. Generational status is not applicable for the Dutch group. As far as knowledge of Dutch among Dutch women was concerned, we assumed that their mastery of Dutch was optimal, and it was therefore not assessed in the questionnaire. Because we are unable to explain all of the differences between the native Dutch and a number of non-Dutch groups, it would be worth investigating whether mastery of Dutch language plays a role, also because health literacy is considered as an important barrier to adequate health care use [41
]. In the Netherlands some migrants are rather fluent in Dutch (Surinamese), while others are less so (especially Turks and Moroccans). Therefore, lack of good Dutch mastery cannot explain all of the remaining differences, especially not in Surinamese-Creole and Antillean women. Future research should assess differences within migrant groups by investigating differences by generational status and mastery of Dutch language.
The results of this study are also relevant for clinicians. Midwives need to inform women of the importance of timely booking for antenatal care especially when they booked late during a previous pregnancy. This is all the more important, given that a previous study demonstrated that the difference between Dutch and non-Dutch women in timely entry was greater among multiparae than among primiparae [42