The findings presented are based on individual in-depth interviews with 285 pregnant women, 105 health providers (involved with the provision of ANC at health facilities or TBAs), 91 relatives and 46 opinion leaders. A further 51 focus group discussions with community members were carried out and 67 women were recruited as case studies and interviewed at least three times (see for site-specific details). The findings are also informed by analysis of the observations carried out at each site and recorded as field notes by members of the research team. Throughout the following section, for reasons of brevity, the sites are referred to as ‘Kenya’, ‘Malawi’, ‘Ashanti Region’ and ‘Upper East Region’. This shorthand should not however be interpreted as any attempt at regional or national generalization.
Women’s Perceptions of ANC and Reasons for Attending
Although women’s descriptions of ANC varied across and within the sites, on the whole, they did not recall receiving all WHO-recommended procedures (). The descriptions were also often vague and focused on the experience of procedures, such as receiving injections or tablets, rather than their aim or purpose. Kenyan women focused on palpation, receiving ‘blood booster’ tablets and injections and were generally less familiar with other procedures or their purpose (such as IPTp). Ghanaian and Malawian women emphasized being weighed (in Malawi and Upper East Region, Ghana ANC was termed, ‘scale’), and also commonly recalled checking the position of the baby, and the provision of medicines and injections. In Malawi, women distinguished ‘blood pills’ from malaria drugs, and recalled being given ITNs. Women in Ghana reported having their arms ‘tied’, but did not explicitly link this with blood pressure measurement. 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. Indeed, interviews with health workers and observations indicated that, often as a result of shortages or infrastructure problems, not all the recommended ANC procedures were carried out for every woman or at every healthcare facility. Lack of delivery of specific procedures, such as syphilis testing and haemoglobin analysis, therefore influenced women’s descriptions of ANC.
At all the sites, women stated that they attended ANC to monitor the progress of their pregnancy or to check the position of the unborn child. In Upper East Region, women attended ANC to identify problems during pregnancy, whereas, in the Ashanti Region, women also highlighted the importance of taking the medicines provided during ANC to ensure the health of the pregnancy and the development of the baby. Furthermore, Ghanaian respondents, particularly in the Ashanti Region, viewed ANC as a normal part of pregnancy: attending the clinic was simply what women did. In Upper East Region, ANC was often considered compulsory: a result of the authority of health staff or the vague idea of it being the ‘law’. Also linked to the authority of health staff, in Kenya, obtaining an ANC (or ‘birth’) card motivated attendance. The cards, completed by health staff, contain details of ANC attendance and Kenyan respondents suggested that without the cards, they would encounter problems if they attended a health facility to deliver: women feared being reprimanded by healthcare staff, or refused care. Although this played a lesser role in Ghana and Malawi, reference was also made to ANC cards’ importance for avoiding conflicts with health staff.
Gestational Age and the Timing of ANC Initiation
Both health staff and other community members confirmed that for women at all sites, gestational age was a meaningful concept and influenced ANC attendance. Although their estimations were not always accurate, women talked about the gestational age of their pregnancies – often measuring the progression in months – and reported that this affected when they initiated ANC. Although primagravidae, particularly young women and adolescents, were less certain (as is elaborated below), generally, women became aware of their pregnancy as a result of one or two months of amenorrhea. However, gestational age had a varied impact on ANC initiation across the sites: respondents from the different categories tended to characterize women in Ghana as generally starting ANC around the third or fourth month of pregnancy, whereas women in Kenya and Malawi were often reported to make their first visit at around the sixth or seventh month.
Reproductive Concerns and Uncertainties
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). In Ghana, generally, women initiated ANC in early pregnancy and, from the first visit, ANC was conducted in a problem-focused manner: health workers reportedly paid attention to women’s complaints and possible remedies. Malawian and Kenyan women who complained of ill health during early pregnancy would however generally not attend ANC but rather seek care at a health facility, without disclosing their pregnancy to staff. Yet, at all the sites, experiences of previous pregnancy complications motivated women to seek ANC in early pregnancy.
Although women described how a couple of months of amenorrhea was generally sufficient to confirm a pregnancy, both health staff and pregnant women reported that, at health facilities, palpation was often used to confirm pregnancy at 12 weeks. Pregnancy tests were available in the larger health facilities at all the sites, but they were often prohibitively expensive, particularly in Kenya and Malawi (around $2 in Kenya). Therefore, generally pregnancies were not confirmed with a test, except in district hospitals in Ghana, where pregnancy tests were used in cases of uncertainty. This uncertainty in the first trimester, prior to palpation, extended to both the woman and the health staff. In Malawi and Kenya, this had implications for ANC attendance: as is explored below, there were reports of health workers instructing women to return when they were able to confirm a pregnancy (or the pregnancy was confirmed elsewhere) and perform ANC procedures.
Any uncertainty around pregnancy status was pronounced for women who had previously had difficulties conceiving or bringing a pregnancy to term. Given the central role that reproduction often plays in the women’s lives and the stigma that surrounds infertility, including the implications that childlessness have for a woman’s relations with a woman’s husband and in-laws, for these women, confirming a pregnancy was particularly important. In Malawi, and to a lesser extent in Ghana, there was also uncertainty about pregnancy linked to the use of traditional and modern methods of contraception. In these three sites, confusion about amenorrhea associated with injectable contraceptives resulted in women being unclear about their pregnancy status and in some instances led to delayed ANC. In Ghana, health professionals linked irregular menstruation and uncertainties regarding pregnancy to sexually transmitted infections. The uncertainty and ambiguity surrounding pregnancy, particularly in the first trimester also had implications for pregnancy disclosure, as detailed below.
Parity, Age and Pregnancy Disclosure
Parity had a complex impact upon ANC initiation. For example, unaccustomed to the experience of pregnancy, the associated signs and symptoms, some primagravidae were more likely to seek advice and assistance and initiate ANC earlier. However, this lack of familiarity with the signs of pregnancy also prompted uncertainty: less likely to recognize a pregnancy, they were more prone to unintentionally delay ANC. Nonetheless, these decisions were not taken alone and on the basis of advice from older women, primagravidae hastened their first ANC visit. For example, if a mother became aware of her daughter’s pregnancy – and, on occasion, this seemingly occurred before the adolescent realized herself – she would assist her in attending ANC as soon as possible.
For primagravidae, pregnancy disclosure influenced timing of ANC. 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. In contrast, older women did not make active efforts to hide their pregnancies. However, they would only directly disclose their pregnancy to close relatives and their husband. Although ambivalent towards others discovering their pregnancy, which they considered inevitable as the pregnancy progressed, women were wary to be accused of boastfulness by spreading the news openly.
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. In Malawi, however, there were reports of women delaying pregnancy disclosure and ANC (till the fourth month) to avoid suffering witchcraft that could harm a pregnancy. In Kenya and in Ghana, pregnant women (and other community members) described how they were at greater risk of witchcraft and sometimes attributed pregnancy interruptions to witchcraft. However, this was not viewed as a reason to delay ANC. Furthermore, in Ghana, although women acknowledged the dangers of witchcraft and personalistic threats to a pregnancy (threats posed by human or non-human sentient beings), they were reticent to talk about them.
At all the sites, disclosure was a particularly sensitive issue for women who had experienced unexplained pregnancy interruption. For example, although one Kenyan woman, who had previously experienced several unexplained pregnancy interruptions, was willing to be interviewed in early pregnancy, she had not informed her closest friends and neighbours. Later, she reported having lost the pregnancy, and although she did not refuse outright to be interviewed, henceforth, whenever approached, she did not have time to talk.
In spite of the concerns about gossip, embarrassment and witchcraft, it was possible to identify and interview women during early pregnancy. Contact was made at health facilities, or with the assistance of community leaders or other pregnant women. Although the numbers varied across the sites – from five in Kenya to twelve in Malawi – in total, over 30 women were interviewed during the first trimester of pregnancy.
With regard to older multiparous women, health workers could confirm that particularly in Kenya and Malawi, and to a lesser extent in Ghana, they visited the clinic in later pregnancy: in some instances, waiting till the ninth month. Being more accustomed to the pregnancy experience, their priority was obtaining the antenatal card and they were less concerned about monitoring the progress of the pregnancy.
Interactions with Healthcare Workers
Pregnant women’s interactions with healthcare staff at ANC had varying implications for ANC attendance. Respondents (including pregnant women, their relatives, community members and opinion leaders) reported that delaying ANC until the third trimester, led to chastisements from health workers; this was particularly the case if a woman arrived at a health facility to deliver without having previously attended ANC. Hence, as previously described, women’s fear of chastisement from health workers sometimes prompted ANC attendance.
Women’s interactions with healthcare staff could also result in delayed ANC. The most extreme examples in Kenya involved one direct and one indirect report of women who attended ANC in the first trimester, but were sent home and instructed to return in the second trimester, when their pregnancy was visible and could be confirmed through palpation. These reports from pregnant women conflicted with the statements of Kenyan healthcare staff who said that they encouraged pregnant women to attend ANC as soon as they realize that they are pregnant. In Malawi, during data collection, three women were referred to the hospital from a health centre because the health staff were unable to confirm a pregnancy. Furthermore, during health talks Malawian health staff did not advise women on when to initiate ANC, but when such messages were given, generally, women were advised to initiate ANC in their third month and only rarely did a staff member state that women should start as soon as they realize they are pregnant. In both sites in Ghana, women were generally advised to attend ANC as soon as they realized that they were pregnant and none of the observed women that attended a health facility for ANC during the first trimester were sent back home.
In spite of the messages and reprimands that women experienced, healthcare workers’ advice was generally trusted and women claimed to follow their instructions. This is epitomized by women’s attitude to follow-up ANC appointments: the scheduling was viewed as compulsory. Furthermore, observations confirmed that communication between women attending ANC and the health staff was limited and often didactic. In Kenya and Malawi, health education was provided in groups and although during the ANC visits there were opportunities for dialogue with healthcare staff, observations suggested that pregnant women rarely took advantage of this. In Ghana, however, health talks were given less often and information was provided on a one-to-one basis during consultations. Moreover, during these consultations, health staff asked women directly about their health concerns. Healthcare staff explained that, as a result of the transition to focused ANC, information was no longer provided to pregnant women during health talks.
Interactions between pregnant women and health workers during ANC were also influenced by social factors. At health facilities, communication tended to be more two-way if a woman was comparatively wealthy or well educated or had a familial relationship or friendship with the health worker. Members of the research team observed such women addressing health staff on relatively equal terms. This contrasted with the typically quiet, reserved, head-down demeanour of other women when interacting with health staff during ANC. Kenyan women also reported chastisements, and social discrimination at health facilities if their birth spacing was deemed inadequate. Some women with young children would therefore avoid attending health facilities, and this could lead to delaying their first visit. In contrast, although at the other sites, appropriate birth spacing was described as important, women did not mention having a young child as a reason to delay ANC.
The Direct and Indirect Costs of ANC
In Kenya, from observations and interviews with pregnant women, it was apparent that charges for ANC varied across health facilities and amongst respondents: small charges were levied for the ANC card and also, where available, laboratory tests. Similarly, and in spite of the free health insurance for pregnant women, in the Ashanti Region, incidences of charging for some ANC services were reported: although, not encountered in all facilities, the pricing system was unclear and consequently the subject of women’s complaints. Furthermore, health staff described the efforts of local health administrations to tackle corruption and prosecute those responsible. In contrast, in Upper East Region, ANC was largely free. However, in some instances, as a result of shortages, women were required to bring with them medical supplies, such as bottles for sampling urine. In Ghana, ITNs were offered at a subsidized charge of 2$ for pregnant women and there were regular shortages. Although charges were not levied for ANC visits in Malawi, women were instructed to buy replacement generic health passports due to a shortage of ANC cards.
Attending ANC also entailed indirect costs. Travel costs varied amongst the sites and the respondents at each site: for example, in northern Ghana, where vehicles providing public transport were scarce, women mainly walked to the clinic and travel costs were minimal. In Kenya and Malawi, bicycle taxis were available, and in light of their pregnancy-related tiredness, women who could afford to pay, did so. Other women travelled on their husband’s bicycle and, in Kenya, a minority of women used motorbike taxis because of their greater comfort. Other indirect costs include the food that women purchased whilst waiting to be attended, either for themselves or their accompanying children. Given the particularly social nature of ANC visits, women with the available resources spent money on clothes and a visit to the hairdresser prior to attending (all women however made efforts to look smart). Many of the women cultivated land along with their husbands and other family members and were often responsible for cooking meals for family members; taking time out from these activities therefore represented an opportunity cost. There are also non-monetary costs: pregnancy, combined with women’s continued labour demands (that continue up to delivery and recommenced shortly after), was often an exhausting experience for women and the journey to health facilities represented a physical burden.
Delays in ANC initiation were not however solely due to the associated indirect and direct costs. 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. 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. In Malawi, appointments were every two months except during the ninth month. Women, particularly in Kenya and Malawi, reported that they would not attend ANC until the sixth or seventh month to minimize the number of journeys and therefore the total cost of ANC. 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).
A range of factors also mediated women’s access to the means necessary to meet the direct and indirect costs of ANC. At all the sites, women were primarily involved in subsistence farming, but, through their involvement in small businesses, some were able to gain access to cash. Women without direct access to cash often relied on their husbands or relatives to meet costs, which further complicates decision-making about ANC initiation. In some instances, however, it was not only a question of access to cash, but also access to the means of transport, such as a husband’s bicycle, to reach the health facility. Reports of women delaying ANC initiation because of an objection from their husbands or a relative responsible for household expenditure were however rare. The difficulties that some women face to access cash were highlighted by the experience of one Kenyan woman who worked as a live-in carer: she reported waiting for her employer, who knew of her pregnancy, to pay her salary before initiating ANC.
Husbands and HIV-related Stigma
In Malawi and Kenya, health staff promoted the involvement of husbands in ANC through, for example, giving preferential treatment and a free shawl for their child if the husband attended ANC with his wife. For a minority of Kenyan women, however, the participation of husbands in ANC decision-making, combined with HIV-related stigma, had negative implications for their ANC attendance: women were wary of attending ANC because they would be informed of their HIV status and a positive result had ramifications if their husbands discovered their status. Husbands often refused to be tested and rather, in the most extreme instances, accused their wives of adultery and abandoned them. In light of this, one of the Kenyan case studies reported delaying ANC to delay discovering her HIV status. This was possible, because although HIV/AIDS was not mentioned on the ANC card, people knew how to interpret the information available on the card to determine HIV status and one Kenyan woman had attempted to damage her ANC card to hide her status. Furthermore, Kenyan women were reticent to talk about HIV testing: unless specifically asked, they would not mention it as part of ANC. Although there were also reports of HIV-related stigma in Malawi, in general, Malawian women described the importance of knowing their status and HIV testing was not given as a reason to delay ANC. In Ghana, the HIV prevalence in the research sites was much lower and HIV/AIDS was not raised as an issue affecting ANC attendance.