Journal of Women's Health Care
Open Access

Reasons for late antenatal care booking in Mizan-Aman, Town Southwest Ethiopia, 2021: a qualitative study method

Gelila Gashawbeza Battu^1*, Roza Teshome Kassa², Haweni Adugna Negeri², Leul Deribe kitawu², Kassahun Demelash Alemu³, Bamlak Gashawbeza Batu⁴ and Kibrework Bezabih Bantero^{5 *}Correspondence: Gelila Gashawbeza Battu, Department of Midwifery, Mizan Aman Health Science College, Aman, Ethiopia, Email:

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Background

Regular contact with a health professional during pregnancy at the recommended time of ANC booking allows women to receive the most benefit for their health and future children. Early ANC scheduling reduces the negative outcomes of pregnancy-related complications [1]. Due to the high burden and its consequences, maternal health is one of the top priorities on the national health agenda, guided by global health initiatives and support from different international communities to improve maternal health [2].

For a healthy pregnancy, the World Health Organization (WHO) recommended a minimum of eight antenatal care (ANC) visits in 2016. In the first trimester, antenatal care should begin; in the second trimester, two contacts (at 20 and 26 weeks of pregnancy) should be made. In the third trimester, there are five encounters (at 30, 34, 36, 38, and 40 weeks of gestation) [1]. In Ethiopia, the first ANC booking is acceptable till the baby is 16 weeks old [3].

ANC services have the potential to reduce maternal and child morbidity and/or mortality and to improve newborn health by preventing, detecting, alleviating, or managing pregnancy-related health problems that affect mothers and babies [4]. For instance, in sub-Saharan Africa, neonatal mortality was decreased by 39% through the utilization of at least one antenatal visit [5]. However, in Ethiopia, late initiation of ANC booking is still a major public health issue; i.e., different studies showed more than 64% of women did not use ANC service in the first trimester [6–8]. This late initiation of ANC is a major challenge to the achievement of the MDG target. According to different studies, socio-economic, cultural, obstetrics, and structural barriers are the major reasons for late ANC booking [8-11].

Globally, the rate of child mortality decreased from 90 to 43 deaths per 1,000 live births between 1990 and 2015. Reducing maternal and child mortality is one of the Sustainable Development Goals (SDGs) objectives. Whereas this achievement is not sufficient to meet the MDG target [2]. Therefore, for sustaining SDG, it is crucial to know the details about the reason for the delay in ANC booking of pregnant women. So, this study aims to find the reason for the delay of the first ANC booking.

Methods

Study design and setting

To accomplish the study's goal, a qualitative, exploratory, and descriptive research method was used. The present study was conducted from February 15 to March 25, 2021 at Mizan-Aman town, southwest of Ethiopia. In the study environment, there are five health stations, one health center, and one teaching hospital. The mainstay of the town's economy is the sale of cash crops, mainly coffee [12].

Study participants and sampling strategy

Data was gathered from 20 participants, 11 of whom were pregnant moms, and 9 of whom were health care practitioners. During the interview process, data saturation occurs when no new information is received. Participants were purposefully chosen based on the researcher's assessment of people that are representative of the study phenomenon. Based on the inclusion criteria, participants were recruited from the Mizan-Aman town health facility in southwest Ethiopia. Before commencing, the data collection screen was conducted to assure the eligibility for in-depth interviews and key informants.

Data collection tools and procedures

The data collection was conducted through in-depth interviews and key informants using a semi-structured interview guide by the principal investigator. One MSc health care provider who is fluent in both the local language and Amharic was used as the translator during the interview process. The translator was trained in the qualitative study and how to translate without introducing his/her idea (being neutral throughout the translation process). The translator knows the local language of those participants who cannot speak Amharic and One MSc note-taker was assisted with the data collection process. Before the interview, the interviewer and note-taker discussed each question to verify that the notes and the interview were in synchronization. Face-to-face interviews were conducted. We can pick up on nonverbal clues from participants' actions using this strategy, which supplies a rich form of data.

The interview guide featured a set of questions with probes to help conversationally drive the interview in a specific direction (see online supplement appendix). The interviews were audio-recorded, allowing for the transcription to be prepared for analysis. Data saturation or adequacy is reached when there are no new emerging ideas of information in the data, the point in coding when no new codes occur in the data. As a supplement to the audio-recorded data, written notes were utilized to record information.

Data analysis

Data collection and analysis were carried out concurrently. To discover new concepts and categories, data was evaluated immediately after the key informant interview and in-depth interview. After frequently listening to the tape recorder to grasp each respondent's concepts, the audio recording data was transcribed verbatim in Amharic of each interview at the same time. Translate the data into English and write it down. The translated data was imported to the qualitative data analysis software package QDA miner lite 1.4.1 for coding. Data were analyzed using the deductive thematic analysis principle. To aid analysis, written notes and memos were linked.

Ethical Consideration

The institutional review board of Addis Ababa University's faculty of health sciences department of nursing and midwifery granted ethical approval. The study's objective and goal were explained to the participants, and written agreements were obtained from each of them. They were also informed that they had the right to refuse or withdraw from the study at any time. The data was gathered anonymously and kept private.

Research Findings

Characteristics of the study participant

In total, 20 people were recruited for the qualitative research, 11 of whom were pregnant women, and 9 of whom were healthcare providers. Nine of the pregnant women were between the ages of 20 and 35, while the other two were over 35. Five of them worked for the government, while the other five were housewives. All of the mothers are married, except one. Nine of the women were multigravida, while two were primigravida. Among health care providers, two are male and seven are female; four are health extension staff; one is a nurse, and four are midwives. (1) Midwife with a bachelor's degree; (1) nurse with a bachelor's degree; and (1) a diploma. Job experience ranged from 6 months to 16 years for the participants.

Emerged themes

After coding interview results, factors that led study participants were categorized into four main themes and sub-themes under the corresponding main themes.

Theme 1: Socio-demographic related factors

The first theme that emerged from the data analysis was factors related to socio-demographics. Under this theme, there are two subthemes: economic and lack of support from spouse and partner. The code was shown in Table 1.

Table 1. Theme 1-Socio-demographic related factors.

Sub-theme 1: Economy

Mothers/healthcare provider participants have, living in a poor socio-economic status, and transport costs as their reasons not to book ANC follow-up early. The mother has a lot of responsibilities, and they are dependent on their husband's income. According to the 30-year-old midwife; “In our nation, mothers have a lot of responsibilities in their families; they don't have their own income and depend on their husband's, and they are waiting for a convenient time to book ANC.” (HCP, 4)

“I lacked the funds to travel to the clinic. It is too far. Moreover, I am unable to pay the ETB 100 transportation charge for Bajaj" (Participant 4).

Theme 2: Socio-cultural belief-related factors

The socio-cultural belief-related factors were the second theme to emerge from the data analysis. Under this theme, we discovered two sub-theme cultural beliefs, community perception. The code was shown in Table 2.

Table 2.  Theme II-Socio-cultural belief-related factors.

Sub-theme 1: Cultural beliefs

According to the responses of pregnant women in the current research, gossip and witchcraft were the factors preventing them from scheduling their first ANC appointment on time. Attendance of ANC services will require disclosure of the pregnancy and therefore it postponed until disclosure is inevitable. According to a gravida one of 23-year-old responses; “I put off my ANC appointment because I was afraid of gossip and the possibility of witchcraft if I revealed my pregnancy too soon” (Participant 7).

Sub-theme 2: Community perception 

A community member was one of the reasons for the late initiation of the first ANC booking. A participant describes the first ANC booking as useless and that the ANC follow-up starting time is after 4 months. Some participants, especially those in their first pregnancy, seek ANC booking when to start from community members (friends and mothers in the village). One, 23-years-old gravida one, says: "I was pregnant at the same time as my friend, and I advised her to begin ANC follow-up; she agreed, but said she would go at four months because we had not received anything from the ANC clinic at the time" (Participant 7).

A 20-year-old gravida said that after learning of her pregnancy, she told the village mother, who advised her to begin ANC service. She stated this by saying, "According to the mothers in my village, ANC follow-up begins after four months." As a result, I started antenatal care when I was five months pregnant” (Participant 5).

Theme 3: Pregnant women-related factors

The third theme that emerged from data analysis was pregnant women related factor. Under this theme, we found five sub-themes. That are late recognition of pregnancy, pregnancy Symptoms Knowledge, busy time, perceiving of pregnancy as a normal health condition, lack of knowledge the ideal booking time and Covid-19 pandemic. The code was shown in Table 3.

Table 3. Theme III-Pregnant women related factor.

Sub-theme 1: Late recognition of pregnancy

The Study participant has listed Failure of unplanned pregnancies, menstrual irregularities, and pregnancies that would not occur while we were breastfeeding. Among the pregnant women, half of them said the current pregnancy was unplanned. The new pregnancy was said to be unplanned by 21-years-old gravida two. When she was getting pregnant, she used family planning methods. The non-adherence of family planning was suggested as a justification. As a result of the sudden pregnancy, she was late for an ANC appointment. The woman stated: “This baby came as a total shock to me because I was used to piles and wasn't prepared for it. I was surprised when they told me I was pregnant, but it had already been five months” (Participant 2).

From the perspective of the healthcare providers, the majority of pregnant women were late due to unplanned pregnancy. According to participants age 30 midwives, due to unplanned pregnancies. Since these women assume they are not pregnant, the timing of their first ANC visit is affected. “When we ask them about the occurrence of pregnancy, they inform us they were pregnant when they used family planning (Depo, implant, and pills); but, I'm not sure if this is due to a lack of awareness about the use of family planning or a lack of knowledge about the use of mothers’’ (HCP, 5).

A 37-years-old gravida seven claimed that her monthly menstruation is unreliable due to an unexplained explanation. She stated this as follows; “My periods are irregular, and they occasionally stop for three months or longer, so I didn't anticipate getting pregnant” (Participant 3)

According to a 27-year-old midwife, some mothers claim that pregnancy would not occur while they were breastfeeding. “They claimed that pregnancy would not occur although breast-feeding; while this is true, it is standard to use this form, and I don't believe they were aware of this, so they arrived late because they didn't know when they were pregnant, particularly the mothers who didn't show any pregnancy symptoms.” (HCP, 2)

Sub- theme 2: Busy time

As mentioned by most participants, they are burdened in their homes and unable to get leave under this sub-theme. In our country, mothers bear a lot of the burdens at home, particularly if they work outside the home. They were too preoccupied with this and other events to arrange their first ANC appointment. A 26-year-old grandmother said the following: "I work for the government, and when I get home from work, I devote time to my child's care" (Participant 6).

The healthcare provider also supports the above reason. In our nation, mothers have a domestic obligation. This was mentioned by a 30-year-old midwife woman. "Mothers, particularly those who live in rural areas, bear a greater burden in the community than men because they care for their children and meet all of their husband's needs." This responsibility is overburdened when the mother works outside the home and earns a living"(HCP, 5).

According to another participant, she wanted to come for an ANC follow-up when she figured out she was pregnant via a urine test at her home, but she couldn't get time off work by saying; “I wanted to go to the health facility for maternal services, but I couldn't because I had a lot of work to do, and I hadn't been able to get leave at work.” (Participant 1)

Sub-theme 3: Perceiving pregnancy as a normal health condition

Some mothers viewed pregnancy as a natural health condition that did not require medical assistance until a concern arose. As a result, they just go to the hospital when they have a medical problem. A 24-year-old gravida said, "I decided to go after four months because I was healthy after I got pregnant" (Participant 8).

Some mothers viewed pregnancy as a natural health condition that did not require medical assistance until a concern arose. As a result, they just go to the hospital when they have a medical problem. A 24-year-old gravida said, "I decided to go after four months because I was healthy after I got pregnant" (Participant 8).

Some Pregnant women would not seek ANC treatment at the health facility until a medical condition arose during the pregnancy. A midwife of 25 years reiterated this by saying; "Since they interpret pregnancy as a natural physiological condition, most mothers who come for ANC follow-up when they are sick, in my experience, do not perceive pregnancy as requiring health care attention, which causes them to be late"(HCP, 1).

Sub-theme 4: Lack of knowledge of the ideal booking time

We found three codes: they used their previous ANC booking experience, were unaware of the start period, and there is a knowledge gap among healthcare providers. Many of the pregnant women didn’t know the appropriate time for the booking. A 32-year-old gravida five says: "I booked my pregnancy last time at 16 weeks, but this time I decided to come at 30 weeks because I saw no purpose to attend before that point." (Participant 4).

Key informants also support the above reasons; unaware of the start period ANC is an important contributor to being late for their ANC booking.

A 27-year-old midwife man mentioned this by saying, "The majority of the mothers arrived at 30 weeks, particularly from outlying areas." I believe the reason for the delay is due to misinformation and a lack of awareness about ANC follow-up; not only pregnant women, but also their family members, have been given incorrect information about ANC services, such as "what do you get from them at 3 and 4 months, you'll go at 9 months"(HCP, 2).

Furthermore, some health personnel advise starting at or after four months of pregnancy, and some others recommend when they feel the fetal movement, if they don’t know the month of their pregnancy. We advise them to start at or after four months of pregnancy if they don’t know the month of their pregnancy. This was mentioned by a 26-year-old health extension worker. "After we found out they were pregnant, we sent them to a health institution because we couldn’t give ANC follow-up service. We do distinguish the pregnant mother and give counsel to begin at or after four months; if they do not know their month, we suggest going when they feel fetal movement, but they can go before that when they have a problem”(HCP, 6).

For four months, the health organization did not have a follow-up. Using the example of a 28-year-old health extension worker, "We advise them to start ANC follow-up as soon as they know their pregnancy; whereas the health center sends them back by advising to return after 4 months because they said it is not visible now" (HCP, 8).

Theme 4: Health care facility -related factors

The fifth theme that emerged from data analysis was Health care facility -related factors. Five sub-themes have been discovered under this theme. They include distance, long queues at ANC clinics, health care provider problem, and record (card) room. The code was shown in Table 4.

Table 4. Theme III-Health care facility -related factors

Sub-theme 1: Distance

We discovered two codes for this sub-theme; clinics too far and inaccessible transportation. The long distance between the health institution and the pregnant mother's home was cited by pregnant mothers as a reason for the late start of the first ANC booking. Since no transportation system exists in that region to assist women in getting to and from the health facility, they were late for their ANC visits. A 37-year-old gravida seven believes that the health center’s locations are inconvenient for her to reach for ANC services as follows: "My house is a long way from the hospital. Since there is no public transportation in this area, I must travel a long distance to get here. As a result, I decided to extend the time for the first ANC visit. But now I'm feeling ill, which is why I've come to see you today“(Participant 3).

The distance was also cited by six health care providers as a factor in late ANC bookings. The physiological condition of pregnant women is a barrier to walking for several hours to reach the health institution, and those who live in rural areas are described as the reason for late ANC booking. The health extension worker mentioned this by saying, "It is extremely difficult for them since they live in a rural area where the village's demographics fluctuate and there is no transportation system that forces the mother to wake up on foot, which is extremely difficult for them." And when we visit them in their homes, it is difficult to get in touch with them” (HCP, 9).

Sub-theme 2: Long queues at ANC clinics

Long lines and a shortage of medical personnel are among the issues. Three respondents said there were long queues in the ANC service area. In the health institution, there is no appointment system, so this pregnant mother waits a long time, sometimes until the whole day to get the service, whereas after waiting they may not receive the service. This makes them disappointed to come in another time and may be late. A 28-year-old gravida four participants specified as follows: "I arrived at 2 p.m. today to begin ANC service, but there were long lines and no appointment system in the institution, so as you can see, I finished the service about 11 p.m. and had no way to get home, so I had to take Bergo to stay the night" (Participant 11).

Health care providers supported the above reason: overburdened health facilities with a shortage of health staff are also an obstacle to providing successful ANC services, according to health care providers. A 28-year-old health extension worker mentioned this by saying: "The facility was very much uncomfortable for waiting in long queues; the ANC clinic and the waiting room were overcrowded with clients, and due to that, the mother felt uncomfortable staying a long time to get the service" (HCP, 8).

“To care for all of us, there is just one nurse. I don't want to return to this health center because it is really tough to receive the proper care” (Participant 5).

Sub-theme 3: Health care provider problem

As mentioned by most participants, unfriendly healthcare providers and time management were mentioned by participants .The quality of the ANC clinic's services depends on the healthcare worker's friendly care. They explained that the ANC services care provider didn’t give appropriate information about their condition and also their baby. A 28-year-old gravida stated this by declaring: "I have child death history twice in the same four days and I have no good memoirs in this hospital because they didn’t give attention to neonates and they didn’t explain the reasons for my child deaths." Loss of children two times is very hard for a mother. I don't want to see my third child’s death. As a result, it is preferable to improve service delivery and health-care provider behavior” (Participant 11).

According to a health extension worker, health care workers in health institutions are not compassionate, respectful, or caring. When mothers visit a health facility, they are not treated with love, they lose faith in the way they are treated, and they are not given the right details about the benefits of ANC booking as suggested and said;“During home visits, many mothers expressed dissatisfaction with the ANC services provided by health institutions. They did not provide appropriate counseling to mothers who lost their child during pregnancy or childbirth, and they also did not provide service in a queue, giving preference to the social and mistreating the mothers.’’(HCP, 8)

Participants stated that health care providers employed in health centers did not begin their work during working hours. A 24-years-old gravida three declared:

Participants stated that health care providers employed in health centers did not begin their work during working hours. A 24-years-old gravida three declared:

Sub-theme 4: Record (card) room

We identified two codes under this sub-theme. These are: card loss, and mistreatment. The card room folder management has received complaints from five participants. They didn’t find their folder when they came for the next time, according to a 21-year-old woman who said: "When I arrived today, the runner informed me that he couldn't locate my card and that it may not be returned, so I asked the health care provider to check the ANC room, but they said they couldn't find it." After a full day of waiting, they encourage us to register as new clients; imagine my entire document being lost” (Participant 2).

A pregnant mother was mistreated by the card room service provider, according to a 23-year-old gravida one by saying, "There is a problem with the card room service provider in that they mistreat the pregnant woman." This is fine for me, but it is very difficult for another pregnant mother who has traveled a long way. Because of them, I don't want to come here” (Participant 7).

Sub-theme 5: COVID-19 pandemic

Two codes perceive the institution is closed due to COVID-19 and the other thing is that it is very fearful to come to a health institution. The COVID-19 pandemic is a worldwide health issue. It has an impact on the health system directly or indirectly. The impact of this pandemic also had an influence on our country's health system. A 36-year-old gravida seven assumes the institution is closed due to COVID-19 by saying; "I heard from the mothers in my village that the ANC service is not being provided due to the COVID-19 pandemic; however, I am sick and have decided to come to this institution" (Participant 3).

There are a large number of clients seeking ANC services, and the waiting area is extremely crowded, so they are hesitant to visit the hospital because there may be contagious patients in the waiting area. A 26-year-old gravida two sated this by saying; "When I found out I was pregnant, there were a lot of COVID-19 patients, so I couldn't come at that time because there were a lot of clients in the ANC clinic area, which could increase the transmission, so I decided to wait; but now I'm almost 6 months and I've decided to see my baby via ultrasound" (Participant 9).

From the perspective of healthcare providers, there is a mother who is not comfortable coming to the health institution. Some mothers are reluctant to visit the hospital because the facility often treats COVID-19 patients, and they are afraid that if they go, the virus will spread to them. This was reported by a 28-year-old health extension worker participant as saying; "Because of the COVID-19 pandemic, mothers are reluctant to visit a health facility because there could be a variety of clients from various areas who have come for service and are at risk of being contaminated." (HCP, 7)

Discussions

The reason for late ANC booking among late ANC bookers and health care providers for commencing ANC after 16 weeks of gestational age was investigated in this paper.

Pregnant women living in rural areas with low economic conditions  are affected  by ANC services because they cannot afford to contract for transportation costs to meet the health institution and service charge costs, causing their first ANC appointment to be delayed. This finding was similar to a study conducted in Tanzania and Cameron and South Africa [13-15].

In the qualitative findings, both pregnant women and health care providers described unplanned pregnancy as a reason for too late initiation of their first ANC appointment. Similarly, two qualitative studies were conducted in our country, in Axum and Sidama zone supports these findings. This may be due to a failure of family planning; people assume that pregnancy will not occur while breastfeeding, menstrual irregularities, and the fear of stigmatization among single women who are afraid to reveal their pregnancy [16,17].

A study also revealed that a lack of knowledge about the ideal booking time is a factor. Some pregnant mothers were perceived the ideal time after four months; this is directly related to the previous experience. Furthermore, the key informant found some health care providers were advising the pregnant women in an appropriate way, i.e. to start at/after four months of their pregnancy, and some of the others were recommending that they feel the fetal movement; if they don’t know the month of their pregnancy.

Cultural beliefs are one of the reasons identified in a qualitative study; pregnant women were late for their first ANC booking due to fear of gossip and witchcraft. This is related to ANC attendance requiring disclosure of pregnancy. This result was supported by different studies conducted in the UK. Tanzania, Cameron, and Sidamo, Ethiopia [13,14,18].

Pregnant women's factors have also had an impact on ANC service initiation. In our qualitative study, the reasons that lead women to first ANC booking were a lack of knowledge on pregnancy symptoms, perceiving pregnancy as normal physiology, a lack of awareness of the ideal time of ANC booking, fear of coming to the ANC clinic due to the COVID-19 pandemic, and having a busy time. This finding is comparable with a study conducted in the United Kingdom and Cameron. Likewise, Ethiopia conducted studies confirming the above reason as a barrier to early initiation of the first ANC visit [13,14,16,17].

The qualitative results showed that healthcare-related problems had an impact on ANC initiation time. Long lines at the ANC clinic, gaps in healthcare provider skill and behavior, and card room service were identified as reasons for the delayed start of the first ANC visit. This finding was similar to a study conducted in Ethiopia, Sidamo and Tselemt district, Tigray [17,19].

Conclusion

The results of the qualitative study showed that socio-demographic factor, socio-cultural belief related factor, pregnant woman related factor, and health care facility related factor. The findings of this qualitative study add to the existing of knowledge already known about pregnant women's and healthcare providers' perspectives. Raising public awareness about contraceptive use is necessary to minimize unwanted pregnancies. A digital system should be implemented because the hospital card room card keeping system is outdated and many pregnant women's cards are commonly lost.

Acknowledgment

We would like to forward our thanks to Addis Ababa University College of Health Science, department of nursing and midwifery support. Our thanks also go to study participants for giving us their time and full commitment.

Foot Notes

Consent form publication: Not applicable

Patient consent for publication: Not required

Ethical Approval

Ethical clearance was obtained from the research ethics committee of the department of midwifery, university of Addis Ababa. Permission to conduct the study was granted by the Bench Shako Zone Health Bureau.

REFERENCES

The paper and its supporting information files contain all necessary data.

Competing Interest

There are no potential conflicts of interest for the authors to disclose.

Funding

This work was funded by Addis Ababa University .The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript

Authors’ Contributions

GG was responsible for gathering the data, processing it through analysis, and interpreting the results. KD collected the data and helped with the interpretation of the results, while RT, HA, and LD read, commented on, and revised the various revisions of the text. The paper has been read and approved by all authors.

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