Equity and access to antenatal care
WP leaders: Angela Harden and Bjorgulf Clausen
In order for behavioural and nutrition interventions developed from the GIFTS programme to be effective in reducing the risk of future metabolic diseases it is crucial that women and their families are able to access and engage with them. These interventions are likely to be delivered before pregnancy, during pregnancy, or in the postnatal period and, ultimately, to be integrated with routine pregnancy related services such as a package of antenatal care. There is evidence that women from both developed and developing countries do not always find it easy to access such pregnancy-related services and that those women who bear the burden of the worst outcomes for themselves and their babies are more likely to access care late or inconsistently.1-3 Work package 10 of the GIFTS programme aimed to explore these issues amongst South Asian women living in Europe and South Asia with a view to making recommendations to ensure that interventions from GIFTS are accessible and engaging.
This work package had two strands. The first was designed to investigate influences on the uptake of antenatal care and other pregnancy-related services by South Asian women living in East London and Oslo. In particular, the perspectives and experiences of South Asian women in relation to barriers and facilitators to accessing and engaging in relevant services were explored. This was achieved through a large qualitative study conducted in London and a smaller scale complementary qualitative study conducted in Oslo. The second strand investigated the factors influencing access to pregnancy related services for women living in urban areas of Bangladesh, Pakistan and India through a review of existing systematic reviews. The findings from both strands were integrated to make recommendations for the promotion of equitable access to, and engagement with, pregnancy related interventions to improve birth outcomes relevant to metabolic diseases in urban areas of Europe and South Asia.
Methods and results
a) Qualitative studies
Thirty interviews and four focus groups were conducted in East London with pregnant or recently pregnant women of Bangladeshi, Indian and Pakistani heritage, and a further three focus groups were conducted in Oslo with recently pregnant women of Pakistani heritage.
The interviews and focus group discussions used semi-structured schedules in which questions were open-ended with prompts to facilitate discussions. This helped to draw out contextual, process-oriented information and allowed respondents to identify issues from their own perspectives, along with providing rich and detailed information about their perceptions and experiences. All the discussions were recorded on a voice recorder. Data were transcribed, coded, and then analysed thematically by researchers trained in social anthropological and qualitative research.
Common themes from women’s accounts of their journeys into and through antenatal and postnatal services across East London and Oslo included: the significance of language barriers and unfamiliarity with the health system; a belief that antenatal and postnatal appointments were compulsory; and the central role of family in a women’s pregnancy (‘a family is pregnant not an individual’) which could work against rather than with the health system. Whilst women in Oslo and East London valued the free and standardised service offered, they also recounted feeling powerless due to a lack of choice and a stretched and impersonal service (‘you can’t get up and leave and take your custom elsewhere’).
There were some findings unique to the East London study from the interview data. There were particular challenges to women seeking pregnancy care in the first trimester. Some women spoke about needing a bit of time before disclosing the pregnancy to others. Although other women told everyone straightaway, the urgency in seeking care very early was not always apparent. Antenatal care sits within a health service associated with the treatment of illness; feeling unwell was a trigger for women to seek care and feeling perfectly fine made seeking care a lower priority and less urgent. When women did begin to seek care, navigating the health system was not always easy and required women to be proactive which can be difficult particularly if there are language barriers. Once on their antenatal journey some women reported feeling not listened to or even judged by midwives and others reported a lack of attention to practical, social and emotional needs.
b) Review of systematic reviews
Systematic searches were designed to identify reviews of qualitative research as well as reviews of statistical data and programs designed to promote access. Our searches identified a total of 422 records from which we identified 21 relevant reviews. Of these, two reviews focused on qualitative research examining factors influencing women’s uptake of antenatal care. Each review was assessed for overall quality; relevance and depth of synthesis and findings were integrated to identify common themes regarding a) the effectiveness of interventions to promote uptake of pregnancy-related services and b) factors influencing women’s uptake of pregnancy-related services.
Common themes amongst factors influencing women’s uptake of pregnancy-related services included: knowledge and awareness of services; socio-demographic factors; cultural factors and beliefs; service delivery; access and availability; and financial and economic.
Common themes identified on the effectiveness of interventions to increase access to pregnancy-related services included: use of peer or lay health workers; additional training and education for health workers; community mobilization and participatory learning and action: and integration of new interventions with routine services.
Discussion and Conclusions
Standardised and free maternity services In European health systems cannot always accommodate, and sometimes conflict with, the socio-cultural factors within the Bangladeshi, Indian and Pakistani communities living in European cities. Care-seeking requires women to be very proactive and barriers such as navigating the complexities of the health system are exacerbated by not being familiar with the service, not speaking the same language and stretched and limited resources. A health system that has a primary focus on ill-health and ‘patients’ can be seen as antithetical to the public health goals of antenatal care. All of these factors can lead to women feeling powerless within services with subsequent consequences for access and engagement.
Implications and recommendations for behavioural and nutrition interventions to reduce the risk of future metabolic diseases include:
· Early pregnancy is not an easy time to identify and recruit women into interventions as many women will not be registered within the health service until they are near the end of their first trimester. Community outreach using peer or lay workers and community organisations will need to be employed as well as targeting efforts towards the pre-conception period.
· Interventions need to be empowering for women with women taking an active role in the development and implementation of the intervention. This can be achieved through activities that mobilise communities such as co-design and co-production and well facilitated group work.
· Interventions will need to involve families and promote positive roles for fathers, parents and in-laws.
· Interventions and their evaluations need to be inclusive by ensuring there is provision for women who speak different languages to be involved (e.g. use of interpreters, visual materials).
(1) Cresswell JA, Yu G, Hatherall B, Morris J, Jamal F, Harden A, Renton A. (2013) Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK. BMC Pregnancy Childbirth. 2013 3;13(1):103. DOI: 10.1186/1471-2393-13-103
(2) Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies PLoS Med 2013;10:e1001373.
(3) Hatherall B, Morris J, Jamal F, Sweeney L, Wiggins M, Kaur I, Renton A, Harden (2016) Timing of the initiation of antenatal care: an exploratory qualitative study of women and service providers in East London. Midwifery, 26:1-7.