The availability, accessibility and utilisation of antenatal care services play a major role in the lives of pregnant women and neonates worldwide (World Health Organization [WHO], 2016a). Globally, underutilisation of antenatal care services is influenced by various factors, such as low maternal education, stigma, teenage pregnancies, multiple parity and cultural factors (WHO, 2016a). Knowledge has been shown to have a direct effect on pregnant women's attitude towards prenatal care and other health issues (Sanda, 2014). A study done by Guevarra et al (2017) found that poverty, unemployment and low levels of education are associated with poor utilisation of antenatal care services in New Zealand. The WHO (2016b) suggests that efforts to reduce maternal mortality must focus on adequate antenatal care services and medical management. Blencowe et al (2016) report that 33% of perinatal mortality (PNM) that occurs at birth is largely the result of avoidable causes, such as late presentation or no attendance at antenatal care services. Poor utilisation of antenatal care services plays a major role in poor maternal and neonatal outcomes.
Majrooh et al (2013) note that in the Punjab province of Pakistan, sociocultural factors, such as low levels of knowledge, influence of spiritual healers, poverty and the distant locations of health facilities, increase the inaccessibility of antenatal care services by women. This has aggravated the underutilisation of antenatal care services by 57.8% of pregnant women. Provision of basic antenatal care is a key strategy to improve the care of pregnant women and achieve the recommended four antenatal care visits by the WHO (Department of Health [DoH], 2015). One crucial service during these visits is early screening, which is done to detect and prevent early complications, such as hypertension and pregnancy diabetes mellitus. This also assists in reducing the occurrence of stillbirths, thereby improving maternal and child healthcare (MCHC) (WHO, 2016b). The utilisation of antenatal care services in other developing countries, such as Bangladesh, Algeria, Georgia and Ghana, is poor, usually because of financial burdens (Mullachery et al, 2016; Blecher et al, 2017). However, in developed countries, such as Norway, Switzerland, Netherlands and New Zealand, Zhao et al (2012) report that 90% of pregnant women initiate antenatal care during the first trimester (within the first 12 weeks of pregnancy), and make five or more antenatal care visits. The following factors are significantly associated with early utilisation of antenatal care as compared to those with low incomes: coming from a high-income household, from urban areas, having reached higher education. In addition, women in these situations are assisted by skilled birth attendants during delivery, with good outcomes. In developing countries, 49% of pregnant women make one antenatal care visit and for two-thirds of these women, delivery is assisted by unskilled birth attendants (Sinyange et al, 2016). Sanda (2014) notes that underutilisation of antenatal care services is associated with higher maternal and neonatal morbidity, such as eclampsia, pre-term birth and low birthweight.
South African health services are severely strained as a result of economic crisis caused by structural and political issues; these have accumulated into insufficient delivery of health services, inclusive of antenatal care services. These issues, as noted by the WHO (2016a), either worsen or cause deterioration of antenatal care services. The South African Institute of Race Relations (2019) reports that maternal and PNM rates remain high (5.14%), particularly in rural areas, such as the Limpopo province. Ragolane (2017) conducted a study in the Mopani district, Limpopo province and reported that more than 79% of pregnant women initiate antenatal care services only after 12 weeks of gestation, increasing the potential risks of pregnancy-induced hypertension (PIH), which may contribute to maternal and neonatal mortality. Underutilisation of antenatal care services is usually associated with personal factors, such as late recognition of pregnancy and lack of support. The majority of pregnant women do not understand the benefits of early attendance at antenatal care services and this escalates the high rate of late antenatal care booking.
In South Africa, MCHC services are available and provided free of charge in all primary healthcare facilities as per the maternity guidelines (DoH, 2015). Prior to 1994, all South African citizens had to pay fees for any healthcare services rendered. In 1994, a Democratic Government of National Unity was established in South Africa, and the African National Congress implemented several measures to combat health fragmentation and inequalities. These included the introduction of free healthcare services for all children under the age of 6 years old, as well as pregnant and breastfeeding women who were using primary healthcare facilities, district hospitals and tertiary hospitals (African National Congress et al, 1994). primary healthcare services are now provided with no cost. primary healthcare facilities within walking distance of less than 5 kilometers, staffed with doctors and midwives, and running mobile services are available, even in the most remote rural areas (DoH, 2015). However, the majority of women from remote rural areas are still living in poverty and cannot afford transport to a primary healthcare facility that is not within walking distance (DoH, 2015). Despite the government's effort, the utilisation of antenatal care services, by pregnant women, remains a major public health challenge, thus the majority of pregnant women (96%) present late (after 12 weeks of pregnancy) for antenatal care services (Sibiya et al, 2018). As mentioned earlier, underutilisation of antenatal care services is influenced by several factors, such as low educational levels, cultural beliefs and transport problems, nonetheless, delays in seeking antenatal care services exposes pregnant women to high risks from untreated medical and neonatal conditions (DoH, 2015). In reviewing the literature, it can be demonstrated that not many studies have been done regarding underutilisation of antenatal care services in the Limpopo Province, South Africa. Therefore, the current study endeavours to explore factors contributing to underutilisation of antenatal care services in Limpopo Province, South Africa.
Methods
Study design
A qualitative, exploratory and descriptive research design was used. This was deemed an appropriate design as the researcher needed to investigate and find meaning in the participants' words, and describe factors associated with underutilisation of antenatal care services. Additionally, this design should establish research priorities that can lead to further investigations, and therefore improve utilisation of antenatal care services (De Vos et al, 2017; Polit and Beck, 2018). It is hoped the results could ensure healthcare procedures can be put in place to mitigate poor utilisation of services and improve access of antenatal care in rural communities.
Study setting
The study was conducted in the clinical setting of 10 government hospitals of the Limpopo Province, South Africa. The Limpopo Province is divided into five districts, within which the DoH operates 44 hospitals, 27 health centres and 408 primary healthcare clinics (DoH, 2015). Pregnant women come for antenatal care services at the hospitals' primary healthcare gateway clinics. Gateway clinics are situated inside hospitals and manage clients with minor ailments, such as flu, render MCHC services, inclusive under 6-year-old service, geriatric services and services for patients with chronic conditions, free of charge. Pregnant women at high risk, such as those with gestational diabetes mellitus, are referred to obstetric gynaecologists for further management.
Population and sampling
The population for this study was 886 pregnant women who were attending antenatal care services at the primary healthcare gateway facilities situated in 10 selected government hospitals. In each of the five districts, the two hospitals with the highest number of antenatal care cases were purposively selected. The target population was comprised of pregnant women who were present during the data collection period, from 1 May to 31 July 2015, and the accessible population was pregnant women who agreed to participate in the study. A non-probability, convenient sampling method was used to sample pregnant women aged 20–45 years who were available at the time of data collection, willingly consented to participate in the study and were not necessarily women who had underutilised antenatal care services. The sample comprised 83 participants who formed part of 10 focus group discussions. The number of participants in each selected hospital varied from 8–10.
Data collection
Appointments for data collection were made through the nursing service managers and area managers with access to pregnant women attending antenatal care services at the selected hospitals. The central question that underpinned the discussions was ‘What do you think could be the factors associated with underutilisation of antenatal care services during pregnancy?’.
Before the focus group discussions, the purpose of the study, activities involved, risks and discomfort, (such as psychological harm because of sensitive questions), benefits, assurance of anonymity and confidentiality were explained to participants. Participants were requested to sign an informed consent form that indicated their willingness to participate in the study and for the interview to be recorded using an audio recorder. Each focus group discussion session took approximately 45 minutes and this time duration was carefully observed. Probing was used to elicit more information from participants. Following the eighth focus group discussion, no new data were collected and the researcher determined that the point of data saturation had been reached. However, the researcher continued to the 10th focus group discussion. Translation and back translation were conducted by linguistic experts and subject specialists who translated and phrased the medical terms into understandable local language for the women. No problem was identified, as the women responded well to the questions during the pretesting period. All narratives and discussions were audio-taped to capture the exact verbal responses of the participant, and these were supported by field and observational notes. All responses, verbal and non-verbal, were summarised to confirm and validate the findings to discover the truth.
Data analysis
Data collected from focus group discussions were analysed using Tesch's open coding method, as described by Creswell and Creswell (2017). Data were typed without names and all transcripts were read carefully to facilitate content analysis. The researcher listened to the tape recorder and checked the field notes several times until familiar with the depth and breadth of the content. Data were transcribed verbatim, developing a deeper understanding of the information. During data translation, a coding system was used to categorise all the participants' information and the topics and ideas of similar interpretations were grouped together to form categories. From each category, topics, ideas and themes emerged and these were used to arrange the collected data into specifications, which were then refined.
Measures to ensure trustworthiness
Trustworthiness was accomplished by applying Lincoln et al (2011) criteria for credibility, transferability, dependability and confirmability; these ensured that the data collected accurately represented the attitudes of the pregnant women. Credibility was ensured by prolonged engagement of the researcher with the participants and triangulation using two or more theories, methods, and data sources. The use of voice recording, field notes, lists of codes and a diagram showing how different themes relate the process of data collection ensured confirmability. Transferability was achieved by selecting a sample that represented the entire population of the study and the in-depth discussions done. Coding and recoding were done to ensure consistency and dependability (Burns and Grove, 2014; Polit and Beck, 2018). Pretesting was conducted with one focus group discussion at a hospital that was purposively selected from one of the districts. It was done to check whether the proposed questions were clear and unambiguous, and the time that would be required for interview. The group and information collected during the pretest did not form part of the main study.
Ethical considerations
The issue of ethical principles was taken into consideration. Ethical clearance was obtained from the University of Venda Research Ethics Committee, and permission was sought from the Research Committee of the DoH, Limpopo Province and the chief executive managers of the 10 selected hospitals. Ethical principles, such as maintenance of confidentiality, informed consent and privacy, were carefully observed (Polit and Beck, 2018). Participation in this study was strictly voluntary, the participants were free to withdraw from the study, if they felt like it, without any threat to the care they received (De Vos et al, 2017).
Results
The results revealed that many of the participants (77%) were single and only 23% were married. Many of the pregnant women (83%) were from rural areas and 78% of participants were unemployed. Most (84%) presented late at antenatal care centres and only 16% initiated antenatal care services within the first three months of pregnancy.
In the focus group discussions, women who presented late for antenatal care services expressed various reasons, such as an unwanted or unplanned pregnancy, number of pregnancies or children and cultural beliefs. Table 1 outlines the subthemes of factors contributing to underutilisation of antenatal care services identified by pregnant women in the Limpopo Province. The sociocultural factors were identified as the core theme/factor that played a role in the underutilisation of antenatal care services. The subthemes of unplanned pregnancy, high parity, fear, and culture and beliefs also emerged during data analysis.
Table 1. Summary of theme and subthemes
| Theme | Subthemes |
|---|---|
| Sociocultural factors associated with utilisation of antenatal care services | Unplanned pregnancyHigh parityFearCulture and beliefs |
Discussion
Sociocultural factors associated with underutilisation of antenatal care services
The results suggest that many women do not adequately utilise antenatal care services, as the majority of pregnant women (84%) visited antenatal care services during the second or third trimester of pregnancy. Pregnant women indicated that unplanned pregnancy, women who have had five pregnancies/children or more, fear, and cultural beliefs are the social, cultural and behavioural factors that affect utilisation of antenatal care services. Similarly, Dapaah and Nachinaab (2019) reported that sociocultural factors such as age, a traditional belief system, education, and marital status influence women's use of MCHC services in the Tallensi district. Some pregnant women do not consider utilisation of antenatal care services important because they are from remote rural areas, living in poverty, and lack information about antenatal care services. Additionally, some experience low support from their spouse or family members. Some women who give birth to their first child without complications may influence other young women to either present late, have only one antenatal care visit or not to book for antenatal care services at all (DoH, 2015; Ragolane, 2017).
Unplanned pregnancy
It is crucial for women to plan their pregnancies prior to conception, to improve their acceptance of the coming baby. Planning would assist them in seeking health advice from nurses and doctors on eating healthily, as well as avoiding smoking and alcohol abuse to improve their health status. This could encourage and motivate pregnant women to seek antenatal care services earlier, improve pregnancy outcomes and minimise complications, such as PIH (DoH, 2015). Pregnant women expressed that being unprepared or having unplanned pregnancies contributed to poor utilisation of antenatal care services.
‘I was not ready for this coming baby although I am term! I tried to hide and to terminate this pregnancy by taking traditional medicine but failed!’
(Participant from hospital D)
Some pregnant women delayed in attending antenatal care services because they had failed when trying to terminate an unwanted pregnancy. Titaley et al (2010) reported similar findings from a study conducted in Indonesia; women with an unwanted pregnancy were more likely to underutilise antenatal care services.
In South Africa, the use of contraceptives as a means of preventing unplanned pregnancy is provided at MCHC services. However, some women might be reluctant to use family planning, resulting in an unplanned pregnancy, and so choose termination of pregnancy as a means of contraception (DoH, 2015). Women might then delay in coming to antenatal care centres because they try to terminate the unwanted pregnancy and only come to the centres after failure. Alternatively, mothers using family planning, especially the injectable method, may experience amenorrhea and then an unplanned pregnancy. In many cases, these women notice their pregnancy by feeling fetal movement or during a consultation (Ragolane, 2017).
‘If I am not sure about pregnancy because I was using injection as a means of family planning, I should adjust myself to pregnancy and wait for fetal movement as a sign of pregnancy’.
(Participant from hospital G)
Kost and Lindberg (2015) reported findings from the US National Survey of Family Growth. In Oklahoma, 40% of the four million annual births in the United States resulted from an unintended or unplanned pregnancy and the majority of those women underutilised antenatal care services or never attended.
Zaki and Albarraqb (2014) and Darega and Dida (2015) noted similar findings that unintentional pregnancies could cause stress, worry, depression and concerns, which usually result in underutilisation of antenatal care services. Sibiya et al (2018) in South Africa showed that up to 50% of pregnancies were unplanned, which is one of the main reasons most women present after the second three months of pregnancy at antenatal care services. Therefore, unplanned pregnancy could contribute to underutilisation of antenatal care services.
High parity
The women in this study reported that parity plays a major role in first attendance at antenatal care centres. Women with five or more pregnancies with successful outcomes were reluctant to attend antenatal care centers. These women asserted that they usually attend after the second trimester, claiming that they had experience in coping with the usual minor disorders of pregnancy. In the literature, multiparous and grande multiparous women have been reported to deliver at home and come to a primary healthcare facility only for processing birth certificates and arranging for child vaccinations (John et al, 2018).
‘I know about pregnancy as well as the time for foetal rotation! Therefore, I start antenatal care services after six or seven months of pregnancy.’
(Participant from hospital C)
‘The journey to antenatal care centers is time-consuming. It is so boring! Nurses ask us about number of children and as if we can make a span!’
(Participant from hospital I)
Titaley et al (2010) conducted a study in Indonesia that reported low utilisation of antenatal care services by multiparous women, hypothesising that this was the result of relying on experience of previous pregnancies and therefore not feeling the need for antenatal care services. Similarly, a study conducted in Nigeria revealed that 80% of grande multiparous women visit antenatal care centers after the second trimester, as they do not see the reason for attending antenatal care centres within the first three months of pregnancy. John et al (2018) conducted a study in Tanzania and revealed that multiparous and grande multiparous women tend to present late at antenatal care centers, compared to nulliparous women, and that 98% of women who make only one antenatal care visit were grande multiparous. This could be attributed to parity, knowledge about antenatal care services and socioeconomic status.
Contrary to this finding, Zhao et al (2013) reported that 90.1% of women who had previous pregnancies and were 35 years old or more adequately utilised antenatal care services in Shanghai, and only a few women (9.9%) had no time for a visit; this was influenced by health insurance and employment status during pregnancy.
Although midwives can give health education when rendering antenatal care services and during pregnancy week campaigns, they are challenged by shortages of staff and insufficient resources, for example, pregnancy testing kits. In a study by Mulondo and Khoza (2015), midwives commented that antenatal care during the first visit is time consuming and they do not follow all the required investigations of pregnant women because of the workload and having to attend to clients with minor ailments. The study further revealed that midwives scold, rebuke and abuse women as a result of work-related stress; these issues discouraged women of high parity from initiating antenatal care services earlier because of their previous experiences. It was also noted that midwives had no time to peruse the available basic antenatal care guidelines and prevention of mother-to-child transmission policy, both of which assist in proper management of pregnancy, labour and the puerperium period (DoH, 2015; Ragolane, 2017).
Underutilisation of antenatal care services could expose women to eclampsia, dysfunctional uterine bleeding (which could lead to death), low birthweight and prematurity among babies.
Fear
Fear, of the known or unknown, was reported as a contributory factor to underutilisation of antenatal care services; pregnant women might be worried and anxious about pregnancy and childbirth. In a study by Ragolane (2017), the majority of women were unmarried and there was no mother-in-law or husband to whom they could disclose their pregnancy, so that they could be advised about early antenatal care booking. In South Africa, the Limpopo province population includes immigrants who cross the Messina border from Mozambique and Zimbabwe for employment opportunities. Immigrant women have reported fearing prenatal care attendance because of language barriers (Mulondo and Khoza, 2015). Grande multiparous women have also been reported not to utilise antenatal care services earlier because they fear tubal ligation (an operation doctors perform to tie women's fallopian tubes so that they can no longer conceive).
‘We are afraid for our womb to be tied and become cramp, cannot work and our husband will no longer come to us or we will keep on draining fluids through the vagina’.
(Grande multiparous participant from hospital B)
Women sometimes only come for antenatal care services to get an antenatal care card as a means of accessing the maternity units during labour; in this situation, opportunities for counseling and preparation for tubaligation would be limited; the women deliver and go home.
A study by Gebremeskel et al (2015) in Ethiopia reported similar findings. Grande multiparous women feared tubaligation and an inability to conceive, contributing to underutilisation of antenatal care services. Therefore, one of the factors associated with underutilisation of antenatal care services is fear. Similarly, Mulondo and Khoza (2015) and Ali et al (2018) reported a fear of testing for HIV has influenced many women not to present for antenatal care services earlier. This is a concern for many pregnant women, as testing positive is associated with the stigma attached to disease, which could reduce the women's social status, causing them to deny the pregnancies. Gebremeskel et al (2015) and Mulondo et al (2015) concurred, reporting that initiation of antenatal care services after 12 weeks of gestation was associated with high maternal mortality and low birthweight, because of poor monitoring of pregnancy. Early utilisation of antenatal care services could assist in early screening, detection and treatment of medical conditions to improve maternal and child health (Majrooh et al, 2013). Ali et al (2010) found that in eastern Sudan, 90% of women made one antenatal care visit; fear and knowledge deficiency were identified as some of the factors contributing to underutilisation of antenatal care services.
Culture and beliefs
Culture was considered by the majority of participants as a factor that affects behaviour towards utilisation of antenatal care services. Dapaah and Nachinaab (2019) explain that ‘culture is a belief, norm and practice of a particular group that are learned, shared and guide decisions, and actions in a patterned way’. Culture and beliefs play a major role in utilisation of antenatal care services.
‘In my culture, it is a taboo to present early for antenatal care services because if pregnancy is known by my family enemies, I may be bewitched, and pregnancy will not succeed well’.
(Participant from hospital A)
‘According to our cultural tradition, I must not disclose pregnancy until period of six months to prevent bewitching’.
(Participant from hospital F)
Finlayson and Downe (2013) found that similar cultural beliefs and customs play a role in initiation of antenatal care services. According to traditional and cultural beliefs, a pregnant woman should not disclose her pregnancy until she has missed her periods for 5–7 months. Those beliefs limit early initiation of antenatal care services. John et al (2018) and Dapaah and Nachinaab (2019) reported similar findings from their studies conducted in Ghana and Tanzania, respectively. Women feared to be cursed by evil spirits, meaning they did not disclose their pregnancies, and registered late for antenatal care services. Furthermore, Ragolane (2017) noted similar beliefs that women underutilised antenatal care services centres because they were afraid their enemies might bewitch them and harm their unborn babies.
‘I am from rural village and most of elderly women did not go to school or didn't finish school, and thus, we do not see the importance of early coming to antenatal care services, unless we have some ill health’.
(Participant from hospital H)
‘When I grew up, I used to hear my mom saying that she did not attend school at all, never went to clinic for antenatal care services and she delivered at home…My mother told me that it is taboo for girls to attend schooling!’
(Participant from hospital J)
The present study's findings affirm that low levels of education or illiteracy among pregnant women can lead to the inability to make informed choices regarding early utilisation of antenatal care services. These women would have difficulties in understanding health-related information, including antenatal care issues. Similar findings from a study conducted in Vietname revealed that pregnant women were prevented from gaining access to education information and social participation, owing to cultural norm and, therefore, these women were unable to make the decision about early presentation at antenatal care services (Akella and Jordan, 2015). Midwives have to respect mothers' decisions and cultural beliefs, even when they are contrary to scientific modern practice. However, midwives should promote relationships of mutual trust, respect and dignity with mothers. Ongoing support, advice, education, and counselling should be provided each time women visit a primary healthcare facility, both prior to and during pregnancy. In this way, women would always be given the opportunity to discuss issues related to pregnancy and childbearing, and be encouraged to ask questions freely (Mogawane et al, 2015). The National Institute for Health and Care Excellence (NICE, 2008) guidelines emphasise a woman-centered approach through which the views, beliefs and values of a pregnant woman, her partner and her family members, in relation to prenatal care, should be sought and respected always. South African maternity guidelines do not clearly spell that out, although much of the information regarding management of pregnancy and labour are similar.
Limitations
The study was conducted in 10 selected hospitals of five districts of the Limpopo Province and the sample size was limited to 83 participants. Therefore, the findings cannot be generalised to the whole Limpopo Province, South Africa.
The scope of the study included only pregnant women aged 20–45 years old. A major study needs to be conducted on a larger scale, targeting the reduction of maternal and PNM rates in South Africa. The results of such a study should be communicated to the South African DoH to include in basic antenatal care and maternal guidelines when managing pregnancy, labour and puerperium.
Conclusions
The findings of the study revealed that underutilisation of antenatal care services is still a challenge in the Limpopo Province in South Africa. The study identified various sociocultural factors contributing to underutilisation of antenatal care services, such as unplanned pregnancy as women are reluctant to use contraceptives for child spacing; high parity among multiparous women as a result of their belief in their own experience regarding pregnancy and childbirth; fear, which is common amongst multiparous women who do not want to undergo bilateral tubaligation; and culture and beliefs that prevent women from disclosing their pregnancy or making an informed decision regarding early initiation of antenatal care services. Midwives should play a major role in giving health education, support and counselling, both prior and during pregnancy, with the aim of improving maternal and neonatal wellbeing and health. Underutilisation of antenatal care services could affect the achievement of the target of less than 70 maternal deaths per 100 000 live births and a reduction of premature deaths of 1/3 by the year 2030, as per the United Nations Development Programme to fulfil the sustainable development goals.
Recommendations
A strong emphasis should be placed on health education during antenatal care visits by pregnant women (both nulliparous, multiparous and grande multiparous), including the importance of antenatal care services, family planning, and awareness of minor disorders during pregnancy, such as urinary tract infection. Women should also be encouraged to visit primary healthcare facilities prior to conception. That would assist in early screening, detection and treatment of medical conditions, such as diabetes mellitus, hypertension and tuberculosis, to prevent maternal and neonatal complications, including pre-eclampsia and low birth weight. Information education communication materials should be distributed by midwives and family planning motivators to increase awareness about family planning and prevent unplanned pregnancies among women. The messages can be disseminated through structures that already exist, such as health awareness campaigns, media such as radio, open days and community Imbizo (meeting or gathering with traditional leaders). This could assist in changing the behaviour of women and increase utilisation of available antenatal care services. It would also increase awareness of the importance of antenatal care services among family members and the community, giving support and encouraging pregnant women to present early. Training of both doctors and midwives should be conducted on the essential steps in managing obstetric emergencies and helping babies breath, with the aim of improving the quality of perinatal care and perinatal outcomes in South Africa.
Key points
- Socioeconomic factors are associated with underutilisation of antenatal care services.
- Culture and beliefs contribute to underutilisation of antenatal care services.
- Women of high parity are reluctant to use antenatal care services.
- Unplanned pregnancy contributes to delay or non-utilisation of antenatal care services.
- Fear of the known or unknown is associated with underutilisation of antenatal care services.