Facilitators and Barriers to Seeking and Engaging with Antenatal Care in High-Income Countries: A Meta-Synthesis of Qualitative Research

This presentation identifies facilitators and barriers to attending at antenatal care in high-income countries. This objective was achieved by gathering all the available qualitative data and conducting a meta-synthesis which was informed by meta-ethnography. We learnt that these barriers and facilitators are not only dependant of the individual, but also the health system and the social and political context.

Ms. Tamara Escañuela Sánchez is a Psychology Graduate with a Master in General Health Psychology currently conducting a PhD as part of the Pregnancy Loss Research Group in University College Cork, Ireland. The aim of her PhD is to develop an evidence-based behaviour change intervention targeting modifiable risk factors for stillbirth.

Ms. Sanchez has disclosed that she does not have any real or perceived conflicts of interest in making this presentation.

ACOG Consensus: Management of Stillbirth

Danielle Otlin: Hi, I’m Danielle Otlin.

Mike Otlin: And I’m Mike Otlin.

Danielle: And we’re Jude’s parents.

Mike: We’re here to introduce Ms. Tamara Escañuela Sánchez. Is a Psychology Graduate with a Master in General Health Psychology from the University of Barcelona. Currently conducting a PhD as part of the Pregnancy Loss Research Group at the University College Cork in Ireland. The aim of her PhD is to develop an evidence-based behavior change intervention targeting the modifiable risk factors for stillbirth.

Danielle: Ms. Escañuela Sánchez’s presentation today is titled, Facilitators and Barriers to Seeking and Engaging with Antenatal Care in High-Income Countries: A Meta-Synthesis of Qualitative Research.

Tamara Escañuela Sánchez: Hi, welcome to my presentation. My name is Tamara. I’m a PhD student at the Pregnancy Loss Research Group and the Infant Center at University College Cork in Ireland. I’m here to present our work titled, Facilitators and Barriers to Seeking and Engaging with Antenatal Care in High-Income Countries.

Let me just give you a little bit of background to put our study in context. Previous studies have associated inadequate attendance of antenatal with negative maternal and fetal outcomes, including increased risk of stillbirth. We know from the conclusions obtained after the publication of the stillbirth series in The Lancet that a large proportion of stillbirths in high-countries are associated with factors that are avoidable. It highlighted the importance of increased clinical and community awareness of those modifiable risk factors associated with stillbirth.

According to the WHO, antenatal care can be defined as the care provided by skilled healthcare professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy. Within its continuum, antenatal care provides an opportunity for communication, health promotion, prevention, screening, and diagnosis of diseases. WHO recommendation for antenatal care include a minimum of eight contacts. Five in the third trimester, one contact in the first trimester, and two contacts in the second trimester.

Hemminki and Blondel conducted a study a few years ago to compare the levels of utilization of antenatal care in different European countries. The authors concluded that the proportion of late attendees was low in Finland, France, and Italy, was moderate in Belgium, Germany, Norway, and Sweden, and it was high in Greece, Ireland, and Portugal.

As I mentioned before, previous studies have associated inadequate attendance of antenatal care with negative maternal and fetal outcomes. Stacey et al, reported that women who attended less than 50% of their recommended antenatal visits were three times more likely to suffer from late stillbirth, and a trend analysis found a significant relationship between decreasing visits and increased risk of stillbirth.

This lack or delay of antenatal care might be preventing healthcare professions to identify issues during pregnancy. Also, antenatal care is an opportunity for healthcare professionals to provide women with vital information about their health, which could lead to healthier lifestyle during pregnancy, decreasing the risk of adverse outcomes.

The aim of this study is to understand women’s attitudes, perceptions, and experiences of antenatal care in order to identify facilitators and barriers to seeking and engaging with their antenatal care. We decided to do so by conducting a meta-synthesis of qualitative research.

I’m going to quickly talk to you about our methods. Meta-synthesis is a systematic review of qualitative studies. The first steps are similar to any other systematic review process. We designed a search strategy that we run through five different databases, and we conducted the screening of titles, abstracts, and full text using our eligibility criteria.

Our eligibility criteria was as follows. Research for all quantitative or mixed method studies that included pregnant or women up to 12 months postpartum, conducted in high-income countries, and research from inception until November of 2020, a moment in which we last updated our search. To assess the quality of the included studies, we used the critical appraisal skills program or CASP. To assess our individual review findings, we use the CERQual approach. This approach facilitates assessment of how much confidence can be placed on individual review findings from a synthesis of qualitative research.

Our synthesis was informed by meta-ethnography. Meta-ethnography is an independent approach originally developed by Noblit and Hare that facilitates pulling together all of the research available by translating qualitative studies into one another. Noblit and Hare proposed a series of phases that overlap and repeat along with the conduction of the synthesis.

Phases 1 and 2 involved identifying research interest and gap and the objectives, and identifying the relevant literature. These steps were completed through a systematic search of the literature that I just explained. Phase 3 involves reading these studies in depth in order to become familiar with them. During this phase, data from the studies were extracted. To do so, each paper was read carefully and notes were taken, identifying the different data that need to be extracted by one author.

During phase 4, the studies were imported into NVivo to facilitate the identification of concepts and themes. We conducted the line by line coding of the results and discussion section of each study consulting with the rest of the team when in doubt. Once the initial coding was completed, the text added to each code was then examined to check consistency of interpretation, and additional coding was performed where necessary. We obtained a list of concepts that were grouped in themes and categories of systematic analysis.

Phases 5 and 6 involved translating the studies into one another and synthesizing those translations. The themes were further refined through the coding process to identify themes reflected domains of its individual status. The initial codes and themes were examined and combined when they described similar findings. To establish the relationship between the concepts, we utilize concept maps, stating the influence of each concept over the other. These maps were discussed with the research team.

Moving on to our results section, if you remember our systematic review process, our first search identified 5,499 potential studies. After removing duplicates, 4,517 cases were screened and 4,336 titles were excluded. 188 studies remain eligible for abstract screen, which resulted in 18 studies potentially eligible for full text screening. Finally, after full text screen, 15 studies were included in the synthesis.

As per the characteristics of the included studies, 14 of them were qualitative and 1 used mixed methods. They represented six different high-income countries. Four of them included pregnant women only, five included postpartum women only, and six included both. The timing of publication of the studies was from 1994 to 2020.

Now moving on to the actual findings of our synthesis, we were able to identify facilitators and barriers at different levels within society. First, we identified facilitators and barriers associated with individual pregnant women. Then we identified facilitators and barriers associated with individual healthcare professionals. Then we identified facilitators and barriers associated with the healthcare system, and finally we identified facilitators and barriers associated with the social environment.

I will begin by explaining the women’s individual factors. Within this theme, name attitudes towards pregnancy and antenatal care. We identified several emotional processes that have an influence on women’s decision making. For example, having feelings of ambivalence towards pregnancy, denying the pregnancy, feeling overwhelmed or unprepared to be a parent, worrying about social services environment, and fear play a very important role that can act as barriers for women to seek antenatal care. Our analysis identified that not having a planned pregnancy also identified these feelings and acted as an additional barrier.

We have here an exemplifying quote where one woman said, “It actually took me a few weeks to feel anything. I didn’t feel anything, because it wasn’t planned.” Or this other one from a woman who took time to consider terminating her pregnancy. “Well, I didn’t start mine right away because I went straight to the abortion clinic. Like I said at the beginning, I wasn’t happy.”

We also identified certain beliefs and attitudes that acted as barriers. For example, some women attributed low value to antenatal care, and some others understood pregnancy as a normal life event that doesn’t require medical attention. An example of this belief is also expressed in this quote. “Booking late is not a big deal to me. Number one, it is not a disease. I am not sick or anything, so I knew what was wrong with me.” Additionally, we also identified that having negative experiences related to healthcare in general led some women to mistrust the system and it also acted as a barrier to seeking antenatal care.

However, we also identified certain attitudes toward pregnancy and antenatal care that acted as facilitators. For example, women having positive feelings towards the pregnancy, actively planning pregnancy were mentioned as facilitators. One example of having positive feelings towards the pregnancy is shown in this quote. “You can always feel this presence, and you can almost, it sounds stupid, but bond with the baby because you feel like you’re together.”

Adopting an active role in their care. The antenatal care is an opportunity for behavior change and understanding the benefits of antenatal were attitudes and beliefs that acted as facilitators. Some women perceive antenatal care as acting as a preventive measure. Being a source of knowledge, support and reassurance and acting as a destruction and a means of socializing and peer mentoring.

Again, some examples of this can be seen in the following quotes. “It would frighten me not to have it. To go through a whole pregnancy without it. It would frighten me when I’m in the labor room. It’s very important.” “Prenatal care, it helps you feel a little bit safer, comfortable about what you’re going through. Sometimes we get nervous. You don’t know.”

Moving on to the next group of things that we identified, this group of things outlines specific behaviors or attitudes adopted by healthcare professionals that might have had an influence on the women’s perception of care and their willingness to engage with the antenatal care. Firstly, we identify issues related to healthcare professionals’ attitudes.

Some women in the studies, especially those from ethnic minorities, reported feeling judged and stigmatized by healthcare professional attitudes. Further, some racist behaviors and a feeling of inequality between patients and professionals was also reported in several instances. Also, several women reported lack of empathy or insensitivity from some healthcare professionals. In some studies, women felt like they were not treated with respect and that healthcare professionals were too task oriented.

We see an example of these bias treatment in the following quotes. “Providers act like I don’t know anything just because I am poor. I want to learn. Didn’t get nothing out of it. Keep repeating. Feel like I’m not smart enough to ask questions.” Or for example this one. “She just came in and it’s like she is so used to it and you’re just another pregnancy, so she doesn’t see you for an individual. She just does her thing and leaves.”

Additionally, we also identified communication issues that were reported to the different studies. Women reported receiving contradicting messages, having concerns dismissed, feeling uninformed, being confused to the use of jargon, and feeling frustrated since healthcare professionals would not do any prior health knowledge assessment.

This poor communication not only might affect the women’s perception of their care, but also of the whole antenatal process in some instances. You might have women disengaged and lose interest in their antenatal care. We have another example of this issue at the following quote. “They didn’t really go over what to expect or what to do when this happens. They didn’t really go over how the day would go, I guess.”

However, in other cases, women also reported different attitudes that healthcare professionals adopted to facilitate the antenatal care process for them. These attitudes influence the women’s perception of the carers in a positive way and made them feel cared for and valued. Non-judgmental, supportive and empathetic healthcare professionals were highly valued.

Positive communication also helped women through their antenatal care process. Healthcare professionals who were engaged in active listening and took time to address women’s concerns, empowered them to participate in the decision-making process were seen as very encouraging by women and facilitated trust.

We can see two examples of these here in these quotes. “I mean, I just feel that they relate to a lot of things. You know, say you going through things that you are dealing with, and when you find yourself in, you know, some type of crossroad, they help you, you know, try to navigate your situation. I mean, I just think they go above and beyond their duties.” Or this other one. “The way she talked, the way she attend to you, you have to understand. That make you feel, really feel good. You know?”

Moving on to the factors associated with the healthcare system, within this section, we examine barriers and facilitators that are associated with the organization functioning or management of the antenatal services or health services at an institutional level. Here, having an unsatisfactory clinical experience was reported by several women as a barrier to engage with antenatal services.

For example, experiencing rushed appointments, feeling that positive care was conditional on insurance status or some sociodemographic factors, feeling excluded from the decision making or feeling that the whole process was a waste of time. Additionally, sometimes women found barriers associated with the organization of antenatal care.

Examples of these are administrative delays or problems with the referral process. Other women report a lack of flexibility. Women that antenatal appointments clash with their other commitments, which impeded their access. Some women found that the application to access antenatal care was too complex and required too much effort. In these cases, women were willing to access antenatal care early, but the application process itself was delaying them.

We have a couple of examples of these issues here in these quotes. For example this one. “It does take a long time because they don’t take women without a GP at the hospital. So to get to the hospital, she needed to get to a GP, register with a GP, get an appointment, and for her to be referred to the hospital it takes time. GP requires proof of address, some bill or something. And she did not have that address because they moved just recently so she was waiting for proof to come.”

Another one is this one here at the bottom. “I think that with Welfare, you have to have predetermination and I didn’t do something right. I went to the doctor’s office and they couldn’t see me because I didn’t know how to get Medicaid until I got there. Then I had to reschedule and wait for them to get the verification that I had it.”

Additionally, a perceived lack of individualized care and lack of continuity of care was also reported as barriers. For some women, not seeing this same healthcare worker in each visit hindered their ability to build rapport and open up to them. These drove some women to avoid antenatal care services and attended general practitioners only for their care.

Finally, we identified factors associated with the social environment of the woman. In this category, the barriers identified are related to the general socioeconomic, culture and environment context where a woman lives. Aspects like homelessness, intimate partner violence, living in deprived areas, having an immigration status or having low economic resources have been identified as barriers to antenatal care attendance.

Most of the time, women living in these conditions do not have their basic needs for survival covered and need to focus their efforts in their more immediate concerns. Therefore, seeking antenatal care is not a priority for them. We have some examples of these issues in the following quotes. “But if the midwife at the hospital says, “You’re not Danish. You can go home or pay.”” “I was mainly worried about my children eating. I didn’t worry about myself.”

Women from different cultural backgrounds also reported issues related to culture inappropriateness or language barriers. Some of the studies included in the analysis look at the experiences of migrant women in high-income countries. Women felt discriminated against due to their immigration status. In some cases felt they needed to justify the right to care even in countries where this right is available for everybody.

Women with an illegal immigration status were afraid of being deported if they attended antenatal care, and they were also afraid of being separated from their babies. Due to their illegal immigration status, some women had uncertainties about the ability to afford care, which led them to believe that they only should access care in case of emergencies or when in labor. On top of that, the lack of familiarity with the healthcare system in hosting country increases their difficulties in accessing care. These women found that attending of health clinics held specifically for immigrant women facilitated their access to care as they felt safe there, and many women depended entirely on these clinics.

The analysis showed that the social discrimination observed connective within the society also acted as a barrier from many women. It was reported in different studies that teenage women, substance users, women from ethnic minorities, or women from lower socio-economic status faced additional challenges when trying to access antenatal care.

In some instances, women felt their care was of lower quality based on their insurance status. As an example, we have this quote here from an African American participant in this study. “It’s not gonna change. It’s not, ’cause it’s been like this forever. You learn to go last. No matter how much people talk about it, it is the same. Yes, it is. It’s been like that forever. That’s how it is.”

An absence of social support heavily influenced women positions to attend antenatal care. In some cases, this lack of support was due to fear of this approval within the women’s community or because the woman had moved to a different part where they didn’t have connections yet. We have a quote here to simplify this. “Like I said, I just moved to Phoenix. They, (the family) didn’t really give a shit. It’s just me and my problem for me to deal with, nobody else.”

Additionally, we also identified issues related to health literacy and reproductive knowledge. Many women in the different studies reported a delay in the recognition of the pregnancy due to the different reasons such as mistiming of the pregnancy, lack of knowledge of pregnancy signs and symptoms, attributing symptoms to other issues, having a history of irregular periods, not expecting the pregnancy or noticing the symptoms.

Again, we have some examples of this issue in the following quotes. “I just started throwing up. I just thought I had an upset stomach, so I waited for about 2-3 months and then I finally went to the hospital.” Or this other one. “When they, (the GP) said ‘I was going through the change,’ I thought, ‘Well, could I be’ because at 37 I thought, ‘Well, I might be,’ because you hear women go through it earlier than I did, and I think I brought that into my head more than anything. I never contemplated that I was pregnant.”

However, there are some lifestyle factors of social position related factors that act as facilitated to access antenatal care. For example, having a higher educational level, a higher economic status, a steady living situation, being older, or being a first-time mom are factors associated with a better attendance and compliance with antenatal care.

Women in further socioeconomic situations are more likely to have less immediate concerns, and so they can focus on seeking antenatal care during their pregnancy. Furthermore, women with great access to education information might be more aware of the different risks during pregnancy and the importance of antenatal care.

Availing of social support from their baby’s father, the community, and the family combined with a positive reaction facilitated the process of acceptance of the pregnancy and promoted engagement with antenatal care. We have an example of this here in this quote. “The girls at my other job, they are so supportive about the situation, ’cause they know I really didn’t want to have any more kids, but they are very supportive.”

To finish up, let me explore some important learning points or take-home messages that we obtain from this study. The first thing that is important to know is that even though we have divided these different factors in groups, themes, and categories, these factors can co-work, and it’s essential to keep them all in mind to understand the whole picture.

We consider that interventions need to be designed to tackle this issue at different levels beyond the individual. We think that healthcare professionals should be encouraged to use sensitive communication styles and take time to build a positive rapport with women to facilitate engagement. Additionally, health literacy and reproductive education should be promoted from the preconceptual period to facilitate family planning and pregnancy symptom recognitions.

Finally, we considered that the identified social determinants of health should be addressed at the different levels. Policy makers should tackle this issue in terms of health, education, employment, housing, and social equality.

That is everything from me. Thank you so much for your time and attention. Please get in touch with me if you have any questions, and I look forward to your comments. Thank you.

This presentation was part of the Stillbirth Summit 2021.   This individual lecture will be awarded .75 hours of continuing education credit to include viewing the lecture and completing evaluation and post-test.  Once received a certificate will be emailed to the address you provide in the post-test.  If you did not register for the Summit WITH Continuing Education, you can purchase the continuing education by clicking here.  This purchase will provide you access to all Stillbirth Summit 2021 lectures including continuing education credit. There is no charge for viewing the presentation.

To receive continuing education credit for this lecture, the participant must complete the evaluation and post-test.