Barriers to the early initiation of antenatal care: a qualitative study of women and service providers in East London

In the UK, guidelines for antenatal care recommend that women receive their first antenatal appointment as early as possible within the first trimester of pregnancy. However, many women have their first antenatal care appointment later than 12 weeks of pregnancy. Research on the barriers to early initiation of antenatal care has mainly focused on identifying socio-demographic predictors of late initiation, rather than exploring women’s perspectives on and experiences of pregnancy and antenatal care, and the qualitative research that has been conducted in the field has been largely confined to North America.

In 2010-11, as part of a mixed methods study funded by the National Institute for Health Research (NIHR), we conducted qualitative research which explored the barriers to early initiation and continued attendance for antenatal care. The research involved 21 in-depth interviews and five focus groups with an ethnically diverse sample of women living in East London and two focus groups with staff of the NHS.

The study identified a range of barriers to early initiation of antenatal care, which both individually and cumulatively result in delayed initiation of antenatal care services; including the perception that antenatal care is only to be initiated for viable and continuing pregnancies, little perceived urgency in initiating antenatal care (particularly if previous pregnancies have been uncomplicated), as well as difficulties accessing referrals to antenatal care and service provider delays in the processing of referrals. Early initiation, continued attendance and satisfaction with antenatal care were found to be influenced by appointment scheduling and waiting times, the nature of interpersonal interactions with staff, and the availability of interpreters for those with limited English. Women from different cultural communities were also found to conceptualise pregnancy in different ways, which may affect engagement with antenatal care services.

To improve early initiation of and experiences of antenatal care, we suggest that a complex intervention package needs to be developed and evaluated within ethnically diverse contexts, which addresses the multiple barriers identified by our research regarding perceptions of the purpose, value and nature of antenatal care, and factors within maternity service organisation, which may delay early initiation of antenatal care.