Table 1 Description of a typical morning at one ANC clinic based on field notes

We arrived at the health facility at 9:30 am. At the RCH clinic, around forty mothers and their children were waiting outside the examination room for the auxiliary nurse to vaccinate the children. The auxiliary nurse was attending the children alone because the nurse midwife had left the facility a month ago. She weighed and vaccinated them, filled in the cards and gave health education to the mothers. Three pregnant women who had arrived in the morning were waiting outside. It was their first visit to the ANC clinic. At 2 pm the auxiliary nurse started to attend them.

History taking

In the attendance room the auxiliary nurse started to collect personal information from the pregnant women and to ask them about their history of previous pregnancies and illnesses. She registered the information on the ANC cards and the health facility register. Using the date of the last menstruation she calculated the expected delivery date. The other two pregnant women listened quietly.

Physical examination

Although the auxiliary nurse initially wanted to postpone the height and length measurement to the women's next visit, she changed her mind and went to measure and weigh the women. Then, she invited the women to the examination room for the physical examination. One at a time, each woman went to the separate delivery room and lay down on the bed. The auxiliary nurse measured fundal height, listened to foetal heart sounds and palpated the child's position.

Drug administration/immunization

Then, the women received Tetanus vaccines and got their blood pressure measured. Finally, the women were asked to get water from the drug dispensing room to swallow SP.

Laboratory investigations

The women were told to come back on the 24^th of the same month to test for Syphilis because the test would then be conducted for all pregnant women. None of the women were tested for HIV/AIDS. The auxiliary nurse explained that she was not able to perform the test because the only person who was trained had gone for training. She told them to get tested in another health facility.

Health education

Then, the health education started. The nurse was first sitting on a chair but got up saying that she was used to standing while giving the health education. She disseminated the health messages in a didactic manner: standing in front of the women, telling them what they should do and asking questions to check the women's attention. Often the women did not respond to her questions. She emphasized the importance of starting ANC attendance early. Then she started to talk about hygiene and stressed that women should keep themselves and their clothes clean. She reminded the women to put small savings to the side in order to be prepared for the delivery and for potential emergencies requiring transport to the hospital. She explained what supplies they would need for the delivery and emphasized the importance of giving birth at the health facility and not with a traditional birth attendant (TBA). She stressed that TBAs lack supplies and experience. She explained the Tetanus schedule to the women with the help of the Tetanus card and asked them to come back to the health facility for the postpartum care.