Perceptions and utilisation of ANC services
Almost all of the women perceived that the ANC services were important for the health of the mothers and the newborn babies. Further, they recommended pregnant women to receive ANC services. Urban women reported receiving ANC services for routine check-ups to prevent complications at the time of delivery, while a dominant perception of rural women was to obtain ANC services for the management of health-related problems during pregnancy. Almost all of the rural women were not aware of when to make first ANC visit and the timing of follow up visits. A substantial majority of the urban women were aware of having ANC visit as soon as possible after becoming pregnant. The urban women perceived that follow-up ANC visits were dependent on the health status of a pregnant woman and the advice of a healthcare provider. However, both the rural and the urban women were not aware of the recommended number of ANC visits in case of uncomplicated pregnancy.
“During pregnancy, I think all women should go for check-up because we feel weakness. We get married in young age and after pregnancy we have many problems, for this reason it is important to go to health facility for treatment.” (A rural mother: FGD participant).
The LHWs and doctors interviewed in this study mentioned that most of the pregnant women had a poor understanding and knowledge about ANC services. However, all of the LHWs stated that they visited all pregnant women in their catchment area every month and referred pregnant women to the nearest government health facility for ANC services or for management of any health-related problem during pregnancy. According to the LHWs, the common health-related problems requiring a referral were: severe vomiting, feeling nausea or dizziness, presence of pallor, any complications such as vaginal bleeding, swelling on legs, and inappropriate weight gain. However, the LHWs perceived that often due to lack of staff, medicines and difficulties to travel to a public health facility, some of the referred pregnant women went to a private clinic. Doctors participated in this study reported that many pregnant women visited the health facility for routine check-ups, usually in the second trimester of pregnancy. The doctors stated that they always advised pregnant women to revisit after a month. However, all of them perceived that some of the pregnant women visited the health facility once or twice for the management of any complications during their pregnancy.
“Majority of them (pregnant women) visit us for their routine check-up as they are concern about their health. Some of them also visit us only in case of any problem and they never get back to us after that. Often these women come at the time of delivery due to a complication.” (A doctor: IDI participant).
Places, services and reasons for visiting a health facility for ANC
A few rural women but the majority of the urban women reported that during their last/ current pregnancy they went to a health facility for ANC services. However, the majority of the urban and the rural women who had ANC services in their last/ current pregnancy visited a private health facility. The reasons for visiting a private health facility for ANC services as reported by urban women included: availability of qualified and skilled providers, trust on healthcare providers at the private health facility, recommendation from a family member or a friend, availability of good quality services including medical equipments and pathology facilities, easy to reach a private health facility, and availability of an after-hours doctor. The reasons reported by urban women for visiting a public health facility for ANC services were: low cost as there was no consultation fee and often availability of free of cost medicines, the husband or the women herself was a government servant, and facilitation from a relative who was working at the public health facility. The availability of blood pressure monitoring equipment, pathology and ultrasonography services and prescriptions of medicines (including iron/folic acid supplements) were also important reasons for visiting a health facility for ANC services. The majority of the urban women reported that during their last visit to a health facility for ANC, they were examined by a doctor, weight and blood pressure were monitored (at private health facilities), they were advised about complications (at private health facilities), utilised pathology and radiology facilities, prescribed medicines/ supplements and were recommended for follow-up visits.
“I went to a private clinic because it is convenient for us to visit a private clinic. It’s near my home and I went in the evening with my husband. Good quality laboratory facilities and medical equipments for monitoring of blood pressure and ultrasound are important for us during a health facility visit. It’s good to diagnose any condition which leads to complication later in pregnancy.” (An urban pregnant woman: IDI participant).
On the other hand, the reasons for visiting a public health facility reported by rural pregnant women for ANC services were: low cost in terms of medicines and pathology services, being recommended by a local LHW, and trust in a government health system. On the other hand, the common reasons reported by the rural pregnant women for visiting a private health facility for ANC services were: easy to reach, recommendation from a family member, trust in healthcare provider and availability of ultrasonography and pathology services. The rural women stated that during their last visit to a health facility for ANC, the healthcare provider examined them, monitored their blood pressure (only at private health facilities), used pathology and radiology services (at private health facilities), medicines/ supplements were prescribed (at private health facilities) and were recommended for follow-up visits. However, few rural women stated that they were given information about complications or nutritional education.
“We (husband and myself) go there (health facility) during pregnancy as it is near to our house and road leads to facility is in a good condition. She (healthcare provider) checks my blood pressure, urine and blood and provides medicines (iron/folic supplements)…I think she (healthcare provider) is a doctor and she has equipment to measure blood pressure. Many women go to her clinic.” (A rural pregnant woman: IDI participant).
Barriers to visiting a health facility for ANC services
Common reasons reported by the rural and the urban women for not visiting either a public or a private health facility for ANC services included: financial limitations including travelling cost and consultation fee in case of a private health facility, experienced or perceived absence of a major health problem during pregnancy, difficulties in reaching a government health facility in rural areas, restrictions from husband or mother-in-law to visit a health facility, busy in performing household chores, had no prior experience of ANC visit in earlier pregnancies, non-availability of staff and/or services at a public health facility and limited working hours of a public health facility. Some of the rural women did not go to a health facility because they were afraid of being diagnosed to have complications or complications related to hospitalisation. Few rural and urban women were also afraid of the side effects of medicines prescribed by a healthcare provider during ANC visit and, therefore, did not visit a health facility for ANC services.
“I did not face any problems and no one ever told me to go to a health facility (during pregnancy). It is also difficult for us to go to a private clinic as we are very poor people.” (A rural mother: FGD participant).
The LHWs perceived that restrictions from the mothers-in-law, mothers or husbands as the most common reason for a pregnant woman not to visit a health facility for ANC services. Other reasons mentioned by the LHWs included not paying attention to the health of the women by their family and themselves, lack of transport to go to a public health facility and financial limitations to visit a private health facility. The doctors perceived lack of information about ANC services, business with household chores, restrictions from the mothers-in-law or other family members, lack of education and financial constraints to visit a private health facility as the major reasons for a pregnant woman not to visit a health facility.
“Often poor women face restrictions especially from their mothers-in-law and do not come for check-up during pregnancy, unless they have any major complications. Lack of education is also a major reason.” (A doctor: IDI participant).
Intentions to use of ANC services in the future
The majority of both the rural and the urban women expressed their intension to visit a public health facility for ANC services during their future pregnancies, if a skilled healthcare provider, essential medical equipment and free of cost medicines were available at the facility. Further, a few rural women suggested that government and other non-government organisations working in their areas should provide them funds for transportation to visit a government health facility for ANC services. In rural areas, the LHWs were hopeful that with their efforts to increase awareness in the community about the importance of ANC, availability of services at public health facilities by the government, and the support from family members, a substantial majority of the pregnant women would visit a government health facility for ANC service. However, in urban areas, the doctors were not sure about how to improve the coverage of ANC and suggested that the government along with other international donor agencies should conduct awareness campaigns through mass media about the importance of ANC, increase the number of skilled health providers, and provide all essential medicines and pathology services free of cost at the government health facilities to improve ANC coverage.
“I am working in my village for the last 15 years and there is an improvement in health behaviour of people of my village. I am hopeful that once they will be aware of benefits of visiting a health facility during pregnancy, which I am trying to impart, more and more pregnant women will visit health facilities during pregnancy.” (A LHW: IDI participant).