title: Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi.
abstract: BACKGROUND
  Antenatal care (ANC) is a key strategy to improve maternal and infant health. However, survey data from sub-Saharan Africa indicate that women often only initiate ANC after the first trimester and do not achieve the recommended number of ANC visits. Drawing on qualitative data, this article comparatively explores the factors that influence ANC attendance across four sub-Saharan African sites in three countries (Ghana, Kenya and Malawi) with varying levels of ANC attendance.
  
  
  METHODS
  Data were collected as part of a programme of qualitative research investigating the social and cultural context of malaria in pregnancy. A range of methods was employed interviews, focus groups with diverse respondents and observations in local communities and health facilities.
  
  
  RESULTS
  Across the sites, women attended ANC at least once. However, their descriptions of ANC were often vague. General ideas about pregnancy care - checking the foetus' position or monitoring its progress - motivated women to attend ANC; as did, especially in Kenya, obtaining the ANC card to avoid reprimands from health workers. Women's timing of ANC initiation was influenced by reproductive concerns and pregnancy uncertainties, particularly during the first trimester, and how ANC services responded to this uncertainty; age, parity and the associated implications for pregnancy disclosure; interactions with healthcare workers, particularly messages about timing of ANC; and the cost of ANC, including charges levied for ANC procedures - in spite of policies of free ANC - combined with ideas about the compulsory nature of follow-up appointments.
  
  
  CONCLUSIONS
  In these socially and culturally diverse sites, the findings suggest that 'supply' side factors have an important influence on ANC attendance: the design of ANC and particularly how ANC deals with the needs and concerns of women during the first trimester has implications for timing of initiation.
authors: Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands. c.l.pell@uva.nl
authors: Christopher
authors: C
authors: Pell
authors: Arantza
authors: A
authors: Meñaca
authors: Florence
authors: F
authors: Were
authors: Nana A
authors: NA
authors: Afrah
authors: Samuel
authors: S
authors: Chatio
authors: Lucinda
authors: L
authors: Manda-Taylor
authors: Mary J
authors: MJ
authors: Hamel
authors: Abraham
authors: A
authors: Hodgson
authors: Harry
authors: H
authors: Tagbor
authors: Linda
authors: L
authors: Kalilani
authors: Peter
authors: P
authors: Ouma
authors: Robert
authors: R
authors: Pool
mesh_terms: D005260:Female; D005865:Gestational Age; D005869:Ghana; D019538:Health Care Surveys; D058015:Health Communication; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007630:Kenya; D008295:Malawi; D008297:Male; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D011295:Prenatal Care / Q000191:economics / Q000706:statistics & numerical data*; D036301:Qualitative Research; D017584:Reproductive History; D012307:Risk Factors