title: Barriers and solutions for timely initiation of antenatal care in Kigali, Rwanda: health facility professionals' perspective.
abstract: OBJECTIVE
  timely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals.
  
  
  METHODS
  health facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis.
  
  
  METHODS
  interviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda.
  
  
  METHODS
  17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care.
  
  
  RESULTS
  inductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits.
  
  
  CONCLUSIONS
  qualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews.
  
  
  CONCLUSIONS
  study findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits.
authors.affiliation: Yale School of Public Health, 135 College Street, Suite 200, New Haven, CT 06510, USA. Electronic address: jmhagey@gmail.com.
authors.forename: Jill
authors.initials: J
authors.lastname: Hagey
authors.forename: Stephen
authors.initials: S
authors.lastname: Rulisa
authors.forename: Rafael
authors.initials: R
authors.lastname: Pérez-Escamilla
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003144:Communication Barriers; D005260:Female; D006801:Humans; D008875:Middle Aged; D008880:Midwifery; D010342:Patient Acceptance of Health Care; D010353:Patient Education as Topic; D018743:Perinatal Care; D011247:Pregnancy; D012432:Rwanda; D055815:Young Adult
keywords: Antenatal care; Health services accessibility; Health-care providers; Maternal health services