Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea.
BACKGROUND
Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.


METHODS
Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.


RESULTS
Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.


CONCLUSIONS
This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.
Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
Erin V W
EV
Andrew
Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.
Christopher
C
Pell
Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
Angeline
A
Angwin
Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
Alma
A
Auwun
Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
Job
J
Daniels
Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea; Infection & Immunity Division, Walter & Eliza Hall Institute, Parkville, Victoria, Australia.
Ivo
I
Mueller
Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
Suparat
S
Phuanukoonnon
Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands.
Robert
R
Pool
D000328:Adult; D005260:Female; D006801:Humans; D010219:Papua New Guinea; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D055815:Young Adult