title: "You cannot know if it's a baby or not a baby": uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya.
abstract: BACKGROUND
  Antenatal care early in pregnancy enables service providers to identify and manage risks to mother and fetus. In the global north, ultrasound scans are routinely offered in pregnancy to provide an accurate estimate of gestational age and identify potential problems. In sub-Saharan Africa, such services are rarely available and women often delay initiating antenatal care. This study describes the uptake and provision of antenatal care in a rural Kenyan hospital and explores how pregnant women and healthcare providers perceived the provision of ultrasound scanning, following its introduction in an international foetal growth study.
  
  
  METHODS
  A descriptive study, using qualitative and quantitative methods, was conducted in Kilifi District Hospital, Kenya, between June 2011 and April 2012. In-depth interviews were conducted with 10 nurses working in the antenatal clinic (ANC) and 59 pregnant women attending ANC. Structured observations of 357 ANC consultations and 30 ultrasound scans were made.
  
  
  RESULTS
  Women sought antenatal care for information about the health of their baby and the protection provided by the ANC services. Uncertainty about pregnancy status contributed to delay in ANC attendance; more than 78 % of women were over 20 weeks' gestation at their first visit. Healthcare workers found it difficult to detect pregnancies below 16 weeks gestation and, accurate assessment of gestational age below 20 weeks' gestation could be problematic. Provision of services depended on the pregnancy being detected and gestational age assessed. The "seeing", made possible through ultrasound scanning was perceived by pregnant women and healthcare workers to be beneficial: confirming the pregnancy, and providing reassurance about the fetus' condition. Few participants raised concerns about ultrasound scanning.
  
  
  CONCLUSIONS
  Uncertainty about pregnancy status and gestational age for women and healthcare providers is a key factor influencing timing of ANC attendance, contributing to delays and restricting early provision of ANC services. Ultrasound scanning was perceived to enhance antenatal care through confirmation of pregnancy status and enabling more accurate estimation of gestational age and the health status of the fetus. There is a need to make available more affordable means of pregnancy testing as a strategy towards encouraging early attendance, and delivery of antenatal care.
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. doluoch@kemri-wellcome.org.
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Oluoch
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. nmwangome@kemri-wellcome.org.
authors.forename: Nancy
authors.initials: N
authors.lastname: Mwangome
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. bryn.kemp@obs-gyn.ox.ac.uk.|Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK. bryn.kemp@obs-gyn.ox.ac.uk.
authors.forename: Bryn
authors.initials: B
authors.lastname: Kemp
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. ASeale@kemri-wellcome.org.|Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. ASeale@kemri-wellcome.org.
authors.forename: Anna C
authors.initials: AC
authors.lastname: Seale
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. koechangela@gmail.com.
authors.forename: Angela
authors.initials: A
authors.lastname: Koech
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK. aris.papageorghiou@obs-gyn.ox.ac.uk.|Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK. aris.papageorghiou@obs-gyn.ox.ac.uk.
authors.forename: Aris T
authors.initials: AT
authors.lastname: Papageorghiou
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. JBerkley@kemri-wellcome.org.|Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. JBerkley@kemri-wellcome.org.
authors.forename: James A
authors.initials: JA
authors.lastname: Berkley
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK. stephen.kennedy@obs-gyn.ox.ac.uk.|Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK. stephen.kennedy@obs-gyn.ox.ac.uk.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Kennedy
authors.affiliation: KEMRI-Wellcome Trust Research Programme, Coast Centre for Geographic Medicine and Research, Kilifi, Kenya. cjones@kemri-wellcome.org.|Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. cjones@kemri-wellcome.org.
authors.forename: Caroline O H
authors.initials: CO
authors.lastname: Jones
mesh_terms: D000328:Adult; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007630:Kenya; D010342:Patient Acceptance of Health Care; D010465:Perception; D011247:Pregnancy; D011295:Prenatal Care / Q000523:psychology*; D036301:Qualitative Research; D012424:Rural Population; D016216:Ultrasonography, Prenatal / Q000523:psychology*