title: 'They would never receive you without a husband': Paradoxical barriers to antenatal care scale-up in Rwanda.
abstract: OBJECTIVE
  To explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss').
  
  
  METHODS
  A study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda.
  
  
  RESULTS
  All informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy.
  
  
  CONCLUSIONS
  'Near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications
  
  
  CONCLUSIONS
  These findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.
authors.affiliation: Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden. Electronic address: jessica.pafs@kbh.uu.se.
authors.forename: Jessica
authors.initials: J
authors.lastname: Påfs
authors.affiliation: Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden; Department of Pediatrics and Child Health, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O. Box 217, Butare, Huye, Rwanda.
authors.forename: Aimable
authors.initials: A
authors.lastname: Musafili
authors.affiliation: Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
authors.forename: Pauline
authors.initials: P
authors.lastname: Binder-Finnema
authors.affiliation: School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden.
authors.forename: Marie
authors.initials: M
authors.lastname: Klingberg-Allvin
authors.affiliation: Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O. Box 3286, Kigali, Rwanda; Department of Clinical Research, University Teaching Hospital of Kigali, BP 655 Kigali, Rwanda.
authors.forename: Stephen
authors.initials: S
authors.lastname: Rulisa
authors.affiliation: Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D003144:Communication Barriers; D005260:Female; D015658:HIV Infections / Q000175:diagnosis; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008880:Midwifery; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D036301:Qualitative Research; D011787:Quality of Health Care; D012432:Rwanda; D018454:Spouses / Q000523:psychology*; D055815:Young Adult
keywords: Care-seeking; HIV-testing; Health inequity; Male involvement; Partner testing; Policy