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Background: When started early in pregnancy and continued up till childbirth, antenatal care (ANC) can be effective in reducing adverse pregnancy outcomes. While the proportion of women who attend ANC at least once in low income countries is high, most pregnant women attend their first ANC late. In Tanzania, while over 51% of pregnant women complete ≥4 visits, only 24% start within the first trimester. This study aimed to understand the factors that lead to delay in seeking ANC services among pregnant women in Tanzania. Methods: This qualitative descriptive case study was conducted in two rural districts in Iringa Region in Tanzania. A total of 40 focus group discussions (FGDs) were conducted involving both male and female participants in 20 villages. In addition, 36 semi-structured interviews were carried out with health care workers, members of health facility committees and community health workers. Initial findings were further validated during 10 stakeholders’ meetings held at ward level in which 450 people participated. Data were analysed using thematic approach. Results: Key individual and social factors for late ANC attendance included lack of knowledge of the importance of early visiting ANC, previous birth with good outcome, traditional gender roles, fear of shame and stigma, and cultural beliefs about pregnancy. Main factors which inhibit early ANC attendance in Kilolo and Mufindi districts include spouse accompany policy, rude language of health personnel and shortage of health care providers. Conclusions: Traditional gender roles and cultural beliefs about pregnancy as well as health system factors continue to influence the timing of ANC attendance. Improving early ANC attendance, therefore, requires integrated interventions that address both community and health systems barriers. Health education on the timing and importance of early antenatal care should also be strengthened in the communities. Additionally, while spouse accompany policy is important, the implementation of this policy should not infringe women’s rights to access ANC services.
A descriptive case study design was used that is suitable to investigate a phenomenon in its real life setting [29]. This study is part of the baseline assessment of the Innovating for Maternal and Child Health in Africa (IMCHA) programme which is being implemented in Iringa Region, Tanzania by the Institute of Development Studies, University of Dar es Salaam in collaboration with Iringa Region Health Department and Health Bridge Foundation of Canada. Iringa Region was selected because of earlier collaboration between some of the IMCHA researchers and the regional and district decision makers on strengthening decentralised district health management. Like in other rural districts in Tanzania, ANC indicators in Iringa Region are low. The proportions of pregnant women who attend ANC within the first trimester were 27% in Kilolo and 17% in Mufindi district [30]. A total of 40 Focus Group Discussions (FGDs) were conducted in 20 villages of Kilolo and Mufindi districts. The villages were selected purposively because they were part of the IMCHA project. Each FGD consisted of 10–12 participants; and females and males had separate sessions in each village. FGD participants were selected purposively in collaboration with the community health workers. The criteria for selecting female participants included: age (15–49 years), experience in utilizing ANC services, and pregnancy or birth in the last 12 months preceding the study. The involved male participants were required to be either married or otherwise live with a female partner and have experience with childbirth. All FGDs were conducted in a private room in the village offices and digitally recorded with permission from the participants. FGD guides were developed and used to guide the discussion (Additional file 1). FGDs were conducted in 2016 and each FGD session lasted for between 45 min and one hour. FGDs were facilitated by trained female and male researchers. In addition, we conducted semi-structured interviews with health care workers. A copy of the interview has been included as supplementary file (Additional file 2). Interviewees were purposively selected based on the active roles in the provision and management of maternal and child health services. In total, 80 interviews were carried out; an average of four interviews for each village. Saturation point was reached when no any new information was coming out of the interviews. Interviews were conducted by SM, CJ and PK in Kiswahili language in 2016. All interviews were recorded after getting permission from the respondents. Furthermore, initial findings of the study were validated during stakeholders’ meetings which were held in all 10 Wards. The stakeholders’ meetings involved male and female champions, community and religious leaders, health care providers and members of the user committees. The meetings were conducted between January and March 2018, and the number of participants in each meeting ranged from 40 to 50. The stakeholders’ meetings were coordinated by the researchers involved in the implementation of the IMCHA project. All FGDs and interviews were transcribed by trained transcribers. The transcripts were reviewed by the core research team members and notes were made for each transcript. A thematic approach [31] was used to analyse FGDs, interviews, and summaries of the stakeholders’ meetings. An initial coding framework was developed by the Principal Investigator (SM) based on the objectives of the study. The coding manual was further discussed and refined by the research team members. NVivo10 qualitative data analysis software was used for coding and managing data [32]. Two members of the research team (SM, CJ) independently coded the first five interviews to ensure consistency. Thereafter, SM and CJ continued to code the transcripts and summaries of the meetings. Responses were compared across different types of respondents and across the two districts. Finally, data were summarized and synthesized and key terms and phrases of respondents were used to support findings.
