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Background: Antenatal care serves as a key entry point for a pregnant woman to receive a broad range of services and should be initiated at the onset of pregnancy. The aim of the study was to understand the reasons for the late initiation of antenatal care by pregnant women in Nkwen Baptist Health Centre, Bamenda, Cameroon. Methods: The study applied purposive sampling to recruit eighteen pregnant women and three key informants for data collection through individual interviews. Pregnant women who initiated antenatal care after the first trimester were recruited during antenatal care clinics and were interviewed in a room at the Antenatal Care Unit. Key informants were midwives working at the Antenatal Care Unit. Participation in the study was voluntary. The purpose of the study was explained to participants, and they signed a consent form if they were willing to participate in the research. Data were audio-recorded and analyzed using thematic coding analysis. Results: Pregnant women placed a low value on early antenatal care because they perceived pregnancy to be a normal health condition or to not be a serious issue that required seeking health care. Furthermore, previous positive pregnancy outcomes for which women did not access care made them less motivated to initiate antenatal care early. Participants perceived the booking system to be user-unfriendly and complained of overcrowded conditions, long waiting times and some rude service providers. The cost of services and distance to health facilities that required travel via uncomfortable transport on poor road networks were identified as perceived barriers. The absence of effective community health programmes, perceived lack of support from parents and spouses, fear of bewitchment and stigma due to cultural beliefs about the early initiation of antenatal care were also identified as variables influencing late initiation. Conclusion: Pregnant women lack information on the purpose of early antenatal care. Health facility barriers as well as socio-cultural beliefs have significant influences on the timing of antenatal care initiation. The government of Cameroon should strengthen the health system and implement activities to engage communities in improving care seeking for antenatal care and thereby improving maternal health status of women.
The study was an exploratory, qualitative study given that it aimed to gain a deeper understanding of the perceptions, opinions and experiences of pregnant women and midwives regarding factors influencing early antenatal care initiation during pregnancy. Qualitative research can develop concepts that enable the understanding of social phenomena in a particular setting with emphasis on the meaning, experiences and views of participants [17]. Hence, the approach enabled the researchers to collect data through in-depth interviews with an interview guide using questions that were broad and open-ended to enable detailed exploration based on the responses provided. The approach also enabled the primary researcher to explore the reasons and opinions behind participants’ responses through asking probing “why”, “how” and “what” questions to gain a deeper understanding of the reasons for the late initiation of antenatal care among pregnant women. The study was conducted in Nkwen Baptist Health Center, a semi-urban health centre located in the Bamenda Health District in the Northwest Region of Cameroon. Nkwen Baptist Health Centre is a faith-based outpatient clinic belonging to the Cameroon Baptist Convention Health Services. The health centre has 144 staff members and an average monthly patient attendance of 12,128. The average monthly antenatal care clinic attendance of pregnant women is 358. The cost to initiate antenatal care is at least 13,000 fcfa ($26) but slightly less in public health facilities. This cost excludes other costs, such as for transportation to the health facility and feeding during clinics. Payment for services is out of pocket both in private and public health facilities with no exemption schemes. The Bamenda Health District is an urban and semi-urban area. With approximately 337,036 inhabitants, the district has 17 health areas and covers a total surface area of 560 km2. There is one main hospital (Bamenda Regional Hospital), which functions as a referral hospital for 17 public, 12 lay private and 5 mission health facilities. The Bamenda Health District is located in the Northwest Region of Cameroon. With Bamenda as its capital city, the Northwest Region is the third most populated region in Cameroon, with an estimated population of more than 1.8 million inhabitants [18]. The study sample comprised eighteen pregnant women and three key informant midwives. The inclusion criteria were pregnant women who presented for their first antenatal care after twelve weeks of pregnancy. The exclusion criteria were pregnant women who were less than eighteen years of age, and pregnant women who could not express themselves in English. Participants were selected through purposive sampling. They were asked some key demographic questions, including the number of weeks of gestation, to determine their eligibility for interviews. Key informants included Midwives serving at the Antenatal Care Unit. The inclusion criteria were midwives who had been serving in the antenatal clinic for at least two years. These midwives were included on the basis that they had been working and interacting with pregnant women and could provide information on their perceptions and views regarding the timing of antenatal care initiation. Interviewing midwives in addition to pregnant women was a means of triangulating data sources to improve the credibility of the findings. Pregnant women who initiated antenatal care after the first trimester were informed about the study by service providers at the Antenatal Care Unit during the provision of antenatal care services. Respondents were only informed of the study at the end of their visits at the Antenatal Care Unit to ensure that the study did not interfere with their access to care. They were informed that participation was voluntary and that if they wished to participate, they would be referred to the primary researcher for interviews in a room in the clinic. Those who agreed to participate were given a piece of paper by the service providers to indicate that they were informed of the study and were directed to the primary researcher for interviews. Data collection was conducted through in-depth interviews. Interviews were conducted face to face. This method provided a rich form of data, as the participant was visible to the interviewer who could pick up on nonverbal cues. Questions were asked from a predetermined interview guide. The guide had a short list of questions with probes to help direct the interview in a particular direction in a conversational manner. Probing was a vital tool to ensure the credibility or true value of the data, as it allowed for the clarification of interesting and relevant issues raised by the respondent. The interviews were audio-recorded. This allowed the interviewer to prepare the transcript for analysis, based on a verbatim account of the interview. With the data recording, the interviewer was able to review the recording multiple times as needed to catch elements that were missed. Written notes were also used to record information as a supplement to the audio- recorded data. Data analysis was conducted alongside data collection and was stopped once saturation was reached. Each interview took between thirty minutes to one hour and was assigned a code and a date to maintain confidentiality. At the end of each interview, the audio recordings were transcribed verbatim by the primary researcher and analyzed manually using thematic coding analysis (TCA). The primary researcher’s diary notes were collated and analyzed at the end of each day to ensure reflexivity. Data analysis was performed manually using TCA. TCA is a form of inductive analysis in which categories or codes are allowed to emerge from the data [19]. The five phases of TCA are as follows: familiarization, coding, identification of themes, reviewing and refining, integration and interpretation [20]. The primary researcher continuously reflected on the setting and context to help interpret the phenomena. The primary researcher also drew on existing research to inform the interpretation as well as strengthen and support the argument. Participation in the study was voluntary for pregnant women and midwives. Respondents were informed of the study by staff only at the end of their visit at the Antenatal Care Unit to ensure that the study did not interfere with their access to care. Each respondent was provided with a letter explaining the study, requesting their participation and assuring them of the confidentiality of the study. Their consent was sought, and a consent form was available for them to sign if they were willing to participate in the research. Participation in the research did not inhibit the respondents’ access to care. The anonymity of the participants was ensured by not asking questions that revealed the identities of the participants and not linking the results to individual participants. Pseudonyms were also used in the presentation of findings to ensure anonymity. It was anticipated that the research would cause no harm to the research participants. However, a professional Counsellor from Nkwen Baptist Health Centre was available in case any of the pregnant women required emotional support or counselling as a result of the research process. Ethical clearance was obtained from the Biomedical Research Ethics Committee of the University of the Western Cape (UWC) and from the Institutional Review Board (IRB) of the Cameroon Baptist Convention Health Services. Administrative clearance was also obtained from the Director of Health Services of the Cameroon Baptist Convention which authorized the researcher to have access to the research participants at Nkwen Baptist Health Centre.
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