Why do pregnant women in Iringa region in Tanzania start antenatal care late? A qualitative analysis

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.

Some women and men did not know the importance of attending ANC early during pregnancy. Since inexperienced women and men were not familiar with the signs of pregnancy, they could not discover or disclose pregnancy early enough. Similarly, students and unmarried young women fear to disclose pregnancy for fear of expulsion from school and from the family as well as abandonment by male partners. Furthermore, it was reported in most FGDs and confirmed during stakeholders’ meetings that women who had previously given birth with good outcome do not see the importance of attending ANC early.

During the stakeholders’ meeting, many participants had the same view regarding the challenges about experience with safe delivery:

It has been a tendency in this village for pregnant women to attend ANC very late. Sometimes I speak with women at my church. It is astonishing to hear, “I gave birth to my last born very easily; I only attended ANC once in the fifth month of pregnancy, and my daughter is healthy. As a man of God, when you hear that you start realizing how big the problem is (Religious Leader during stakeholders’ meeting).

Female participants demonstrated awareness that couples should attend ANC together. It was further learnt that in most cases, pregnant women initiate the need to attend ANC. However, men have high decision-making power to approve or disapprove women’s proposal to attend ANC. As a result, women’s decision to attend ANC early was perceived to be limited. Women in the FGDs reported that men control almost everything, including farms, livestock and businesses. In some cases, women could not attend ANC early due to lack of fare and other necessary needs related to maternity.

Men were perceived as breadwinners and their main role was to support their partners financially. Relevant to ANC attendance, men were expected to be responsible for birth preparedness and complication readiness. According to our participants, men who attend ANC with their wives were perceived to be dominated by women, and this was shameful. During stakeholders’ meetings, female participants reported that even when their spouses attended ANC with them, they were ridiculed for engaging in traditionally defined women’s work.

Families in Kilolo and Mufindi districts face the problem of short birth spacing, referred to as “Kufudikira” in Hehe and Bena languages. This was not acceptable in the family, community and by health care providers. As a result, once women realize that they are pregnant within a short time after the last birth, they delay ANC attendance. FGD’s participants indicated that women were afraid to be scorned if health care providers learnt they left babies under six months at home. Nurses and doctors tend then to shout with loud voices such that they are heard even outside the consultation room. This was also confirmed in an interview with a member of a health facility committee who said that;

Men always do not feel comfortable to attend ANC with their partners who have little babies because they will be stigmatised by their fellow men and health care providers. This makes women delay ANC while waiting for the children to grow (Interview with a male committee member).

Some women and men feared witchcraft particularly during the early months of pregnancy. A woman stated;

During my first pregnancy, my mother- in- law instead that I should not disclose my pregnancy early even to the health care providers. She even informed my parents in the nearby village the risk I might face if people knew my status. There is nothing more they fear than prevalent witchcraft in this village (Interview with a woman in Kilolo District).

The villagers still believe that care is only needed when women are pregnant until when their bellies become visibly big. As a result, emphasis is more on how pregnant women should be careful about witches instead of attending ANC early or completing recommended visits.

As part of prevention of mother-to-child transmission of HIV/AIDS, couples are required to attend the first ANC together in order to undergo HIV screening. In almost all FGDs women reported that if they attend ANC clinics for the first time without their partners, they are denied services. Female participants reported that this requirement increased the likelihood of many women to delay ANC attendance. This finding was also confirmed during stakeholders’ meetings, whereby almost all health care providers reported that if pregnant women went without partners, they were not attended to. Instead, they were instructed to request the company of their partners or otherwise present a letter from the village leaders in case their partners were not able to attend for some reasons. It was also found that some men tended to abandon their families especially when women become pregnant. This is affirmed in an interview with a health care provider:

When many husbands in this area see that their wives are pregnant, they leave their home and seek casual labour elsewhere. Therefore, the wives have to keep waiting until their husbands come back because they cannot start the clinic alone. This was found to be a major challenge of the accompany policy in this area. (Health care provider, Mufindi District).

Various factors were reported to discourage men from attending ANC with their partners (Table 1).

There was consensus among health care providers and some community members that denying services to women who attended ANC clinics without partners was important because it motivated men to attend ANC and screen for HIV. However, other participants in stakeholders’ meetings had the opinion that women were being punished for offences that were beyond their control.

Rude language used by health care workers deter pregnant women to seek ANC on time. It was noted, for example, that nurses say that the constant complaints of pregnant women are nonsense as long as they receive their monthly salaries. Therefore, they should not expect them to behave the way women want them to. The views held by women resonated with that of men who stated that prevalence of harsh language affected not only their wives’ attendance, but also discouraged men to accompany their partners.

Personally, I didn’t accompany my wife when she was pregnant recently. You know, at first we had a doctor who was very friendly; unfortunately, he was transferred to another facility. The new one, who is with us, discourages us from giving company to our wives. You feel so uneasy for disrespectful words when she attends to our wives (FGD with men in Kilolo District)

Further investigation was done to explore the reasons for harsh language among health care providers. Heavy workload among them was one reason. Respondents also reported that health care providers staying in one station for a long time is a problem. Furthermore, failure of pregnant women to abide by given instructions incited health care providers to use impolite language.

Acute shortage of health care providers in Kilolo and Mufindi districts affects effective provision of ANC. As a result, some pregnant women do not get ANC on time. Based on the 2014 staffing levels established by the Ministry of Health and Social Welfare, the minimum number of health care providers required is 15 for a dispensary and 39 for a health centre. There was consensus among participants of FGDs and interviews that health facilities were facing acute staff shortages (Table 2).

In our study data were collected from diversified respondents namely women, men and health care workers. This made it possible to triangulate the findings across different types of respondents. In addition, the initial findings were validated during stakeholders’ meetings. However, the study was conducted in only two rural districts and the findings may not adequately reflect experiences in other districts in Tanzania.