Provision and uptake of routine antenatal services: a qualitative evidence synthesis

Soo Downe, Kenneth Finlayson, Özge Tunçalp, Ahmet Metin Gülmezoglu, Soo Downe, Kenneth Finlayson, Özge Tunçalp, Ahmet Metin Gülmezoglu

Abstract

Background: Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

Objectives: To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.

Search methods: To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

Selection criteria: We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

Data collection and analysis: Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

Main results: We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

Authors' conclusions: This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Conflict of interest statement

  1. Soo Downe is an editor with the Cochrane Effective Practice and Organisation of Care group.

  2. Kenny Finlayson, Özge Tunçalp, and A Metin Gülmezoglu have no interests to report.

Figures

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Gjalt‐Jorn Peters. Graphical representation of the reasoned‐action approach. CC BY‐SA 3.0 [https://creativecommons.org/licenses/by‐sa/3.0] https://commons.wikimedia.org/wiki/File:Reasoned_action_approach_text_as_paths.svg
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Flow Diagram to Illustrate Analytic Phases
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PRISMA flow diagram.
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Logic Model of FULL ANC Uptake using findings relating to beliefs (superscript letters and numbers refer to Summary of qualitative findings table above)
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Logic Model of NO ANC Uptake using findings relating to beliefs (superscript letters and numbers refer to Summary of qualitative findings table above)
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Logic Model of INITIAL ANC Uptake using findings relating to beliefs (superscript letters and numbers refer to Summary of qualitative findings table above)

References

References to studies included in this review Abrahams 2001 {published data only}

    1. Abrahams N, Jewkes R, Mvo Z. Health care‐seeking practices of pregnant women and the role of the midwife in Cape Town, South Africa. Journal of Midwifery and Women’s Health 2001;46(40):240‐7.
Agus 2012 {published data only}
    1. Agus Y, Horiuchi S, Porter SE. Rural Indonesia women’s traditional beliefs about antenatal care. BMC Research Notes 2012;5:589. [.]
Alderson 2004 {published data only}
    1. Alderson P, Williams C, Farsides B. Pracitioners’ views about equity within prenatal services. Sociology 2004;38(1):61‐80.
Andrew 2014 {published data only}
    1. Andrew EV, Pell C, Angwin A, Auwun A, Daniels J, Mueller I, et al. Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea. PLOS One 2014;9(5):e93025. [DOI: 10.1371/journal.pone.0093025]
Armstrong 2005 {published data only}
    1. Armstrong TM, Pooley JA. Being pregnant: a qualitative study of women's lived experience of being pregnant. Journal of Prenatal and Perinatal Psychology and Health 2005;20(1):4‐25.
Ayala 2013 {published data only}
    1. Ayala LS, Blumenthal PD, Sarnquist CC. Factors influencing women’s decision to seek antenatal care in the Andes of Peru. Maternal and Child Health Journal 2013;17(6):1112‐18. [DOI: 10.1007/s10995-012-1113-9]
Ayiasi 2013 {published data only}
    1. Ayiasi MR, Royen K, Verstraeten R, Atuyambe L, Criel B, Garimoi CO, et al. Exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural Uganda. BMC Pregnancy and Childbirth 2013;13:176. []
Baffour‐Awuah 2015 {published data only}
    1. Baffour‐Awuah A, Mwini‐Nyaledzigbor PP, Richter S. Enhancing focused antenatal care in Ghana: an exploration into perceptions of practicing midwives. International Journal of Africa Nursing Sciences 2015;2:59‐64.
Bessett 2010 {published data only}
    1. Bessett D. Negotiating normalization: the perils of producing pregnancy symptoms in prenatal care. Social Science & Medicine 2010;71(2):370‐7.
Biondi 2018 {published data only}
    1. Biondi HS, Pinho EC, Kirchhof AL, Rocha LP, Costa Kerber NP. Workloads and inter‐relationships with the program for the humanization of prenatal and childbirth care. Cogitare Enfermagem 2018;23(3):e52801. [DOI: ]
Bradley 2012 {published data only}
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Cabral 2013 {published data only}
    1. Cabral FB, Hirt LM, Sand IS. Prenatal care from puerperal women’s point of view: from medicalization to the fragmentation of care. Revista da Escola de Enfermagem da U S P 2013;47(2):281‐7.
Cardelli 2016 {published data only}
    1. Cardelli AA, Marrero TL, Ferrari RA, Martins JT, Serafim D. Expectations and satisfaction of pregnant women: unveiling prenatal care in primary care. Investigación y Educación en Enfermería 2016;34(2):252‐60. [DOI: 10.17533/udea.lee.v34n2a04]
Chapman 2003 {published data only}
    1. Chapman RR. Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk. Social Science and Medicine 2003;57(2):355‐74.
Chimezie 2013 {published data only}
    1. Chimezie RO. A Case Study of Primary Healthcare Services in Isu, Nigeria [Dissertation]. Minneapolis: Walden University, 2013. [Available from ]
Choudhury 2011 {published data only}
    1. Choudhury N, Ahmed SM. Maternal care practices among the ultra‐poor households in rural Bangladesh: a qualitative exploratory study. BMC Pregnancy and Childbirth 2011;11:15. [DOI: 10.1186/1471-2393-11-15]
Chowdhury 2003 {published data only}
    1. Chowdhury AM, Mahbub A, Chowdhury AS. Skilled attendance at delivery in Bangladesh: an ethnographic study. Research Monograph Series 2003; Vol. 22. [ ]
Conrad 2012 {published data only}
    1. Conrad P, Allegri M, Moses A, Larsson EC, Neuhann F, Müller O, et al. Antenatal care services in rural Uganda: missed opportunities for good‐quality care. Qualitative Health Research 2012;22(5):619‐29.
Coverston 2004 {published data only}
    1. Coverston CR, Franklin CY, Davis JP. Seeking safe passage: Argentine women's experiences of prenatal care. Health Care for Women International 2004;25(7):620‐35.
Dako‐Gyeke 2013 {published data only}
    1. Dako‐Gyeke P, Aikins M, Aryeetey R, Mccough L, Adongo PB. The influence of socio‐cultural interpretations of pregnancy threats on health seeking behavior among pregnant women in urban Accra, Ghana. BMC Pregnancy and Childbirth 2013;13:211. []
De Castro 2010 {published data only}
    1. Castro ME, Moura, MA, Silva LM. Quality of prenatal assistance: A perspective of the new puerpera’s. Revista da Rede de Enfermagem do Nordeste 2010;11:72‐81.
Docherty 2011 {published data only}
    1. Docherty A, Bugge C, Watterson A. Engagement: an indicator of difference in the perceptions of antenatal care from pregnant women from diverse socioeconomic backgrounds. Health Expectations 2011;15(2):126‐38.
Duarte 2012 {published data only}
    1. Duarte SJ. Reasons that pregnant women visit prenatal care: a social representation study. Ciencia y Enfermería 2012;18(2):75‐82.
Earle 2000 {published data only}
    1. Earle S. Pregnancy and the maintenance of self‐identity: implications for antenatal care in the community. Health and Social Care in the Community 2000;8(4):235‐41.
Family Care International 2003 {published data only}
    1. Family Care International. Care seeking during pregnancy, delivery and the post‐partum period: a study in Hombay and Migori districts, Kenya. 2003; Vol. (accessed 20 May 2019).
Franngard 2006 {published data only}
    1. Franngard C, Hansveden A, Lijestrand J. Compassion and severe challenges: an exploratory study of being a midwife in rural Uganda. MIDIRS Midwifery Digest 2006;16(4):461‐6.
Ganle 2014 {published data only}
    1. Ganle JK, Parker M, Fitzpatrick R, Otupiri E. A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user‐fee abolition. BMC Pregnancy and Childbirth 2014;14:425. [DOI: 10.1186/s12884-014-0425-8]
Gheibizadeh 2016 {published data only}
    1. Gheibizadeh M, Ali Abedi H, Mohammadi E, Abedi P. Iranian women and care providers' perceptions of equitable prenatal care: A qualitative study. Nursing Ethics 2016;23(4):465‐77.
Graner 2010 {published data only}
    1. Graner S, Mogren I, Duong Le Q, Krantz G, Klingberg‐Allvin M. Maternal health care professionals’ perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam. BMC Public Health 2010;10:608. [DOI: 10.1186/1471-2458-10-608.; ]
Graner 2013 {published data only}
    1. Graner S, Klingberg‐Allvin M, Duong LQ, Krantz G, Mogren I. Pregnant women’s perception on signs and symptoms during pregnancy and maternal health care in a rural low‐resource setting. Acta Obstetricia et Gynecologica Scandinavica 2013;92(9):1094‐100.
Griffiths 2001 {published data only}
    1. Griffiths P, Stephenson R. Understanding users’ perspectives of barriers to maternal health care use in Maharashtra, India. Journal of Biosocial Science 2001;33(3):339‐59.
Gross 2011 {published data only}
    1. Gross K, Schellenberg JA, Kessy F, Pfeiffer C, Obrist B. Antenatal care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley, south eastern Tanzania. BMC Pregnancy and Childbirth 2011;11:36. [ ]
Haddrill 2014 {published data only}
    1. Haddrill R, Jones GL, Mitchell CA, Anumba DO. Understanding delayed access to antenatal care: a qualitative interview study. BMC Pregnancy and Childbirth 2014;14:207. [ ]
Heaman 2015 {published data only}
    1. Heaman MI, Sword W, Elliott L, Moffat M, Helewa ME, Morris H, et al. Perceptions of barriers, facilitators and motivators related to use of prenatal care: a qualitative descriptive study of inner‐city women in Winnipeg, Canada. SAGE Open Medicine 2015;3:2050312115621314. [DOI: ]
Heberlein 2016 {published data only}
    1. Heberlein EC, Picklesimer AH, Billings DL, Covington‐Kolb S, Farber N, Frongillo EA. Qualitative comparison of womens perspectives on the functions and benefits of group and individual prenatal care. Journal of Midwifery & Women's Health 2016;61(2):224‐34. [DOI: 10.1111/jmwh.12379]
Hunter 2017 {published data only}
    1. Hunter A, Devane D, Houghton C, Grealish A, Tully A, Smith V. Woman‐centred care during pregnancy and birth in Ireland: thematic analysis of women's and clinicians' experiences. BMC Pregnancy and Childbirth 2017;17:322. [DOI: 10.1186/s12884-017-1521-3]
Kabakian‐Khasholian 2000 {published data only}
    1. Kabakian‐Khasholian T, Campbell O, Shediac‐Rizkallah M, Ghorayeb F. Women’s experiences of maternity care: satisfaction or passivity?. Social Science and Medicine 2000;51(1):103‐13.
Khoso 2016 {published data only}
    1. Khoso A, Khan AZ, Sayed SA, Rafique G. Perspectives regarding antenatal care, delivery and breastfeeding practices of women from Baluchistan, Pakistan. Journal of Ayub Medical College, Abbottabad 2016;28(1):105‐9.
Kraschnewski 2014 {published data only}
    1. Kraschnewski JL, Chuang CH, Poole ES, Peyton T, Blubaugh I, Pauli J, et al. Paging “Dr. Google”: does technology fill the gap created by the prenatal care visit structure? Qualitative Focus Group Study with pregnant women. Journal of Medical Internet Research 2014;16(6):e147. [DOI: 10.2196/jmir.3385]
Lagan 2011 {published data only}
    1. Lagan BM, Sinclair M, Kernohan WG. What is the impact of the internet on decision making in pregnancy? a global study. Birth 2011;38(4):336‐45.
Larsen 2004 {published data only}
    1. Larsen GL, Lupiwa S, Kave HP, Gillieatt S, Alpers MP. Antenatal care in Goroka: issues and perceptions. Papua amd New Guinea Medical Journal 2004;47(3‐4):202‐14.
Larsson 2017 {published data only}
    1. Larsson A, Warna‐Furu C, Nasman Y. The meaning of caring in prenatal care from Swedish women’s perspectives. Scandinavian Journal of Caring Sciences 2017;31(4):702‐9. [DOI: 10.1111/scs.12383]
Lasso Toro 2012 {published data only}
    1. Lasso Toro P. Prenatal care: tensions or possible routes between culture and health system. Pensamiento Psicológico 2012;10(2):123‐133.
Leal 2018 {published data only}
    1. Leal NJ, Barreiro MS, Mendes RB, Alves CK, Freitas C. Prenatal care: Nurses testimonial. Journal of Research: Fundamental Care Online 2018;10(1):113‐22. [DOI: ]
LeMasters 2018 {published data only}
    1. LeMasters K, Wallis AB, Chereches R, Gichane M, Tehei C, Varga A, et al. Pregnancy experiences of women in rural Romania: understanding ethnic and socioeconomic disparities. Culture, Health & Sexuality 2018;21(3):249‐62. [DOI: 10.1080/13691058.2018.1464208]
Mahiti 2015 {published data only}
    1. Mahiti GR, Mkoka DA, Kiwara AD, Mbekenga CK, Hurtig AK, Goicolea I. Womens perceptions of antenatal delivery and postpartum services in rural Tanzania. Global Health Action 2015;8:28567. [DOI: ]
Manithip 2013 {published data only}
    1. Manithip C, Edin K, Sihavong A, Wahlstrom R, Wessel H. Poor quality of antenatal care services—Is lack of competence and support the reason? An observational and interview study in rural areas of Lao PDR. Midwifery 2013;29(3):195‐202.
Maputle 2013 {published data only}
    1. Maputle MS, Lebese RT, Khoza LB, Shilubane NH, Netshikweta LM. Knowledge and attitudes of pregnant women towards antenatal care services at Tshino village, Vhembe district, South Africa. African Journal for Physical, Health Education, Recreation and Dance 2013;March(Supplement 1):126‐37.
Mathole 2005 {published data only}
    1. Mathole T, Linndmark G, Ahlberg BM. Dilemmas and paradoxes in providing and changing antenatal care: a study of nurses and midwives in rural Zimbabwe. Health Care Women International 2005;26(10):937‐56.
Matsuoka 2010 {published data only}
    1. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A. Perceived barriers to utilization of maternal health services in rural Cambodia. Health Policy 2010;95(2‐3):255‐63.
Mayca 2009 {published data only}
    1. Mayca J, Palacios‐Flowers E, Medina A, Velasquez JE, Castañeda D. Perceptions of health personnel and the community in relation to the cultural appropriateness of maternal perinatal services in rural areas in the Andes and Amazon from Huanuco region. Revista Peruana de Medicina Experimental y Salud Publica 2009;26(2):145‐160.
McDonald 2014 {published data only}
    1. McDonald SD, Sword W, Eryuzlu LE, Biringer AB. A qualitative descriptive study of the group prenatal care experience: perceptions of women with low‐risk pregnancies and their midwives. BMC Pregnancy and Childbirth 2014;14:334. [ ]
McNeil 2012 {published data only}
    1. McNeil DA, Vekved M, Dolan SM, Siever J, Horn S, Tough SC. Getting more than they realized they needed: a qualitative study of women's experience of group prenatal care. BMC Pregnancy and Childbirth 2012;12:17. [ ]
Miteniece 2018 {published data only}
    1. Miteniece E, Pavlova M, Shengelia L, Rechel B, Groot W. Barriers to accessing adequate maternal care in Georgia: a qualitative study. BMC Health Services Research 2018;18:631. [DOI: ]
Molina 2011 {published data only}
    1. Molina G, Vargas G, Shaw A. Compromised quality of maternal healthcare in a market economy: Medellin, Colombia. Colombia Medica 2011;42(3):294‐302.
Mrisho 2009 {published data only}
    1. Mrisho M, Obrist B, Schellenberg JA, Haws RA, Mushi AK, Mshinda H, et al. The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy and Childbirth 2009;9:10. [DOI: 10.1186/1471-2393-9-10]
Mugo 2018 {published data only}
    1. Mugo NS, Dibley MJ, Damundu EY, Alam A. Barriers faced by the health workers to deliver maternal care services and their perceptions of the factors preventing their clients from receiving the services: a qualitative study in South Sudan. Maternal and Child Health Journal 2018;22:1598‐606. [DOI: ]
Mumtaz 2007 {published data only}
    1. Mumtaz Z, Salway SM. Gender, pregnancy and the uptake of antenatal care services in Pakistan. Sociology of Health and Illness 2007;29(1):1‐26. [DOI: 10.1111/j.1467-9566.2007.00519.x]
Munguambe 2016 {published data only}
    1. Munguambe K, Boene H, Vidler M, Bique C, Sawchuck D, Firoz T, et al. Barriers and facilitators to health care seeking behaviours in pregnancy in rural communities of southern Mozambique. Reproductive Health 2016;13(Suppl 1):31. [DOI: 10.1186/s12978-016-0141-0]
Myer 2003 {published data only}
    1. Myer L, Harrison A. Why do women seek antenatal care late? Perspectives from rural South Africa. Journal of Midwifery & Women's Health 2003;48(4):268‐72.
Neves 2013 {published data only}
    1. Neves PR, Salim N, Soares GCF, Gualda DM. Experiences of women in a pregnant group: a descriptive study. Online Brazilian Journal of Nursing [Internet] 2013;12(4):862‐71. [DOI: ; ]
Novick 2011 {published data only}
    1. Novick G, Sadler LS, Kennedy HP, Cohen SS, Groce NE, Knafl KA. Women's experience of group prenatal care. Qualitative Health Research 2011;21(1):97‐116.
Novick 2013 {published data only}
    1. Novick G, Sadler LS, Knafl KA, Groce NE, Kennedy HP. In a hard spot: Providing group prenatal care in two urban clinics. Midwifery 2013;29(6):690‐7. [DOI: 10.1016/j.midw.2012.06.013]
Pretorius 2004 {published data only}
    1. Pretorius CF, Greeff M. Health‐service utilization by pregnant women in the greater Mafikeng‐Mmbatho district. Curationis 2004;27(1):72‐81.
Rahmani 2013 {published data only}
    1. Rahmani Z, Brekke M. Antenatal and obstetric care in Afghanistan – a qualitative study among health care receivers and health care providers. BMC Health Services Research 2013;13:166. [ ]
Rath 2010 {published data only}
    1. Rath S, Nair N, Tripathy PK, Barnett S, Rath S, Mahapatra R, et al. Explaining the impact of a women’s group led community mobilization intervention on maternal and newborn health outcomes: the Ekjut trial process evaluation. BMC International Health and Human Rights 2010;10:25. []
Saftner 2017 {published data only}
    1. Saftner MA, Neerland C, Avery MD. Enhancing women's confidence for physiologic birth: Maternity care providers’ perspectives. Midwifery 2017;53:28‐34. []
Santos 2010 {published data only}
    1. Santos AL, Radovanovic CA, Marcon SS. Prenatal care: satisfaction and expectations. Revista da Rede de Enfermagem do Nordeste 2010;11:61‐71.
Shabila 2014 {published data only}
    1. Shabila HP, Ahmed HM, Yasin MY. Women’s views and experiences of antenatal care in Iraq: a Q methodology study. BMC Pregnancy and Childbirth 2014;14:43. []
Simkhada 2010 {published data only}
    1. Simkhada B, Porter MA, Teijlingen ER. The role of mothers‐in‐law in antenatal care decision‐making in Nepal: a qualitative study. BMC Pregnancy and Childbirth 2010;10:34. [DOI: 10.1186/1471-2393-10-34]
Spindola 2012 {published data only}
    1. Spindola T, Progianti JM, Garcia Penna LH. Pregnant women’s experiences about the obstetrics nurse support during prenatal care at a university hospital. Ciencia y Enfermería 2012;18(2):65‐73.
Stokes 2008 {published data only}
    1. Stokes E, Dumbaya I, Owens S, Brabin L. The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women. BJOG 2008;115(13):1641‐7. [DOI: 10.1111/j.1471-0528.2008.01950.x]
Sword 2003 {published data only}
    1. Sword W. Prenatal care use among women of low income: a matter of "taking care of self". Qualitative Health Research 2003;13(3):319. [DOI: 10.1177/0095399702250128]
Sword 2012 {published data only}
    1. Sword W, Heaman MI, Brooks S, Tough S, Janssen PA, Young D, et al. Women’s and care providers’ perspectives of quality prenatal care: a qualitative descriptive study. BMC Pregnancy and Childbirth 2012;12:29. []
Sychareun 2016 {published data only}
    1. Sychareun V, Somphet V, Chaleunvong K, Hansana V, Phengsavanh A, Xayavong S, et al. Perceptions and understandings of pregnancy, antenatal care and postpartum care among rural Lao women and their families. BMC Pregnancy and Childbirth 2016;16:245. [DOI: 10.1186/s12884-016-1031-8]
Teate 2011 {published data only}
    1. Teate A, Leap N, Rising SS, Homer CS. Women’s experiences of group antenatal care in Australia ‐ the Centering Pregnancy Pilot Study. Midwifery 2011;27(2):138‐45. [DOI: 10.1016/j.midw.2009.03.001]
Teate 2013 {published data only}
    1. Teate A, Leap N, Homer CS. Midwives’ experiences of becoming Centering Pregnancy facilitators: a pilot study in Sydney, Australia. Women and Birth 2013;26:e31‐36.
Thwala 2011 {published data only}
    1. Thwala SB, Jones LK, Holroyd E. Swaziland rural maternal care: Ethnography of the interface of custom and biomedicine. International Journal of Nursing Practice 2011;17(1):93‐101. [DOI: 10.1111/j.1440-172X.2010.01911.x]
Titaley 2010 {published data only}
    1. Titaley CR, Hunter CL, Heywood P, Dibley MJ. Why don’t some women attend antenatal and postnatal care services?: a qualitative study of community members’ perspectives in Garu, Sukambi and Ciamis districts of West Java Province, Indonesia. BMC Pregnancy and Childbirth 2010;10:61. [DOI: 10.1186/1471-2393-10-61.]
Umeora 2008 {published data only}
    1. Umeora OU, Ejikeme BN, Sunday‐Adeoye I, Ogu RN. Implementing the new WHO antenatal care model: voices from end‐users in a rural Nigerian community. Nigerian Journal of Clinical Practice 2008;11(3):260‐4.
Walburg 2014 {published data only}
    1. Walburg V, Friederich F, Callahan S. Embarrassment and modesty feelings during pregnancy, childbirth and follow‐up care: A qualitative approach. Journal of Reproductive and Infant Psychology 2014;32(2):126‐36. [DOI: ]
Wilmore 2015 {published data only}
    1. Wilmore M, Rodger D, Humphreys S, Clifton VL, Dalton J, Flabouris M, et al. How midwives tailor health information used in antenatal care. Midwifery 2015;31(1):74‐99. [DOI: ]
Worley 2004 {published data only}
    1. Worley BL, Bullock LF, Geden E. The incubator model: is it effective prenatal care?. Clinical Excellence for Nurse Practitioners 2004;8(1):29‐34.
Wright 2018 {published data only}
    1. Wright D, Pincombe J, McKellar L. Exploring routine hospital antenatal care consultations — An ethnographic study. Women and Birth 2018;31(3):e162‐e169. [DOI: 10.1016/j.wombi.2017.09.010]
Østergaard 2015 {published data only}
    1. Østergaard LR. Maternal healthcare in context: A qualitative study of women's tactics to improve their experience of public healthcare in rural Burkina Faso. Social Science & Medicine 2015;147:98‐104. [DOI: ]
References to studies excluded from this review Lohmann 2018 {published data only}
    1. Lohmann S, Mattern E, Ayerle GM. Midwives' perceptions of women's preferences related to midwifery care in Germany: A focus group study. Midwifery 2018;61:53‐62. []
Murira 2003 {published data only}
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Nigenda 2003 {published data only}
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