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The National Institute for Health and Care Excellence (NICE) guidelines recommend that all women should commence maternity care before 10 weeks gestation.1 This offers the opportunity to screen for sexually transmitted infections, family violence, maternal mental health issues and congenital abnormalities. It also allows for early recognition of underlying medical conditions that may impact on the pregnancy, as well as an opportunity to provide education about nutrition, smoking and drug use during pregnancy. Under-attendance and non- attendance for antenatal care has been linked to poor pregnancy outcomes, including low birth weight and foetal or neonatal death.2-4The Fifth Annual Report of the Perinatal and Maternal Mortality Review (PMMR) Committee released in July 2011 indicated that barriers to accessing or engaging with maternity and health services were the most common factors contributing to perinatal mortality.5 This report also found that Māori and Pacific mothers, women from the most deprived socioeconomic quintile, and teenage mothers were more likely to have stillbirths and neonatal deaths.In overseas studies, demographic factors shown to be associated with late booking for or inadequate antenatal care include: minority ethnic group,6-8 low educational level,6,9 age under 20 years or over 35 years,9 multi-parity,9 residing in areas with few antenatal care providers (inner city or rural),10,11 and low socioeconomic status.12There is a paucity of research on barriers to early initiation of antenatal care in the New Zealand (NZ) context. Given New Zealand's unique population and maternity system, conclusions drawn from overseas research may not be generalisable to NZ. In the one study previously conducted in Pacific women residing in the Counties Manukau District Health Board (CMDHB) catchment area, high parity, first pregnancy, unemployment prior to pregnancy and Cook Island ethnicity were associated with late initiation of antenatal care.13CMDHB serves the most economically deprived areas of New Zealand, with a high proportion of young mothers, and women of Māori and Pacific ethnicity. There is a high rate of late booking for antenatal care; in 2000, 26% of mothers of Pacific infants in CMDHB booked after the 15th week of pregnancy.13 CMDHB also has the highest perinatal mortality rate in New Zealand with a 3-year perinatal-related mortality rate of 13.70 per 1000 births compared with the national rate of 10.75 per 1000 births.5This study aims to identify barriers to early initiation of antenatal care among women utilising CMDHB maternity services, by surveying a sample of women in late pregnancy (>37 weeks gestation) or who have recently delivered (within 6 weeks). Identifying these barriers provides the CMDHB an opportunity to find more targeted approaches in providing antenatal care to women at greatest need in the community it serves.MethodsThis cross-sectional study was undertaken at CMDHB maternity facilities during July to September 2011. In order to ensure recruitment of a representative sample, participants were sought from women attending all CMDHB facilities. A convenience sample comprising of pregnant women at>37 weeks gestation and postnatal women within 6 weeks of delivery were invited to complete the questionnaire. All participants gave informed written consent. The study protocol was approved by the Northern Y Regional Ethics Committee (NTY/11/EXP/026) and the Māori Research Review Committee.Options for maternity care in CMDHB area at the time of the study included: 1) Lead Maternity Carer (LMC) such as a self-employed midwife, general practitioner (GP) or private obstetrician; 2) DHB bulk-funded primary maternity services (such as community midwives or Shared Care); and 3) Referrals to secondary care for women identified as high risk, which includes both the Obstetric Medical Clinic and Diabetes in Pregnancy Service. Shared Care is a unique system that developed in CMDHB in response to a shortage of self-employed LMCs. Women in the Shared Care model receive most of their antenatal care from a GP who enters into a shared care arrangement with the DHB. In addition, these women are offered three antenatal visits with a DHB-employed community midwife and are delivered at a CMDHB facility by a DHB-employed midwife. GPs providing Shared Care are not currently required to have either specific training in antenatal care or a postgraduate Diploma of Obstetrics and Gynaecology.Women were eligible to participate if they were>37 weeks pregnant or had delivered within 6 weeks (<6 weeks postnatal). Potential participants were identified for recruitment while seeking antenatal care, or labour and postnatal care. Eligible women were invited to participate by consultants, registrars, house officers, hospital midwives, maternity nurses, breastfeeding educators, health care assistants, and self-employed midwives. Interpreters were offered to women who did not speak English. For eligible women who at discharge had not completed the questionnaire, one was mailed their home address with a prepaid envelope to facilitate its return. Women residing outside the Counties Manukau area who had booked to deliver elsewhere were excluded.Questionnaire design was guided by a literature review of comparable studies in other countries, as well as clinicians' experiences in CMDHB antenatal care settings. A pilot of the questionnaire was undertaken with 10 women, all of whom were late bookers, with English as a second language. After completing the questionnaire, the women were interviewed about barriers to care and the questionnaire's ease of use and understanding. Responses provided on the questionnaire were compared to qualitative interviews to ensure consistency and comprehension.The questionnaire collected data on: demographic factors (age, ethnicity, education level, parity, relationship status); National Health Index (NHI) number and date the questionnaire was completed (in order to avoid duplication); gestation when pregnancy was first diagnosed and at booking with a Lead Maternity Carer; the number of visits to a midwife or doctor for pregnancy care; knowledge about the need for care during pregnancy; and specific barriers to antenatal care. In addition, qualitative data was obtained using open-ended questions to allow participants to comment on the difficulties faced in getting antenatal care and what would ease this.Information obtained from the participants' electronic health records included: due date, baby's date of birth, gravidity, parity, eligibility for free maternity care, date of the initial antenatal booking visit, and with whom women had booked antenatal care (self-employed midwife, shared care, closed unit or case-loading midwife).Late booking was defined as booking for antenatal care with any healthcare provider after 18 weeks gestation, which was based on self-report. The discrepancy in the gestation at booking obtained through self-report versus that noted in the hospital registration form was determined; this illustrated the unreliability of using hospital registration form data when ascertaining the number of women who book late.The majority of published studies have used a cut-off of 12 or 14 weeks to define late booking, as it is recommended that antenatal care start in the 1st trimester.14 However, with the current maternity system at CMDHB, many women see their GP in the first trimester to diagnose pregnancy, and to make arrangements to have blood tests and ultrasound scans before finding a midwife for ongoing care.Since many midwives will not schedule a booking visit until after 15 weeks gestation (but almost always before 18 weeks), defining late booking as>12 weeks gestation will include a large proportion of women who have had adequate antenatal care. Therefore, in this study 18 weeks was chosen as an appropriate cut-off as by then, women with access to adequate care should have been booked.The sample size was estimated based on data obtained from an audit of all hospital registration forms completed at CMDHB between 1 August 2008 and 31 July 2009 (n=8423). This audit showed that of the 7093 women registered to deliver at Middlemore Hospital, 2777 (39%) registered after 18 weeks of gestation. It was estimated that a sample of 800 women would be required to detect an odds ratio of 1.75 with 80% power. Sample demographics were compared after recruiting 100, 300, 500 and 800 women to check for consistency.Demographic characteristics were described for the total study sample (n=826). For participants with information on gestation at booking for antenatal care (n=767), the Chi-squared test was used to assess whether late booking for antenatal care was related to each demographic factor and potential barrier to accessing care. From this analysis, variables significantly associated with late booking for antenatal care were considered as covariates for multivariate logistic regression analysis.Associations between all covariates were determined to avoid using similar/collinear covariates in the multivariate model. For instance, given the significant positive association between maternal age and parity as well as the higher proportion of missing data on parity than maternal age (10% vs. 1.3%), maternal age (but not parity) was entered into the multivariate model. In addition, a variable (“limited resources”) was created using four associated variables to capture information on women's lack of one or more of the following: transport; childcare; phone credit or phone; and money for clinic visits/scans. The most parsimonious multivariate logistic model (n=705) was selected based on Akaike's information criterion and the results summarised using odds ratios (OR) and 95% confidence intervals (CI). All analyses were performed using SAS® version 9.3 software (SAS Institute Inc., Cary, N.C., USA).ResultsOf the 826 women participated in this study, 137 (17%) booked for antenatal care at>18 weeks (late bookers) and 630 (76%) booked at ≤18 weeks; for the remaining 7%, data on gestation at antenatal care booking was unavailable.The ethnic composition of the sample was as follows: 43% Pacific Peoples, 20% Māori, 14% Asian and 21% European or other ethnicities (Table 1). This was fairly comparable to the ethnicity of women who registered to deliver at Middlemore Hospital in August 2008 through July 2009 (38% Pacific, 22% Māori, 13% Asian and 27% European/other ethnicities). Most of the women had either secondary or tertiary education and were eligible for free maternity services. A little less than a quarter did not live with a husband/partner.Upon learning about their pregnancy, most women initially sought care from a GP (72%) or midwife (19%). Compared to the overall sample, the group booking late for antenatal care had a higher proportion of women of Pacific ethnicity, aged <20 years, with secondary education, not living with a husband/partner, with ≥3 children, and ineligible for free maternity services.In the univariate analysis, late booking for antenatal care was significantly associated with several demographic factors (Table 1) and potential barriers to accessing care (Table 2). Factors unrelated to late booking for antenatal care (Table not shown) were: help from GP to find pregnancy care; the source of initial pregnancy care (GP, midwife or other care); learning about an LMC from friends/family; having the same LMC as in the previous pregnancy; spending a long time in waiting rooms during appointments; and forgetting appointments.Table 1. Characteristics of the study populationTable 2. Late booking for antenatal care in relation to potential barriers to accessing care in pregnancy (n=767)The multivariate analysis identified factors independently associated with late booking for antenatal care (Table 3). The adjusted analysis indicated that the odds of late booking were approximately two times higher among women with limited resources, with no tertiary education, and not living with a husband/partner. In addition, the odds of late booking for antenatal care was almost six times higher for both Māori and Pacific women compared to those of European and other ethnicities.Table 3. Logistic regression analysis for late booking for antenatal care (n=705)It was not possible to determine the late booking status for 7% (n=59) of the sample as data on gestation at initiation of antenatal care was unavailable. There were no significant difference between women missing data on gestation at initiation of antenatal and those with valid values (Chi-squared test, Table not shown) on the following demographic variables: ethnicity (p=0.42, n=815); age group (p=0.42, n=815); having husband/partner (p=0.38, n=812); parity (p=0.53, n=744); and eligibility for free maternity services (p=0.39, n=744). However, these two groups differed on maternal education (p<0.001, n=793) whereby the proportion of women with a tertiary education was greater in the group with data on gestation at booking compared to the group missing this data (48% vs. 29%). Given the results from this study show that women without tertiary education are more likely book late for antenatal care, the magnitude of this association has likely been underestimated.DiscussionFindings from this study show that women with limited resources, with no tertiary education, or not living with a husband/partner are at a greater disadvantage when it comes to timely booking for antenatal care. Māori and Pacific women are also much more likely to book late for antenatal care than women of European and other ethnicities. This suggests that late booking for antenatal care in CMDHB is likely due to sociodemographic factors, social deprivation, and inadequate social support. Our findings are consistent with research undertaken to assess factors related to untimely initiation of prenatal care among women in high-income countries who reside in disadvantaged areas. This research has identified some comparable barriers including, inadequate social support,15-18 lower maternal educational level,15,18-20 economic hardships,15,17,20 and transportation and access difficulties.19,21The main strength of this study is its large multi-ethnic sample size, which adds to a small body of existing literature regarding antenatal care in this NZ population. It also provides additional insight and information to guide local system design and policy. However, it must also be recognised that the characteristics of the CMDHB resident population are different to other parts of NZ, which would limit generalisability of findings to the rest of country. Nonetheless, our findings would be applicable to women in high-income countries who reside in disadvantaged areas. There is no current NZ guideline on when antenatal care should commence and hence, a cut-off was chosen in line with other literature that used 18 weeks as a definition of very late booking.22A study limitation is the unavailability of a response rate due to lack of information on the number of women approached for recruitment and who declined participation. Our study relied on participant recall of gestation at pregnancy diagnosis and booking, which may be subject to misclassification bias that we expect occurred indiscriminately. Because of the large number of participants, a quantitative design was chosen which may mean that some novel barriers were not identified. A validated, standardized and widely used questionnaire was not available limiting the extent to which this study's findings could be compared to previous research.Given the barriers to timely initiation to antenatal care identified in this study, maternity care providers may consider more flexible models of care and ways of delivering care within the community. This could be done via home visits, after hour's clinics, and having midwifery clinics within GP practices in the local community. Location of hospitals and clinics should be considered when planning public transport routes or vice versa. In order to provide the best care to a multi-ethnic population, it is vital to continue to actively recruit and train multi-ethnic medical and midwifery staff, ensure interpreters are available, and provide written information in a range of languages.Interventions are needed to improve the early diagnosis of pregnancy which could lead to more timely initiation of antenatal care. This may include emphasis on the importance of school health programs that educate girls about normal menstruation and seeking medical attention for missed or abnormal periods, as well as consideration of ways to extend this knowledge to adult women. Options should be explored for making pregnancy tests more freely available.Currently, women have free visits to their GP if the pregnancy test is positive, but have to pay for the consultation if the test is negative. Public health interventions are needed to improve specific knowledge on the importance of seeking care early and how to go about getting care. The general practitioner is an important facilitator of maternity care in our study population, being the first point of contact for many women. By using pre-existing networks, consultation regarding current unmet needs can be undertaken, and strategies to facilitate early risk assessment and support timely access to maternity services can be disseminated.There is a need for robust pregnancy data collection and management in order to be able to accurately assess the proportion of women booking late for antenatal care, which would enhance the success of any future interventions. Currently, it is not possible to use existing data collection processes to accurately identify the number and characteristics of the women who book late for pregnancy care. With an improvement in the maternity data collection systems, further research could address whether the rates of late booking seen in Pacific and Māori women are accounted for primarily by higher levels of socioeconomic deprivation, or if there are also elements within the current system that are not culturally appropriate. Research among women who have a late diagnosis of pregnancy and factors associated with this would help inform public health strategies to reduce this problem.\r\n

Summary

Abstract

Aim

To identify barriers to early initiation of antenatal care amongst pregnant women in South Auckland, New Zealand.

Method

Women in late pregnancy (>37 weeks gestation) or who had recently delivered (

Results

Of the 826 women who participated, 137 (17%) booked for antenatal care at >18 weeks (late bookers). The ethnic composition of the sample was: 43% Pacific Peoples, 20% Mori, 14% Asian, and 21% European or other ethnicities. The multivariate analysis indicated that women were significantly more likely to book late for antenatal care if they had limited resources (OR=1.86; 95% CI=1.17-2.93), no tertiary education (OR=1.96; 95% CI=1.23- 3.15), or were not living with a husband/partner (OR=2.34; 95% CI=1.48-3.71). In addition, the odds of late booking for antenatal care was almost six times higher among Mori (OR=5.70; 95% CI=2.57-12.64) and Pacific (OR=5.90; 95% CI=2.83-12.29) women compared to those of European and other ethnicities.

Conclusion

Late booking for antenatal care in the Counties Manukau District Health Board area (South Auckland) is associated with sociodemographic factors, social deprivation, and inadequate social support.

Author Information

Sarah Corbett, Obstetric Registrar, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland; Carol Chelimo, Research Fellow, Department of Obstetrics and Gynaecology, School of Medicine, University of Auckland, Auckland; Kara Okesene-Gafa, Specialist Obstetrician, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland

Acknowledgements

This study was funded by the Centre of Clinical Research and Effective Practice (CCREP) at Counties Manukau District Health Board (CMDHB). The authors gratefully acknowledge the women who participated in the study and the clinicians who assisted with recruiting the women into the study. We thank Professor Lesley McCowan for her valuable advice on this work.

Correspondence

Dr Kara Okesene-Gafa, South Auckland Clinical School, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.

Correspondence Email

Kara.Okesene-Gafa@middlemore.co.nz

Competing Interests

Nil.

1. NICE. Antenatal Care: NICE clinical guideline 62 [homepage on the Internet]. London: National Institute for Health and Care Excellence; 2008 [updated June 2010; cited 2014 April 01]. Available from: http://guidance.nice.org.uk/CG62. 2. Raatikainen K, Heiskanen N, Heinonen S. Under-attending free antenatal care is associated with adverse pregnancy outcomes. BMC Public Health. 2007;7:268. 3. Stacey T, Thompson JM, Mitchell EA, et al. Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth: findings from the Auckland Stillbirth Study. Aust N Z J Obstet Gynaecol. 2012;52(3):242-7. 4. Vintzileos AM, Ananth CV, Smulian JC, et al. The impact of prenatal care on neonatal deaths in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;186(5):1011-6. 5. PMMRC. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. Wellington, NZ: Health Quality & Safety Commission, 2011. 6. Frisbie WP, Echevarria S, Hummer RA. Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans. Matern Child Health J. 2001;5(1):21-33. 7. Healy AJ, Malone FD, Sullivan LM, et al. Early access to prenatal care: implications for racial disparity in perinatal mortality. Obstet Gynecol. 2006;107(3):625-31. 8. Laditka SB, Laditka JN, Probst JC. Racial and ethnic disparities in potentially avoidable delivery complications among pregnant Medicaid beneficiaries in South Carolina. Matern Child Health J. 2006;10(4):339-50. 9. Williams L, Morrow B, Shulman H, et al. PRAMS 2002 surveillance report. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2006. 10. Adams EK, Gavin NI, Benedict MB. Access for pregnant women on Medicaid: variation by race and ethnicity. J Health Care Poor Underserved. 2005;16(1):74-95. 11. McLafferty S, Grady S. Prenatal care need and access: a GIS analysis. J Med Syst. 2004;28(3):321-33. 12. Williams LM, Morrow B, Lansky A, et al. Surveillance for selected maternal behaviors and experiences before, during, and after pregnancy. Pregnancy Risk Assessment Monitoring System (PRAMS), 2000. Morb Mortal Wkly Rep Surveill Summ. 2003;52(11):1-14. 13. Low P, Paterson J, Wouldes T, et al. Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. N Z Med J. 2005;118(1216):U1489. 14. Enkin M. Support for pregnant women. In: Enkin M, editor. Guide to effective care in pregnancy and childbirth. Oxford, UK: Oxford University Press; 2000. 15. Delvaux T, Buekens P, Godin I, Boutsen M. Barriers to prenatal care in Europe. Am J Prev Med. 2001;21(1):52-9. 16. Downe S, Finlayson K, Walsh D, Lavender T. 'Weighing up and balancing out': a meta- synthesis of barriers to antenatal care for marginalised women in high-income countries. BJOG. 2009;116(4):518-29. 17. Nepal VP, Banerjee D, Perry M. Prenatal Care Barriers in an Inner-city Neighborhood of Houston, Texas. J Prim Care Community Health. 2011;2(1):33-6. 18. Sunil TS, Spears WD, Hook L, et al. Initiation of and barriers to prenatal care use among low- income women in San Antonio, Texas. Matern Child Health J. 2010;14(1):133-40. 19. Braveman P, Marchi K, Egerter S, et al. Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors. Obstet Gynecol. 2000;95(6 Pt 1):874-80. 20. Park J-H, Vincent D, Hastings-Tolsma M. Disparity in prenatal care among women of colour in the USA. Midwifery. 2007;23(1):28-37. 21. Cook CA, Selig KL, Wedge BJ, Gohn-Baube EA. Access barriers and the use of prenatal care by low-income, inner-city women. Soc Work. 1999;44(2):129-39. 22. Kupek E, Petrou S, Vause S, Maresh M. Clinical, provider and sociodemographic predictors of late initiation of antenatal care in England and Wales. BJOG. 2002;109(3):265-73.

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The National Institute for Health and Care Excellence (NICE) guidelines recommend that all women should commence maternity care before 10 weeks gestation.1 This offers the opportunity to screen for sexually transmitted infections, family violence, maternal mental health issues and congenital abnormalities. It also allows for early recognition of underlying medical conditions that may impact on the pregnancy, as well as an opportunity to provide education about nutrition, smoking and drug use during pregnancy. Under-attendance and non- attendance for antenatal care has been linked to poor pregnancy outcomes, including low birth weight and foetal or neonatal death.2-4The Fifth Annual Report of the Perinatal and Maternal Mortality Review (PMMR) Committee released in July 2011 indicated that barriers to accessing or engaging with maternity and health services were the most common factors contributing to perinatal mortality.5 This report also found that Māori and Pacific mothers, women from the most deprived socioeconomic quintile, and teenage mothers were more likely to have stillbirths and neonatal deaths.In overseas studies, demographic factors shown to be associated with late booking for or inadequate antenatal care include: minority ethnic group,6-8 low educational level,6,9 age under 20 years or over 35 years,9 multi-parity,9 residing in areas with few antenatal care providers (inner city or rural),10,11 and low socioeconomic status.12There is a paucity of research on barriers to early initiation of antenatal care in the New Zealand (NZ) context. Given New Zealand's unique population and maternity system, conclusions drawn from overseas research may not be generalisable to NZ. In the one study previously conducted in Pacific women residing in the Counties Manukau District Health Board (CMDHB) catchment area, high parity, first pregnancy, unemployment prior to pregnancy and Cook Island ethnicity were associated with late initiation of antenatal care.13CMDHB serves the most economically deprived areas of New Zealand, with a high proportion of young mothers, and women of Māori and Pacific ethnicity. There is a high rate of late booking for antenatal care; in 2000, 26% of mothers of Pacific infants in CMDHB booked after the 15th week of pregnancy.13 CMDHB also has the highest perinatal mortality rate in New Zealand with a 3-year perinatal-related mortality rate of 13.70 per 1000 births compared with the national rate of 10.75 per 1000 births.5This study aims to identify barriers to early initiation of antenatal care among women utilising CMDHB maternity services, by surveying a sample of women in late pregnancy (>37 weeks gestation) or who have recently delivered (within 6 weeks). Identifying these barriers provides the CMDHB an opportunity to find more targeted approaches in providing antenatal care to women at greatest need in the community it serves.MethodsThis cross-sectional study was undertaken at CMDHB maternity facilities during July to September 2011. In order to ensure recruitment of a representative sample, participants were sought from women attending all CMDHB facilities. A convenience sample comprising of pregnant women at>37 weeks gestation and postnatal women within 6 weeks of delivery were invited to complete the questionnaire. All participants gave informed written consent. The study protocol was approved by the Northern Y Regional Ethics Committee (NTY/11/EXP/026) and the Māori Research Review Committee.Options for maternity care in CMDHB area at the time of the study included: 1) Lead Maternity Carer (LMC) such as a self-employed midwife, general practitioner (GP) or private obstetrician; 2) DHB bulk-funded primary maternity services (such as community midwives or Shared Care); and 3) Referrals to secondary care for women identified as high risk, which includes both the Obstetric Medical Clinic and Diabetes in Pregnancy Service. Shared Care is a unique system that developed in CMDHB in response to a shortage of self-employed LMCs. Women in the Shared Care model receive most of their antenatal care from a GP who enters into a shared care arrangement with the DHB. In addition, these women are offered three antenatal visits with a DHB-employed community midwife and are delivered at a CMDHB facility by a DHB-employed midwife. GPs providing Shared Care are not currently required to have either specific training in antenatal care or a postgraduate Diploma of Obstetrics and Gynaecology.Women were eligible to participate if they were>37 weeks pregnant or had delivered within 6 weeks (<6 weeks postnatal). Potential participants were identified for recruitment while seeking antenatal care, or labour and postnatal care. Eligible women were invited to participate by consultants, registrars, house officers, hospital midwives, maternity nurses, breastfeeding educators, health care assistants, and self-employed midwives. Interpreters were offered to women who did not speak English. For eligible women who at discharge had not completed the questionnaire, one was mailed their home address with a prepaid envelope to facilitate its return. Women residing outside the Counties Manukau area who had booked to deliver elsewhere were excluded.Questionnaire design was guided by a literature review of comparable studies in other countries, as well as clinicians' experiences in CMDHB antenatal care settings. A pilot of the questionnaire was undertaken with 10 women, all of whom were late bookers, with English as a second language. After completing the questionnaire, the women were interviewed about barriers to care and the questionnaire's ease of use and understanding. Responses provided on the questionnaire were compared to qualitative interviews to ensure consistency and comprehension.The questionnaire collected data on: demographic factors (age, ethnicity, education level, parity, relationship status); National Health Index (NHI) number and date the questionnaire was completed (in order to avoid duplication); gestation when pregnancy was first diagnosed and at booking with a Lead Maternity Carer; the number of visits to a midwife or doctor for pregnancy care; knowledge about the need for care during pregnancy; and specific barriers to antenatal care. In addition, qualitative data was obtained using open-ended questions to allow participants to comment on the difficulties faced in getting antenatal care and what would ease this.Information obtained from the participants' electronic health records included: due date, baby's date of birth, gravidity, parity, eligibility for free maternity care, date of the initial antenatal booking visit, and with whom women had booked antenatal care (self-employed midwife, shared care, closed unit or case-loading midwife).Late booking was defined as booking for antenatal care with any healthcare provider after 18 weeks gestation, which was based on self-report. The discrepancy in the gestation at booking obtained through self-report versus that noted in the hospital registration form was determined; this illustrated the unreliability of using hospital registration form data when ascertaining the number of women who book late.The majority of published studies have used a cut-off of 12 or 14 weeks to define late booking, as it is recommended that antenatal care start in the 1st trimester.14 However, with the current maternity system at CMDHB, many women see their GP in the first trimester to diagnose pregnancy, and to make arrangements to have blood tests and ultrasound scans before finding a midwife for ongoing care.Since many midwives will not schedule a booking visit until after 15 weeks gestation (but almost always before 18 weeks), defining late booking as>12 weeks gestation will include a large proportion of women who have had adequate antenatal care. Therefore, in this study 18 weeks was chosen as an appropriate cut-off as by then, women with access to adequate care should have been booked.The sample size was estimated based on data obtained from an audit of all hospital registration forms completed at CMDHB between 1 August 2008 and 31 July 2009 (n=8423). This audit showed that of the 7093 women registered to deliver at Middlemore Hospital, 2777 (39%) registered after 18 weeks of gestation. It was estimated that a sample of 800 women would be required to detect an odds ratio of 1.75 with 80% power. Sample demographics were compared after recruiting 100, 300, 500 and 800 women to check for consistency.Demographic characteristics were described for the total study sample (n=826). For participants with information on gestation at booking for antenatal care (n=767), the Chi-squared test was used to assess whether late booking for antenatal care was related to each demographic factor and potential barrier to accessing care. From this analysis, variables significantly associated with late booking for antenatal care were considered as covariates for multivariate logistic regression analysis.Associations between all covariates were determined to avoid using similar/collinear covariates in the multivariate model. For instance, given the significant positive association between maternal age and parity as well as the higher proportion of missing data on parity than maternal age (10% vs. 1.3%), maternal age (but not parity) was entered into the multivariate model. In addition, a variable (“limited resources”) was created using four associated variables to capture information on women's lack of one or more of the following: transport; childcare; phone credit or phone; and money for clinic visits/scans. The most parsimonious multivariate logistic model (n=705) was selected based on Akaike's information criterion and the results summarised using odds ratios (OR) and 95% confidence intervals (CI). All analyses were performed using SAS® version 9.3 software (SAS Institute Inc., Cary, N.C., USA).ResultsOf the 826 women participated in this study, 137 (17%) booked for antenatal care at>18 weeks (late bookers) and 630 (76%) booked at ≤18 weeks; for the remaining 7%, data on gestation at antenatal care booking was unavailable.The ethnic composition of the sample was as follows: 43% Pacific Peoples, 20% Māori, 14% Asian and 21% European or other ethnicities (Table 1). This was fairly comparable to the ethnicity of women who registered to deliver at Middlemore Hospital in August 2008 through July 2009 (38% Pacific, 22% Māori, 13% Asian and 27% European/other ethnicities). Most of the women had either secondary or tertiary education and were eligible for free maternity services. A little less than a quarter did not live with a husband/partner.Upon learning about their pregnancy, most women initially sought care from a GP (72%) or midwife (19%). Compared to the overall sample, the group booking late for antenatal care had a higher proportion of women of Pacific ethnicity, aged <20 years, with secondary education, not living with a husband/partner, with ≥3 children, and ineligible for free maternity services.In the univariate analysis, late booking for antenatal care was significantly associated with several demographic factors (Table 1) and potential barriers to accessing care (Table 2). Factors unrelated to late booking for antenatal care (Table not shown) were: help from GP to find pregnancy care; the source of initial pregnancy care (GP, midwife or other care); learning about an LMC from friends/family; having the same LMC as in the previous pregnancy; spending a long time in waiting rooms during appointments; and forgetting appointments.Table 1. Characteristics of the study populationTable 2. Late booking for antenatal care in relation to potential barriers to accessing care in pregnancy (n=767)The multivariate analysis identified factors independently associated with late booking for antenatal care (Table 3). The adjusted analysis indicated that the odds of late booking were approximately two times higher among women with limited resources, with no tertiary education, and not living with a husband/partner. In addition, the odds of late booking for antenatal care was almost six times higher for both Māori and Pacific women compared to those of European and other ethnicities.Table 3. Logistic regression analysis for late booking for antenatal care (n=705)It was not possible to determine the late booking status for 7% (n=59) of the sample as data on gestation at initiation of antenatal care was unavailable. There were no significant difference between women missing data on gestation at initiation of antenatal and those with valid values (Chi-squared test, Table not shown) on the following demographic variables: ethnicity (p=0.42, n=815); age group (p=0.42, n=815); having husband/partner (p=0.38, n=812); parity (p=0.53, n=744); and eligibility for free maternity services (p=0.39, n=744). However, these two groups differed on maternal education (p<0.001, n=793) whereby the proportion of women with a tertiary education was greater in the group with data on gestation at booking compared to the group missing this data (48% vs. 29%). Given the results from this study show that women without tertiary education are more likely book late for antenatal care, the magnitude of this association has likely been underestimated.DiscussionFindings from this study show that women with limited resources, with no tertiary education, or not living with a husband/partner are at a greater disadvantage when it comes to timely booking for antenatal care. Māori and Pacific women are also much more likely to book late for antenatal care than women of European and other ethnicities. This suggests that late booking for antenatal care in CMDHB is likely due to sociodemographic factors, social deprivation, and inadequate social support. Our findings are consistent with research undertaken to assess factors related to untimely initiation of prenatal care among women in high-income countries who reside in disadvantaged areas. This research has identified some comparable barriers including, inadequate social support,15-18 lower maternal educational level,15,18-20 economic hardships,15,17,20 and transportation and access difficulties.19,21The main strength of this study is its large multi-ethnic sample size, which adds to a small body of existing literature regarding antenatal care in this NZ population. It also provides additional insight and information to guide local system design and policy. However, it must also be recognised that the characteristics of the CMDHB resident population are different to other parts of NZ, which would limit generalisability of findings to the rest of country. Nonetheless, our findings would be applicable to women in high-income countries who reside in disadvantaged areas. There is no current NZ guideline on when antenatal care should commence and hence, a cut-off was chosen in line with other literature that used 18 weeks as a definition of very late booking.22A study limitation is the unavailability of a response rate due to lack of information on the number of women approached for recruitment and who declined participation. Our study relied on participant recall of gestation at pregnancy diagnosis and booking, which may be subject to misclassification bias that we expect occurred indiscriminately. Because of the large number of participants, a quantitative design was chosen which may mean that some novel barriers were not identified. A validated, standardized and widely used questionnaire was not available limiting the extent to which this study's findings could be compared to previous research.Given the barriers to timely initiation to antenatal care identified in this study, maternity care providers may consider more flexible models of care and ways of delivering care within the community. This could be done via home visits, after hour's clinics, and having midwifery clinics within GP practices in the local community. Location of hospitals and clinics should be considered when planning public transport routes or vice versa. In order to provide the best care to a multi-ethnic population, it is vital to continue to actively recruit and train multi-ethnic medical and midwifery staff, ensure interpreters are available, and provide written information in a range of languages.Interventions are needed to improve the early diagnosis of pregnancy which could lead to more timely initiation of antenatal care. This may include emphasis on the importance of school health programs that educate girls about normal menstruation and seeking medical attention for missed or abnormal periods, as well as consideration of ways to extend this knowledge to adult women. Options should be explored for making pregnancy tests more freely available.Currently, women have free visits to their GP if the pregnancy test is positive, but have to pay for the consultation if the test is negative. Public health interventions are needed to improve specific knowledge on the importance of seeking care early and how to go about getting care. The general practitioner is an important facilitator of maternity care in our study population, being the first point of contact for many women. By using pre-existing networks, consultation regarding current unmet needs can be undertaken, and strategies to facilitate early risk assessment and support timely access to maternity services can be disseminated.There is a need for robust pregnancy data collection and management in order to be able to accurately assess the proportion of women booking late for antenatal care, which would enhance the success of any future interventions. Currently, it is not possible to use existing data collection processes to accurately identify the number and characteristics of the women who book late for pregnancy care. With an improvement in the maternity data collection systems, further research could address whether the rates of late booking seen in Pacific and Māori women are accounted for primarily by higher levels of socioeconomic deprivation, or if there are also elements within the current system that are not culturally appropriate. Research among women who have a late diagnosis of pregnancy and factors associated with this would help inform public health strategies to reduce this problem.\r\n

Summary

Abstract

Aim

To identify barriers to early initiation of antenatal care amongst pregnant women in South Auckland, New Zealand.

Method

Women in late pregnancy (>37 weeks gestation) or who had recently delivered (

Results

Of the 826 women who participated, 137 (17%) booked for antenatal care at >18 weeks (late bookers). The ethnic composition of the sample was: 43% Pacific Peoples, 20% Mori, 14% Asian, and 21% European or other ethnicities. The multivariate analysis indicated that women were significantly more likely to book late for antenatal care if they had limited resources (OR=1.86; 95% CI=1.17-2.93), no tertiary education (OR=1.96; 95% CI=1.23- 3.15), or were not living with a husband/partner (OR=2.34; 95% CI=1.48-3.71). In addition, the odds of late booking for antenatal care was almost six times higher among Mori (OR=5.70; 95% CI=2.57-12.64) and Pacific (OR=5.90; 95% CI=2.83-12.29) women compared to those of European and other ethnicities.

Conclusion

Late booking for antenatal care in the Counties Manukau District Health Board area (South Auckland) is associated with sociodemographic factors, social deprivation, and inadequate social support.

Author Information

Sarah Corbett, Obstetric Registrar, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland; Carol Chelimo, Research Fellow, Department of Obstetrics and Gynaecology, School of Medicine, University of Auckland, Auckland; Kara Okesene-Gafa, Specialist Obstetrician, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland

Acknowledgements

This study was funded by the Centre of Clinical Research and Effective Practice (CCREP) at Counties Manukau District Health Board (CMDHB). The authors gratefully acknowledge the women who participated in the study and the clinicians who assisted with recruiting the women into the study. We thank Professor Lesley McCowan for her valuable advice on this work.

Correspondence

Dr Kara Okesene-Gafa, South Auckland Clinical School, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.

Correspondence Email

Kara.Okesene-Gafa@middlemore.co.nz

Competing Interests

Nil.

1. NICE. Antenatal Care: NICE clinical guideline 62 [homepage on the Internet]. London: National Institute for Health and Care Excellence; 2008 [updated June 2010; cited 2014 April 01]. Available from: http://guidance.nice.org.uk/CG62. 2. Raatikainen K, Heiskanen N, Heinonen S. Under-attending free antenatal care is associated with adverse pregnancy outcomes. BMC Public Health. 2007;7:268. 3. Stacey T, Thompson JM, Mitchell EA, et al. Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth: findings from the Auckland Stillbirth Study. Aust N Z J Obstet Gynaecol. 2012;52(3):242-7. 4. Vintzileos AM, Ananth CV, Smulian JC, et al. The impact of prenatal care on neonatal deaths in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;186(5):1011-6. 5. PMMRC. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. Wellington, NZ: Health Quality & Safety Commission, 2011. 6. Frisbie WP, Echevarria S, Hummer RA. Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans. Matern Child Health J. 2001;5(1):21-33. 7. Healy AJ, Malone FD, Sullivan LM, et al. Early access to prenatal care: implications for racial disparity in perinatal mortality. Obstet Gynecol. 2006;107(3):625-31. 8. Laditka SB, Laditka JN, Probst JC. Racial and ethnic disparities in potentially avoidable delivery complications among pregnant Medicaid beneficiaries in South Carolina. Matern Child Health J. 2006;10(4):339-50. 9. Williams L, Morrow B, Shulman H, et al. PRAMS 2002 surveillance report. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2006. 10. Adams EK, Gavin NI, Benedict MB. Access for pregnant women on Medicaid: variation by race and ethnicity. J Health Care Poor Underserved. 2005;16(1):74-95. 11. McLafferty S, Grady S. Prenatal care need and access: a GIS analysis. J Med Syst. 2004;28(3):321-33. 12. Williams LM, Morrow B, Lansky A, et al. Surveillance for selected maternal behaviors and experiences before, during, and after pregnancy. Pregnancy Risk Assessment Monitoring System (PRAMS), 2000. Morb Mortal Wkly Rep Surveill Summ. 2003;52(11):1-14. 13. Low P, Paterson J, Wouldes T, et al. Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. N Z Med J. 2005;118(1216):U1489. 14. Enkin M. Support for pregnant women. In: Enkin M, editor. Guide to effective care in pregnancy and childbirth. Oxford, UK: Oxford University Press; 2000. 15. Delvaux T, Buekens P, Godin I, Boutsen M. Barriers to prenatal care in Europe. Am J Prev Med. 2001;21(1):52-9. 16. Downe S, Finlayson K, Walsh D, Lavender T. 'Weighing up and balancing out': a meta- synthesis of barriers to antenatal care for marginalised women in high-income countries. BJOG. 2009;116(4):518-29. 17. Nepal VP, Banerjee D, Perry M. Prenatal Care Barriers in an Inner-city Neighborhood of Houston, Texas. J Prim Care Community Health. 2011;2(1):33-6. 18. Sunil TS, Spears WD, Hook L, et al. Initiation of and barriers to prenatal care use among low- income women in San Antonio, Texas. Matern Child Health J. 2010;14(1):133-40. 19. Braveman P, Marchi K, Egerter S, et al. Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors. Obstet Gynecol. 2000;95(6 Pt 1):874-80. 20. Park J-H, Vincent D, Hastings-Tolsma M. Disparity in prenatal care among women of colour in the USA. Midwifery. 2007;23(1):28-37. 21. Cook CA, Selig KL, Wedge BJ, Gohn-Baube EA. Access barriers and the use of prenatal care by low-income, inner-city women. Soc Work. 1999;44(2):129-39. 22. Kupek E, Petrou S, Vause S, Maresh M. Clinical, provider and sociodemographic predictors of late initiation of antenatal care in England and Wales. BJOG. 2002;109(3):265-73.

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The National Institute for Health and Care Excellence (NICE) guidelines recommend that all women should commence maternity care before 10 weeks gestation.1 This offers the opportunity to screen for sexually transmitted infections, family violence, maternal mental health issues and congenital abnormalities. It also allows for early recognition of underlying medical conditions that may impact on the pregnancy, as well as an opportunity to provide education about nutrition, smoking and drug use during pregnancy. Under-attendance and non- attendance for antenatal care has been linked to poor pregnancy outcomes, including low birth weight and foetal or neonatal death.2-4The Fifth Annual Report of the Perinatal and Maternal Mortality Review (PMMR) Committee released in July 2011 indicated that barriers to accessing or engaging with maternity and health services were the most common factors contributing to perinatal mortality.5 This report also found that Māori and Pacific mothers, women from the most deprived socioeconomic quintile, and teenage mothers were more likely to have stillbirths and neonatal deaths.In overseas studies, demographic factors shown to be associated with late booking for or inadequate antenatal care include: minority ethnic group,6-8 low educational level,6,9 age under 20 years or over 35 years,9 multi-parity,9 residing in areas with few antenatal care providers (inner city or rural),10,11 and low socioeconomic status.12There is a paucity of research on barriers to early initiation of antenatal care in the New Zealand (NZ) context. Given New Zealand's unique population and maternity system, conclusions drawn from overseas research may not be generalisable to NZ. In the one study previously conducted in Pacific women residing in the Counties Manukau District Health Board (CMDHB) catchment area, high parity, first pregnancy, unemployment prior to pregnancy and Cook Island ethnicity were associated with late initiation of antenatal care.13CMDHB serves the most economically deprived areas of New Zealand, with a high proportion of young mothers, and women of Māori and Pacific ethnicity. There is a high rate of late booking for antenatal care; in 2000, 26% of mothers of Pacific infants in CMDHB booked after the 15th week of pregnancy.13 CMDHB also has the highest perinatal mortality rate in New Zealand with a 3-year perinatal-related mortality rate of 13.70 per 1000 births compared with the national rate of 10.75 per 1000 births.5This study aims to identify barriers to early initiation of antenatal care among women utilising CMDHB maternity services, by surveying a sample of women in late pregnancy (>37 weeks gestation) or who have recently delivered (within 6 weeks). Identifying these barriers provides the CMDHB an opportunity to find more targeted approaches in providing antenatal care to women at greatest need in the community it serves.MethodsThis cross-sectional study was undertaken at CMDHB maternity facilities during July to September 2011. In order to ensure recruitment of a representative sample, participants were sought from women attending all CMDHB facilities. A convenience sample comprising of pregnant women at>37 weeks gestation and postnatal women within 6 weeks of delivery were invited to complete the questionnaire. All participants gave informed written consent. The study protocol was approved by the Northern Y Regional Ethics Committee (NTY/11/EXP/026) and the Māori Research Review Committee.Options for maternity care in CMDHB area at the time of the study included: 1) Lead Maternity Carer (LMC) such as a self-employed midwife, general practitioner (GP) or private obstetrician; 2) DHB bulk-funded primary maternity services (such as community midwives or Shared Care); and 3) Referrals to secondary care for women identified as high risk, which includes both the Obstetric Medical Clinic and Diabetes in Pregnancy Service. Shared Care is a unique system that developed in CMDHB in response to a shortage of self-employed LMCs. Women in the Shared Care model receive most of their antenatal care from a GP who enters into a shared care arrangement with the DHB. In addition, these women are offered three antenatal visits with a DHB-employed community midwife and are delivered at a CMDHB facility by a DHB-employed midwife. GPs providing Shared Care are not currently required to have either specific training in antenatal care or a postgraduate Diploma of Obstetrics and Gynaecology.Women were eligible to participate if they were>37 weeks pregnant or had delivered within 6 weeks (<6 weeks postnatal). Potential participants were identified for recruitment while seeking antenatal care, or labour and postnatal care. Eligible women were invited to participate by consultants, registrars, house officers, hospital midwives, maternity nurses, breastfeeding educators, health care assistants, and self-employed midwives. Interpreters were offered to women who did not speak English. For eligible women who at discharge had not completed the questionnaire, one was mailed their home address with a prepaid envelope to facilitate its return. Women residing outside the Counties Manukau area who had booked to deliver elsewhere were excluded.Questionnaire design was guided by a literature review of comparable studies in other countries, as well as clinicians' experiences in CMDHB antenatal care settings. A pilot of the questionnaire was undertaken with 10 women, all of whom were late bookers, with English as a second language. After completing the questionnaire, the women were interviewed about barriers to care and the questionnaire's ease of use and understanding. Responses provided on the questionnaire were compared to qualitative interviews to ensure consistency and comprehension.The questionnaire collected data on: demographic factors (age, ethnicity, education level, parity, relationship status); National Health Index (NHI) number and date the questionnaire was completed (in order to avoid duplication); gestation when pregnancy was first diagnosed and at booking with a Lead Maternity Carer; the number of visits to a midwife or doctor for pregnancy care; knowledge about the need for care during pregnancy; and specific barriers to antenatal care. In addition, qualitative data was obtained using open-ended questions to allow participants to comment on the difficulties faced in getting antenatal care and what would ease this.Information obtained from the participants' electronic health records included: due date, baby's date of birth, gravidity, parity, eligibility for free maternity care, date of the initial antenatal booking visit, and with whom women had booked antenatal care (self-employed midwife, shared care, closed unit or case-loading midwife).Late booking was defined as booking for antenatal care with any healthcare provider after 18 weeks gestation, which was based on self-report. The discrepancy in the gestation at booking obtained through self-report versus that noted in the hospital registration form was determined; this illustrated the unreliability of using hospital registration form data when ascertaining the number of women who book late.The majority of published studies have used a cut-off of 12 or 14 weeks to define late booking, as it is recommended that antenatal care start in the 1st trimester.14 However, with the current maternity system at CMDHB, many women see their GP in the first trimester to diagnose pregnancy, and to make arrangements to have blood tests and ultrasound scans before finding a midwife for ongoing care.Since many midwives will not schedule a booking visit until after 15 weeks gestation (but almost always before 18 weeks), defining late booking as>12 weeks gestation will include a large proportion of women who have had adequate antenatal care. Therefore, in this study 18 weeks was chosen as an appropriate cut-off as by then, women with access to adequate care should have been booked.The sample size was estimated based on data obtained from an audit of all hospital registration forms completed at CMDHB between 1 August 2008 and 31 July 2009 (n=8423). This audit showed that of the 7093 women registered to deliver at Middlemore Hospital, 2777 (39%) registered after 18 weeks of gestation. It was estimated that a sample of 800 women would be required to detect an odds ratio of 1.75 with 80% power. Sample demographics were compared after recruiting 100, 300, 500 and 800 women to check for consistency.Demographic characteristics were described for the total study sample (n=826). For participants with information on gestation at booking for antenatal care (n=767), the Chi-squared test was used to assess whether late booking for antenatal care was related to each demographic factor and potential barrier to accessing care. From this analysis, variables significantly associated with late booking for antenatal care were considered as covariates for multivariate logistic regression analysis.Associations between all covariates were determined to avoid using similar/collinear covariates in the multivariate model. For instance, given the significant positive association between maternal age and parity as well as the higher proportion of missing data on parity than maternal age (10% vs. 1.3%), maternal age (but not parity) was entered into the multivariate model. In addition, a variable (“limited resources”) was created using four associated variables to capture information on women's lack of one or more of the following: transport; childcare; phone credit or phone; and money for clinic visits/scans. The most parsimonious multivariate logistic model (n=705) was selected based on Akaike's information criterion and the results summarised using odds ratios (OR) and 95% confidence intervals (CI). All analyses were performed using SAS® version 9.3 software (SAS Institute Inc., Cary, N.C., USA).ResultsOf the 826 women participated in this study, 137 (17%) booked for antenatal care at>18 weeks (late bookers) and 630 (76%) booked at ≤18 weeks; for the remaining 7%, data on gestation at antenatal care booking was unavailable.The ethnic composition of the sample was as follows: 43% Pacific Peoples, 20% Māori, 14% Asian and 21% European or other ethnicities (Table 1). This was fairly comparable to the ethnicity of women who registered to deliver at Middlemore Hospital in August 2008 through July 2009 (38% Pacific, 22% Māori, 13% Asian and 27% European/other ethnicities). Most of the women had either secondary or tertiary education and were eligible for free maternity services. A little less than a quarter did not live with a husband/partner.Upon learning about their pregnancy, most women initially sought care from a GP (72%) or midwife (19%). Compared to the overall sample, the group booking late for antenatal care had a higher proportion of women of Pacific ethnicity, aged <20 years, with secondary education, not living with a husband/partner, with ≥3 children, and ineligible for free maternity services.In the univariate analysis, late booking for antenatal care was significantly associated with several demographic factors (Table 1) and potential barriers to accessing care (Table 2). Factors unrelated to late booking for antenatal care (Table not shown) were: help from GP to find pregnancy care; the source of initial pregnancy care (GP, midwife or other care); learning about an LMC from friends/family; having the same LMC as in the previous pregnancy; spending a long time in waiting rooms during appointments; and forgetting appointments.Table 1. Characteristics of the study populationTable 2. Late booking for antenatal care in relation to potential barriers to accessing care in pregnancy (n=767)The multivariate analysis identified factors independently associated with late booking for antenatal care (Table 3). The adjusted analysis indicated that the odds of late booking were approximately two times higher among women with limited resources, with no tertiary education, and not living with a husband/partner. In addition, the odds of late booking for antenatal care was almost six times higher for both Māori and Pacific women compared to those of European and other ethnicities.Table 3. Logistic regression analysis for late booking for antenatal care (n=705)It was not possible to determine the late booking status for 7% (n=59) of the sample as data on gestation at initiation of antenatal care was unavailable. There were no significant difference between women missing data on gestation at initiation of antenatal and those with valid values (Chi-squared test, Table not shown) on the following demographic variables: ethnicity (p=0.42, n=815); age group (p=0.42, n=815); having husband/partner (p=0.38, n=812); parity (p=0.53, n=744); and eligibility for free maternity services (p=0.39, n=744). However, these two groups differed on maternal education (p<0.001, n=793) whereby the proportion of women with a tertiary education was greater in the group with data on gestation at booking compared to the group missing this data (48% vs. 29%). Given the results from this study show that women without tertiary education are more likely book late for antenatal care, the magnitude of this association has likely been underestimated.DiscussionFindings from this study show that women with limited resources, with no tertiary education, or not living with a husband/partner are at a greater disadvantage when it comes to timely booking for antenatal care. Māori and Pacific women are also much more likely to book late for antenatal care than women of European and other ethnicities. This suggests that late booking for antenatal care in CMDHB is likely due to sociodemographic factors, social deprivation, and inadequate social support. Our findings are consistent with research undertaken to assess factors related to untimely initiation of prenatal care among women in high-income countries who reside in disadvantaged areas. This research has identified some comparable barriers including, inadequate social support,15-18 lower maternal educational level,15,18-20 economic hardships,15,17,20 and transportation and access difficulties.19,21The main strength of this study is its large multi-ethnic sample size, which adds to a small body of existing literature regarding antenatal care in this NZ population. It also provides additional insight and information to guide local system design and policy. However, it must also be recognised that the characteristics of the CMDHB resident population are different to other parts of NZ, which would limit generalisability of findings to the rest of country. Nonetheless, our findings would be applicable to women in high-income countries who reside in disadvantaged areas. There is no current NZ guideline on when antenatal care should commence and hence, a cut-off was chosen in line with other literature that used 18 weeks as a definition of very late booking.22A study limitation is the unavailability of a response rate due to lack of information on the number of women approached for recruitment and who declined participation. Our study relied on participant recall of gestation at pregnancy diagnosis and booking, which may be subject to misclassification bias that we expect occurred indiscriminately. Because of the large number of participants, a quantitative design was chosen which may mean that some novel barriers were not identified. A validated, standardized and widely used questionnaire was not available limiting the extent to which this study's findings could be compared to previous research.Given the barriers to timely initiation to antenatal care identified in this study, maternity care providers may consider more flexible models of care and ways of delivering care within the community. This could be done via home visits, after hour's clinics, and having midwifery clinics within GP practices in the local community. Location of hospitals and clinics should be considered when planning public transport routes or vice versa. In order to provide the best care to a multi-ethnic population, it is vital to continue to actively recruit and train multi-ethnic medical and midwifery staff, ensure interpreters are available, and provide written information in a range of languages.Interventions are needed to improve the early diagnosis of pregnancy which could lead to more timely initiation of antenatal care. This may include emphasis on the importance of school health programs that educate girls about normal menstruation and seeking medical attention for missed or abnormal periods, as well as consideration of ways to extend this knowledge to adult women. Options should be explored for making pregnancy tests more freely available.Currently, women have free visits to their GP if the pregnancy test is positive, but have to pay for the consultation if the test is negative. Public health interventions are needed to improve specific knowledge on the importance of seeking care early and how to go about getting care. The general practitioner is an important facilitator of maternity care in our study population, being the first point of contact for many women. By using pre-existing networks, consultation regarding current unmet needs can be undertaken, and strategies to facilitate early risk assessment and support timely access to maternity services can be disseminated.There is a need for robust pregnancy data collection and management in order to be able to accurately assess the proportion of women booking late for antenatal care, which would enhance the success of any future interventions. Currently, it is not possible to use existing data collection processes to accurately identify the number and characteristics of the women who book late for pregnancy care. With an improvement in the maternity data collection systems, further research could address whether the rates of late booking seen in Pacific and Māori women are accounted for primarily by higher levels of socioeconomic deprivation, or if there are also elements within the current system that are not culturally appropriate. Research among women who have a late diagnosis of pregnancy and factors associated with this would help inform public health strategies to reduce this problem.\r\n

Summary

Abstract

Aim

To identify barriers to early initiation of antenatal care amongst pregnant women in South Auckland, New Zealand.

Method

Women in late pregnancy (>37 weeks gestation) or who had recently delivered (

Results

Of the 826 women who participated, 137 (17%) booked for antenatal care at >18 weeks (late bookers). The ethnic composition of the sample was: 43% Pacific Peoples, 20% Mori, 14% Asian, and 21% European or other ethnicities. The multivariate analysis indicated that women were significantly more likely to book late for antenatal care if they had limited resources (OR=1.86; 95% CI=1.17-2.93), no tertiary education (OR=1.96; 95% CI=1.23- 3.15), or were not living with a husband/partner (OR=2.34; 95% CI=1.48-3.71). In addition, the odds of late booking for antenatal care was almost six times higher among Mori (OR=5.70; 95% CI=2.57-12.64) and Pacific (OR=5.90; 95% CI=2.83-12.29) women compared to those of European and other ethnicities.

Conclusion

Late booking for antenatal care in the Counties Manukau District Health Board area (South Auckland) is associated with sociodemographic factors, social deprivation, and inadequate social support.

Author Information

Sarah Corbett, Obstetric Registrar, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland; Carol Chelimo, Research Fellow, Department of Obstetrics and Gynaecology, School of Medicine, University of Auckland, Auckland; Kara Okesene-Gafa, Specialist Obstetrician, Department of Obstetrics and Gynaecology, Middlemore Hospital, Auckland

Acknowledgements

This study was funded by the Centre of Clinical Research and Effective Practice (CCREP) at Counties Manukau District Health Board (CMDHB). The authors gratefully acknowledge the women who participated in the study and the clinicians who assisted with recruiting the women into the study. We thank Professor Lesley McCowan for her valuable advice on this work.

Correspondence

Dr Kara Okesene-Gafa, South Auckland Clinical School, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.

Correspondence Email

Kara.Okesene-Gafa@middlemore.co.nz

Competing Interests

Nil.

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