The findings are limited by the fact that exploring ANC attendance was a supplemental objective of the programme of research, which was primarily orientated towards investigating the social and cultural context of malaria during pregnancy. University of Massachusetts Medical School, United States of America, Received: September 18, 2012; Accepted: December 3, 2012; Published: January 15, 2013. Furthermore, this inflexibility illustrates that WHO recommendations for focused ANC were interpreted in different ways: often, rather than focusing on a minimum of four visits, health staff continued to follow the previous version of ANC, with monthly visits scheduled. delivery and appropriate management . A flexible and iterative approach was taken to data collection. 34, 36, 38- and 40-weeks’ gestation . obstetrical history, support from spouse, quality of care and Moreover, during these consultations, health staff asked women directly about their health concerns. Nonetheless, these decisions were not taken alone and on the basis of advice from older women, primagravidae hastened their first ANC visit. PLOS ONE promises fair, rigorous peer review, The nature of ANC appointment scheduling by health staff, and women’s understanding of appointments as compulsory also contributed to delayed initiation, particularly in Kenya. behavioral factors such as smoking during pregnancy [16,17]. Local healthcare facilities and ANC services vary amongst these settlements: urban areas are located within a 30-minute walk to the district hospital, whereas, in rural areas, women mainly access ANC at the small community clinics or dispensaries, which, for some women, are up to two hours’ walk from home. Women, particularly in Kenya and Malawi, reported that they would not attend ANC until the sixth or seventh month to minimize the number of journeys and therefore the total cost of ANC. medications, use of alcohol, tobacco and other substances and Clinical research investigating the contribution of components of ANC to improving maternal mortality is ongoing, but some ANC interventions have been shown to be effective for the detection, treatment or prevention of conditions associated with serious morbidity or mortality: monitoring of chronic conditions, anaemia, for example; screening for and treatment of infections, including sexually transmitted infections ; prevention of mother-to-child transmission of HIV (PMTCT) ; insecticide treated bed nets (ITNs) ; and intermittent preventive treatment of malaria (IPTp) with sulfadoxine-pyrimethamine (SP) . perceived bad quality of service at the healthcare facility . Although women described how a couple of months of amenorrhea was generally sufficient to confirm a pregnancy, both health staff and pregnant women reported that, at health facilities, palpation was often used to confirm pregnancy at 12 weeks. socioeconomic status and the utilization of ANC . Using Atlas Ti 6 (Scientific Software, Berlin, Germany), codebooks were developed, in collaboration with the fieldworkers/social scientists, using a combination of established categories based on the original research questions (examples of basic broad codes included ‘first ANC’, ‘IPTp’ etc) and codes that emerged from the data using a Grounded Theory approach . The capacity of ANC service design to meet the needs of women in the first trimester influences timing of ANC initiation. These studies have correlated a range of factors with ANC attendance: for example, a woman’s and/or her husband’s level of education; a woman’s occupation; economic status; distance to health facility; parity; and age . Given the specific social repercussions of pregnancy at this age and the fact that this analysis did not focus specifically on this age group, further exploration of the factors influencing ANC attendance and pregnancy care amongst adolescents and young women is also needed. A comparative approach is taken and data from four research sites (in three countries) are presented; this approach to the analysis of a similar phenomenon, ANC attendance, across diverse social and cultural and healthcare contexts facilitates the identification, and prompts the interrogation, of relevant themes that might otherwise be taken for granted . Different studies have found that inappropriate antenatal care has been associated with adverse pregnancy outcomes. Antenatal care is an important determinant of high maternal mortality rate and one of the basic components of maternal care on which the life of mothers and babies depend. services . For more information about PLOS Subject Areas, click tetanus toxoid to prevent neonatal tetanus. In these socially and culturally diverse sites, the findings suggest that both demand and supply side factors have an important influence on ANC attendance. here. Members of the research team observed such women addressing health staff on relatively equal terms. planning and developing strategies for the utilization of ANC many factors affecting the utilization of antenatal care in Altering the design of ANC could therefore promote earlier initiation. A point of saturation approach was also applied to the total sample of healthcare workers, local opinion leaders and the relatives of pregnant women. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes. Ejisu Juaben District is however more densely populated and closer to Kumasi than Ahafo Ano South. Moreover, the direct charges levied for ANC procedures – not authorized in national ANC policy – represented only part of the wider cost of ANC. their spouses or partners utilized ANC services almost three Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for important health-care functions, including health promotion, screening and diagnosis, and disease prevention. Although there were also reports of HIV-related stigma in Malawi, in general, Malawian women described the importance of knowing their status and HIV testing was not given as a reason to delay ANC. Women’s interactions with healthcare staff could also result in delayed ANC. Additional social pressures were also reported: particularly, in Kenya (as in Tanzania ), avoiding reprimands from health staff when they attended a health facility for delivery – through obtaining an ANC card – was important; the insults that women feared had social implications (embarrassment and shame) but refusal of care was also a concern. factors such as the availability of transport, the total cost of For instance, Chapman  addressed the question of why pregnant women in a peri-urban settlement of Mozambique with accessible ANC services delayed initiation. However, this was not viewed as a reason to delay ANC. . This was evidenced by findings in different studies in Nonetheless, the findings suggest that Ghanaian women were more likely to attend ANC in the first trimester as a result of a combination of the following inter-related reasons.