Provision and uptake of routine antenatal services

What is the aim of this review?

The aim of this Cochrane qualitative evidence synthesis is to explore women’s and healthcare workers’ views and experiences of antenatal care. We collected and analysed all relevant qualitative studies to answer this question, and include 85 studies.

The synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. The synthesis was designed to inform the World Health Organization guidelines for a positive pregnancy experience.

Key messages

Three areas of antenatal care are important to both women and service providers in all regions of the world. These are: the need to recognise and take account of the socio-cultural context in which care is provided; the need to ensure that service design and provision are appropriate, accessible, acceptable and of high quality: and that what matters to women and staff is personalised supportive care, information, and safety.

What was studied in this review?

Antenatal care is the health care women get while they are pregnant. During antenatal care visits, pregnant women are provided with support, reassurance, and information about pregnancy and birth, as well as tests and examinations to see if they and their baby are healthy. If any issues or problems are discovered, these can be managed during the clinic visit. If needed, women can be referred to other care providers. Different types of healthcare workers can give antenatal care. These include midwives, doctors, nurses, and, sometimes, traditional birth attendants.

The World Health Organization recommends that all pregnant women get antenatal care, but pregnant women do not always use this care. This may be because they do not think it is important, or because they cannot get to the healthcare facility. It may also be because the antenatal care they receive is of poor quality or because they are badly treated when they are there. By looking at studies of women’s and healthcare workers’ views and experiences of antenatal care, we aimed to learn more about what might help women to use antenatal care, and what might stop them using it.

What are the main findings of this review?

We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of women who were pregnant or who had recently given birth. 17 studies explored the views and experiences of healthcare providers, including lay or community health workers, and 22 studies included the views of both women and healthcare providers. The studies took place in eight high-income countries, 18 middle-income countries and 12 low-income countries, in rural and urban locations.

Our findings suggest that women use antenatal care if they find it is a positive experience that fits with their beliefs and values, is easy for them to access, affordable, and treats them as an individual. They want care that helps them to feel that they and their baby are safe, and that is provided by kind, caring, culturally sensitive, flexible, and respectful staff that have time to give them support and reassurance about the health and well-being of them and their babies. They also value tests and treatments that are offered when they need them, and information and advice that is relevant to them.

Our findings also suggest that healthcare staff want to be able to offer this kind of care. They would like to work in antenatal services that are properly funded, and that give them proper support, pay, training and education. They believe this will help them to have enough time to treat each pregnant woman as an individual, and to have the knowledge, skills resources and equipment to do their job well.

How up-to-date is this review?

The review authors searched for studies that had been published up to February 2019.

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.

Read the full abstract...

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.


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 strategy: 

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.