Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill
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- Bu səhifədəki naviqasiya:
- Chapter 5: Results from the qualitative study 5.1 Introduction
- 5.1.1 The characteristics of the women
- 5.1.2 Overview of the thematic analysis
- Table 5.1.1: Socio-demographic characteristics of the women interviewed (n = 27)
- Deprivation ranking of home address (2010)
- Table 5.1.2: brief narratives for the 27 women interviewed
- Table 5.1.3: taxonomy of themes for late booking
- KNOWING Avoidance
- DELAYED Professional failures in primary care
- Women’s knowledge and empowerment issues
- 5.2 Themes 5.2.1 Not knowing
- 5.2.1.1 Realisation 5.2.1.1.1 Delayed confirmation of pregnancy
- 5.2.1.1.2 Women’s misinterpretation or misdiagnosis of symptoms
- Attributing symptoms to other life event, past or current medical condition
- Lack of reproductive knowledge or pregnancy experience
- 5.2.1.1.3 The influence of others Lay hindrance
- Rejection of lay influence
- 5.2.1.2 Belief 5.2.1.2.1 Age affecting fertility
- 5.2.1.2.2 Past illness affecting fertility
- 5.2.1.2.3 Using contraception
- 5.2.1.2.4 Not planning, expecting to be pregnant
4.4 ConclusionsMethods were chosen to complement the goal of the research, to develop a better understanding of late booking, and specifically to answer the research question “what perceptions and beliefs do late booking women express about the delayed initiation of antenatal care?” Such methods reflect the chosen qualitative methodology, the conventions and quality criteria of qualitative research, but also ethical and practical considerations. The methods were iterative: as described, compromises and adaptations were made as the study progressed, largely as a result of recruitment challenges and interview limitations. As Bryman (2008) observes however, such compromises are a normal part of the research process as “all research is the coming together of the ideal and the feasible” (p27). The methods enabled the collection and analysis of detailed and personal stories of late booking, from pregnant women’s perspectives. The study has rejected the ‘value-free’ claims of positivist research and acknowledges the influence of context and reflexivity in the construction of the findings, through the systematic yet creative process of thematic analysis. These methods are designed to present the findings with sufficient clarity and detail for the reader to judge their transferability: their potential application elsewhere in other contexts and with other groups. This reflects in part the study’s pragmatic roots: to contribute to improving access through strategies for wider application (Polit and Beck 2012, Green and Thorogood 2014). The findings are presented in chapter five. Chapter 5: Results from the qualitative study 5.1 Introduction This chapter presents the results of the thematic analysis of the data from interviews conducted with 27 pregnant women who booked for antenatal care after 19 completed weeks gestation. The interviews were conducted in women’s homes, community children’s centres and hospital antenatal clinics in Sheffield, between January 2007 and July 2008. 5.1.1 The characteristics of the women Table 5.1.1 summarises the characteristics of the women. The full demographic table can be found in appendix 5.1. The sample was theoretically informed by an initial literature review and supervisory discussion, and was diverse, particularly in terms of age, parity and educational level. The mean age of the women was 26 years (range 15-37 years) and parity ranged from zero to four; 15 women were nulliparous and two had had previous children removed for adoption, as a result of child protection procedures. Twenty one women were White British, however women from six other ethnic groups were also interviewed. The women reported a range of occupations from professional and managerial to manual and service positions; 16 were not employed, including seven who were school and college students. Educational level included up to postgraduate, 13 were educated to secondary school only and 3 had self-declared learning difficulties. Whilst women were interviewed from a range of locations across the city, a large percentage lived in Sheffield neighbourhoods with high deprivation indices, as determined by the English Index of Multiple Deprivation Score (Department for Communities and Local Government 2011, Office for National Statistics (ONS) 2010). 5.1.2 Overview of the thematic analysis The inductive process of thematic analysis, detailed in chapter four, identified emergent themes and subthemes relating to late booking. Table 5.1.2 presents a narrative summary of each of the interviewed women’s stories. A taxonomy of these Table 5.1.1: Socio-demographic characteristics of the women interviewed (n = 27)
themes and subthemes was developed through this analytical process; this is presented in table 5.1.3. A chart mapping the themes and subthemes and their frequency can be found in appendix 4.15. The women presented a complex variety of often interrelated personal and organisational reasons for not accessing antenatal care early in their pregnancies, and attitudes towards their late booking. Three major themes emerged from the women’s interviews: women not realising or believing they were pregnant and therefore not accessing care (not knowing), women knowing they were pregnant and avoiding or postponing antenatal care (knowing) and women being prevented from accessing care by others (delayed). As the thematic chart (appendix 4.15) and the women’s narratives shown in table 5.1.2 illustrate, most women had primary and secondary reasons for late booking. For example, late diagnosis of pregnancy was sometimes compounded by system or professional failures and/or personal avoidance, resulting in further delays. The themes are presented in detail below, with the words of some of the interviewed women to illustrate. Table 5.1.2: brief narratives for the 27 women interviewed
Table 5.1.3: taxonomy of themes for late booking
5.2 Themes 5.2.1 Not knowing The majority of the women interviewed (n=19) had said they had not known they were pregnant for weeks or sometimes months, which had contributed to the delay in them accessing care. As previously mentioned, this was often compounded by other factors (as appendix 4.15 illustrates) leading to further delay. Women had not realised that they were pregnant and/or did not believe that they could be pregnant: a lack of pregnancy planning and a pregnancy ‘mindset’ was evident in many cases. 5.2.1.1 Realisation 5.2.1.1.1 Delayed confirmation of pregnancy The women who had not realised that they were pregnant were divided into those who said that they didn’t have any of the typical symptoms of pregnancy, and those who had symptoms but didn’t recognise them as pregnancy. Ten women reported that they had felt well and/or that they had not noticed any of the ‘classic’ [cardinal] symptoms of early pregnancy, for example nausea, vomiting, lethargy and amenorrhoea, particularly primigravidas: “I didn’t have any feelings whatsoever, I weren’t having any movements from baby, I was still having proper periods and my belly were flat because I’ve always been slim, so it were just flat and you know, like, sometimes you can get cravings and stuff, can’t you, and I ain’t got any cravings really, so, I had no idea.” (#24, G1P0, age 15) “I didn’t actually have any sort of signs in my stomach or breasts, so there was no signs there.” (#1, G1P0) “I didn’t find out until I was 23 weeks, I was still having periods all the time, a month before, February, and then I missed a month, so that’s when I went to the doctors a month after. So I just didn’t know really, that’s why I never went. Thinking about it they weren’t as heavy, but I was still on the same amount of days, the same time every month, no different.” (#10, G1P0) For eight women, both primigravid and multigravid, irregular or non-existent periods were normal for them. In one woman’s (#25) case the amenorrhoea was a result of long-term substance misuse but for most of these women irregular periods were something they had grown up with and accepted as a normal part of their lives. This cycle irregularity masked their perception of the key symptom of pregnancy and for this reason they did not realise they were pregnant, which affected a woman’s ability to confirm the pregnancy early and delayed access to antenatal care. “I don’t get periods so, that’s why I didn’t think I were pregnant. I: Right. When did you last have a period? Years and years ago.” (#25, G4P3, on methadone) ‘I were having, like, they weren’t regular periods, they were just like on and off but I’d been having trouble with my periods like since I started them, so, I didn’t really think nothing of it.” (#21, G1P0, age 15) “To be honest, my periods aren’t regular so I didn’t know how many weeks I were. I can go without periods for six months... So I don’t find out while I’m three months anyway if I’m pregnant, because they’re not monthly, they’re every two months. And because of my periods I suppose it took a while before I knew I was pregnant for definite.” (#8, G3P2) One woman commented how she had been encouraged by her GP in the past to consider her irregular periods as normal for her and therefore nothing to worry about, so didn’t consider amenorrhoea at that time as anything to be concerned about. “I: Did you have any periods in this time? No. But that’s not unusual at all, so… since I was 14, I could go a year and not have one every month and then I could go a year and have maybe two or three and they said we’ll put you on the Pill, which I’ve been since I was 16 and I still never had regular periods after that really and they said ‘oh it’s just the way you are, not to worry’.” (#16, G1P0) 5.2.1.1.2 Women’s misinterpretation or misdiagnosis of symptoms Some women, in retrospect, recognised that they had experienced some classical pregnancy symptoms but had misinterpreted/misdiagnosed these early symptoms and signs for a number of reasons, often because they had not planned or expected to become pregnant. “I never contemplated being pregnant and then I started feeling really tired and I had got no energy, I was feeling sick and then I was bleeding really heavy… so I went to the doctor’s about this because I was quite concerned and they thought I was going through the change… And it was only after I had the blood test at the doctors that I realised I was pregnant. (#12, G4P3) Attributing symptoms to other life event, past or current medical condition Some multigravid women and one primigravid woman attributed symptoms such as nausea to stressful/other life events or weight change due to lifestyle issues (a lay explanation that in one case was reinforced by the woman’s family). As a result the women rationalised their symptoms and didn’t consider pregnancy initially, so didn’t access care. “I had a bleed and I thought I’d just had a period. We were opening this pub and it was just really stressful and I thought I was feeling sick because we weren’t eating; we were like working from ten in morning until two or three at night. So I just thought I was run down” (#5, G2P1) “I went to see the doctors Tuesday, and she said you’re about 22-24 week. I just thought it was wind, because I’d lost loads of weight, I’d lost three stone in weight. All of my family they normally look at my face and know, but because I’d lost weight I’d lost it in my face. So nobody knew at all.” (#4, G3P2-1) I just started putting on loads of weight, I thought coz it was from eating rubbish.” (#3, G2P1) For six women, the classical symptoms of pregnancy that they were experiencing were misinterpreted for a current medical problem, for example a water infection or related to their Polycystic Ovarian Syndrome (PCOS): I thought I had a water infection, cos when I had a water infection my stomach swelled like that before. That’s what I thought were probably up with me and it wasn’t. It was pregnancy” (#6, G1P0, learning difficulties) “My belly had been swelling up a lot, because I’ve got polycystic ovaries so they said that I couldn’t have kids yet, because I’m not coming on every month. So I thought ‘right, that’s it’, my belly was swelling but I ain’t been to toilet, I felt constipated” (#22, G1P0) Lack of reproductive knowledge or pregnancy experience In some instances, women (particularly primigravid but also including one multigravid woman) did not realise they were pregnant because of a lack of reproductive knowledge and experience of what to expect when pregnant. Some women acknowledged this lack of knowledge had delayed confirmation. “not many of my friends have got children, and I think because, you know I mentioned before I’m adopted, so, and that was because my adopted mother couldn’t have children, she’d had a hysterectomy, so I’d never got to, spoken to her about it because obviously she’s never been through everything that happened. So, no, I didn’t really know what to expect or anything really.” (#17, G1P0) I know bits and pieces from school and that but not really that much... probably if I knew, like, a bit more about it then I’d have, like, realised a lot sooner” (#21, G1P0, age 15) It was only when the pregnancy had been confirmed in other ways, e.g. with a positive pregnancy test, or when symptoms were explained to them, that women realised what they had been experiencing. “I just remember it were right low down and it felt like flutter, I said ‘feel it’, I didn’t think he’d be able to feel it and he felt it more than me…..[it felt] like trapped air bubbles and then I found it was kicking! (#22, G1P0)
(#21, G1P0, age 15) “I do now because she told me when I went to the doctors, she told me what it [fetal movements] were like and I were like ‘yes’” (#10, G1P0) Key groups for whom this was the main reason they didn’t realise they were pregnant, were those women with learning difficulties and teenagers, both primigravid and multigravid. “I found movements moving about in my stomach and I wondered what it were, so I went to see my GP….[I didn’t have] no sickness or owt like that, er I went to see my GP, he examined me and said I could be like six months pregnant.” (#2, G2P1, learning difficulties) “I found out when I had the pregnancy test, the two lines come up, when I went to the GP. I couldn’t believe it, I was gutted. I didn’t even know” (#6, G1P0, learning difficulties) “I: you said you didn’t have any [periods]? No, I didn’t have none. I: So did you think that was strange, that you didn’t have any periods? No, cos normally I usually get stomach pains to tell you when you’re coming on to your period, I didn’t even get none of them. I: So what did you think was happening then? Nothing, I thought nowt’s happening yet so fine, just wait.” (#27, G2P1, learning difficulties) 5.2.1.1.3 The influence of others Lay hindrance Women’s acceptance of their pregnancies, and the need to access care, was influenced by their peers and family members, in both positive and negative ways. Lay hindrance was identified as a barrier in some cases: some women did not realise they were pregnant because family, friends and partners had also attributed the classical pregnancy symptoms to another reason. This was most evident in relation to symptoms of nausea and vomiting, where explanations such as food poisoning or stomach upsets were given as the cause of the problem rather than pregnancy. “I were being sick a few times but my mum said ‘it’s just something you’ve ate’”. (#15, G1P0, age 16) “Even M didn’t think owt to it. We all just used to be sat there and I‘d go to the toilet and M used to say ‘she’s got upset stomach’. That’s all she used to say, that’s all we put it down to, just upset stomach, we didn’t think of owt else.” (#27, G2P1, learning difficulties) In one young woman’s case her pregnant step-mother who she lived with didn’t recognise the pregnancy either, despite them spending time together and having lots of information about the subject: “My step-mum, she were pregnant, well, obviously she were pregnant at the time that I was so, like, I read a lot of stuff with her and that and, like, it just didn’t make any difference at all. It’s like my step-mum would be reading it and, like, I’m with her most of the time, so it was like reading it and looking at it together and that, didn’t really trigger anything at all.” (#21, G1P0, age 15)
In other cases it was family members or close friends, particularly women who had experience of pregnancy, who played an important role in ensuring women did eventually access antenatal care; noticing the pregnancy before the woman herself and urging her to seek care. Women did not always listen to their advice however, and only acknowledged their recognition significantly later, leading to further delays in accessing care. “The only person that kept suggesting it was my sister-in-law and both her sisters had had children last year and she kept saying ‘I think you’re pregnant, I think you’re pregnant’…
(#16, G1P0) “My tummy started to get a bit bigger and everyone kept saying to me ‘you’re pregnant’, ‘no, I’m not!’ I: So how long had your friends been saying - ? About a month or so, two months”. (#25, G4P3, on methadone). “Me dad had an idea that I could be pregnant because I was a bit swollen. He says “you’re pregnant”. I says “I haven’t got a bloody idea”. He says “I think you ought to go and get checked”. So a fortnight later I went and checked, I went back home and said “Dad, you’re right, I am pregnant”. He went “I told you I were bloody right didn’t I?” (#6, G1P0, learning difficulties) “J used to like, lay with his head on my stomach and it used to just kick and we never thought nowt of it until it went right hard on his head, kicked his head off me stomach. And that’s when he said “you’re bloody pregnant!” and I said “I’m not!” (#27, G2P1, learning difficulties) “it’s just that everyone was getting on at me and I thought ‘well right I’ll do a test to prove to you all that I’m not’ and then, so I did the test and it come back that I were, so I did two and it come back that I were and I was, like, oops – they was all saying it, like, way before that but, like, everyone’s been saying ‘we know your body better than you do’, I was, like, ‘well yes you do’.” (#21, G1P0, age 15) 5.2.1.2 Belief 5.2.1.2.1 Age affecting fertility Some of the women who accessed antenatal care late did so because they didn’t believe they could be pregnant and so did not have a pregnancy ‘mindset’, in some cases even when experiencing cardinal symptoms of pregnancy such as amenorrhoea. Two women in their thirties assumed age would more significantly adversely affect their fertility than was actually the case. One primigravid woman assumed it would take her a long time to conceive, when in reality the opposite happened: “when I came off the Pill, I thought it was going to take ages to get pregnant and I think because, and like I said as well before, because I would have like to have had, ideally had a baby earlier, I was, it meant so much to me that I was almost setting myself up for failure before I started, if you know what I mean, so I was almost saying to myself ‘well, you might never be able to have children, don’t count on it, it might take years’, you know, all those sort of things were running through my head so to think that, actually, it probably only took 3 months, that was the least likely scenario that I thought would happen” (#17, G1P0, age 31) This woman acknowledged that being adopted by someone who was unable to have children had irrationally affected her own expectations about conceiving, and resulted in her creating a barrier to accepting she was pregnant: “because I’m adopted and my adopted mother couldn’t have children, for some reason, I don’t know why, but I thought that the same thing would happen to me, which is silly [laughs], really silly but, again, that was in the back of my mind, I thought ‘well the same thing might happen to me, so I have to prepare myself for that… it was the fact that I just didn’t honestly really think that I was having a baby and then I was… I think it was me that put the barriers there” (#17, G1P0, age 31)
“when they said ‘I was going through the change’ I thought ‘well could I be?’ because like 37 I thought ‘well I might be’ because you hear women go through it earlier than I did and I think I got that into my head more than anything and I never contemplated that I were pregnant.” (#12, G5P4, age 37)
Some women didn’t believe they could be pregnant because they had existing medical conditions that meant that it was more difficult for them to conceive, or they had been ill recently or in the past and thought this would affect their fertility. For example, two women described how they had attributed amenorrhoea to conditions such as polycystic ovarian syndrome or even recurrence of a cancer rather than pregnancy, and another to how childhood cancer had influenced her expectations of being able to conceive. “My belly, like’s, fluttering, like trapped air and he went ‘you’d better go and get a test’, I’d say ‘I don’t need one, I don’t need one, I’m not pregnant, I can’t be’.” (#22, G1P0, PCOS) “I didn’t think I could have any, and that was the problem. Because of what had happened to me in the past. The pituitary tumour… I knew I weren’t coming on but I thought it was the tumour growing back, or something like that. Obviously, with what I’ve been through in the past.” (#6, G1P0, learning difficulties) “I had a feeling, though, I had a feeling before that I were always thinking to myself, oh well I wonder if I can have children when I’m older and stuff, because of the cancer.” (#24, G1P0, age 15) 5.2.1.2.3 Using contraception Eight women, both nulliparous and multiparous, were using contraception when they conceived, most commonly taking the contraceptive pill, which significantly affected their acceptance of pregnancy. Consequently, these women did not believe that they could be pregnant and amenorrhoea was attributed to the contraception, and in some cases to their ‘normal’ (i.e. irregular) cycle. “I was on depo injections so I didn’t think I could get caught on that.” (#2, G1P0) “I were on the pill at the time. So obviously we didn’t think that anything would come of it.” (#7, G1P0, age 18) “I took contraceptives I did them continually, Microgynon, so not to have a period” (#1, G1P0) “I: So they never did a pregnancy test or even suggested it to you? No, no, no, and I’d been on the Pill so it wasn’t something I’d thought about and I’ve never had regular periods so it didn’t occur to me to check back or anything” (#16, G1P0) “But protection was used” (#24, G1P0, age 15) For one woman with learning difficulties, this was her second late booking pregnancy and she had experienced contraceptive failure with both. “Last time were alright, it were just weird because I went for the Depo and they told me I were 25 weeks pregnant. I got caught on the Depo and I didn’t know that, and I took the pills and I got caught on the contraceptive pill this time with… and I didn’t know with this one.” (#27, G2P1, learning difficulties) Another multigravid woman assumed breastfeeding would probably provide her with enough contraception. Her pregnancy was unplanned but not unexpected: “I was breast feeding and I know it’s not a full protection but I thought oh, you know, it’s something. I thought I’ll just see what happens.” (#11, G4P3) 5.2.1.2.4 Not planning, expecting to be pregnant Seventeen of the 27 women in the study stated that they had not planned to become pregnant, and for another six this was implied. Other women suggested that their pregnancy was intended but mistimed. As such, many of these women did not have a pregnancy ‘mindset’ so were not expecting the symptoms of pregnancy and expressed ambivalence towards the idea of being pregnant. This, in combination with a lack of pregnancy knowledge and experience amongst primigravid women, had affected how long it had taken some of them to confirm they were pregnant: “I think if I had wanted to have a child as well I probably would have been looking for the signals as well, but I think even now why didn’t I know, that was the last thing” (#1, G1P0) “I think sometimes you might have symptoms or things change, you can say it’s just the way I am, you might not associate that with being pregnant, even though we wanted to start trying and it was something that, it was in the forefront of my mind in the next months this is something that was going to happen anyway, it didn’t even occur to me in, maybe not knowing the signs, that could be something you’ve got to look for” (#17, G1P0) Yüklə 0,62 Mb. Dostları ilə paylaş:
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