Why do women not use antenatal services in low and middle income countries? A metasynthesis of qualitative studies

Background: Almost 50% of women in lowand middle-income countries (LMICs) don’t receive adequate antenatal care. Women’s views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable. We aimed to inform the development of future antenatal care programmes through a synthesis of findings in all relevant qualitative studies. Methods and Findings: Using a predetermined search strategy, we identified robust qualitative studies reporting on the views and experiences of women in LMICs who received inadequate antenatal care. We used meta-ethnographic techniques to generate themes and a line-of-argument synthesis. We derived policy-relevant hypotheses from the findings. We included 21 papers representing the views of more than 1,230 women from 15 countries. Three key themes were identified: ‘‘pregnancy as socially risky and physiologically healthy’’, ‘‘resource use and survival in conditions of extreme poverty’’, and ‘‘not getting it right the first time’’. The line-of-argument synthesis describes a dissonance between programme design and cultural contexts that may restrict access and discourage return visits. We hypothesize that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. Conclusions: Our findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings. Please see later in the article for the Editors’ Summary. Citation: Finlayson K, Downe S (2013) Why Do Women Not Use Antenatal Services in Lowand Middle-Income Countries? A Meta-Synthesis of Qualitative Studies. PLoS Med 10(1): e1001373. doi:10.1371/journal.pmed. 1001373 Academic Editor: Karen Daniels, South African Medical Research Council, South Africa Received March 19, 2012; Accepted December 5, 2012; Published January 22, 2013 Copyright: 2013 Finlayson, Downe. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No direct funding was received for this study. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper). Competing Interests: The authors have declared that no competing interests exist. Abbreviations: LMIC, lowand middle-income country; MDG 5, Millennium Development Goal 5; MMR, maternal mortality ratio; WHO, World Health Organization * E-mail: sdowne@uclan.ac. uk