Facility-imposed barriers to early utilization of focused antenatal care services in Mangochi District, Malawi - a mixed methods assessment.

backgroundFocused Antenatal Care (FANC) is advocated by the World Health Organization (WHO) as a key service approach to improving the health of pregnant women. Four targeted visits to antenatal clinics are recommended starting in the first trimester. First trimester attendance for FANC in Mangochi District, Malawi was low at 8%. FANC has mainly been promoted through health facility based communication activities with less emphasis on activities at community level. We developed and tested a community focused health communication approach "Community Driven Total FANC Attendance (CDTFA)" with the aim of increasing FANC clinic attendance. We included a research component in order to understand the context and responses of community members to this intervention.

methodsCDTFA meetings were designed in parallel with data gathering with approval of the local research ethics committee and community stakeholders. Participants in both the CDTFA meetings and data gathering activities, undertaken from December, 2015 to June, 2016 were of reproductive age (15-49 years). Data were collected through flexible interactive processes from participants through recording on pre-designed forms. Quantitative data were processed and analyzed in Microsoft Excel, while qualitative data were manually analyzed to identify themes.

resultsIn total, 403 CDTFA meetings were held. In the course of interactions with community members, some barriers that affected early utilization of FANC services were identified. Women who did not bring their partners and those who could not bring along with them cloth wraps for the newborn to clinics were not allowed to access FANC services. Payment for authorization letters from village heads for women who have no partners and user fees in non-governmental health facilities were also identified as barriers.

conclusionsDespite the benefits of FANC services, health authorities in the District should ensure that use and promotion of the approach does not inadvertently bar some pregnant women from accessing services. There is a need to explore strategies and redesign an approach to health promotion that will promote uptake of the integrated services in FANC clinics without infringing on women's rights to access health care.