A qualitative study of decision-making processes for antenatal care utilization among pregnant women in Dar es Salaam, Tanzania

Abstract

Antenatal care (ANC) utilization is crucial for protecting maternal and newborn health. However, ANC utilization during pregnancy remains low in sub-Saharan Africa. Prior research has largely identified factors associated with ANC attendance but often treats utilization as a static outcome. This study extends current research by framing ANC use as a dynamic, sequential process encompassing initiation, continuation, and timing of care. Understanding these processes is vital for effective interventions. This cross-sectional, exploratory qualitative study was conducted from January to March 2024 at two purposively selected public antenatal care clinics with contrasting service coverage to capture diverse utilization experiences. Data were collected through 18 in-depth interviews with pregnant women purposively recruited based on their ANC experiences. NVivo 15 was used for data management and organization. Data analysis followed Braun and Clarke’s six-step thematic approach, combining inductive and deductive coding and guided by Andersen’s Behavioral Model of Health Services Use. Ethical approval was obtained from the institutional review board, and all participants provided written informed consent. Three interrelated themes shaped women’s sequential decision-making about ANC utilization. Predisposing factors, including physical access, health education, maternal age, and gravidity, shaped motivations for initiating ANC. First-time mothers often began ANC early due to uncertainty and inexperience. Enabling factors, particularly social support – such as accompaniment, reminders, and transport assistance – strongly influenced continued attendance. Need factors, including symptoms, pregnancy complications, the need for medicines and tests, or delivery preparations, often prompted adjustments in timing, such as late initiation or maintaining continuity. Divergent cases highlighted that ANC decision-making is iterative and nonlinear, even when risks are perceived. ANC decisions arise from a dynamic interplay among personal motivations, social support, and perceived health needs that evolve throughout pregnancy. Programs should move beyond simple information provision to adopt family-inclusive strategies, engage partners and social networks, and implement institutional cue-based interventions, such as reminders and follow-ups, to support timely initiation and sustained ANC utilization.