"Well, not me, but other women do not register because..."- Barriers to seeking antenatal care in the context of prevention of mother-to-child transmission of HIV among Zimbabwean women: a mixed-methods study

Background: While barriers to uptake of antenatal care (ANC) among pregnant women have been explored, much

less is known about how integrating prevention of mother-to-child transmission (PMTCT) programmes within ANC

services affects uptake. We explored barriers to uptake of integrated ANC services in a poor Zimbabwean

community.

Methods: A cross-sectional survey was conducted among post-natal women at Mbare Clinic, Harare, between

September 2010 and February 2011. Collected data included participant characteristics and ANC uptake. Logistic

regression was conducted to determine factors associated with ANC registration. In-depth interviews were held

with the first 21 survey participants who either did not register or registered after twenty-four weeks gestation to

explore barriers. Interviews were analysed thematically.

Results: Two hundred and ninety-nine participants (mean age 26.1 years) were surveyed. They came from ultra-poor

households, with mean household income of US$181. Only 229 (76.6%) had registered for ANC, at a mean gestation of

29.5 weeks. In multivariable analysis, household income was positively associated with ANC registration, odds ratio (OR)

for a $10-increase in household income 1.02 (95% confidence interval, CI, 1.0–1.04), as was education which interacted

with having planned the pregnancy (OR for planned pregnancy with completed ordinary level education 3.27 (95%CI 1.

55–6.70). Divorced women were less likely to register than married women, OR 0.20 (95%CI 0.07–0.58). In the qualitative

study, barriers to either ANC or PMTCT services limited uptake of integrated services. Women understood the importance

of integrated services for PMTCT purposes and theirs and the babies’ health and appeared unable to admit to barriers

which they deemed “stupid/irresponsible”, namely fear of HIV testing and disrespectful treatment by nurses. They

represented these commonly recurring barriers as challenges that “other women” faced. The major proffered personal

barrier was unaffordability of user fees, which was sometimes compounded by unsupportive husbands who were the

breadwinners.

Conclusion: Women who delayed/did not register were aware of the importance of ANC and PMTCT but were either

unable to afford or afraid to register. Addressing the identified challenges will not only be important for integrated

PMTCT/ANC services but will also provide a model for dealing with challenges as countries scale up ‘treat all’ approaches.

Keywords: Antenatal care; PMTCT, Qualitative study, User fees, HIV testing