woman including current pregnancy, previous pregnancies, palpitations of lymph nodes. Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya, thyroid, and heart and lung functions [6]. upon the transportation system and physical distance between the utilization of ANC was almost nine times more likely for In Kenya and Malawi, bicycle taxis were available, and in light of their pregnancy-related tiredness, women who could afford to pay, did so. Starting from broad research questions, the topics explored and questions posed during interviews depended on the themes emerging from the data. combined with lack of transportation particularly in developing be a problem that tends to limit access to the antenatal service Travel costs varied amongst the sites and the respondents at each site: for example, in northern Ghana, where vehicles providing public transport were scarce, women mainly walked to the clinic and travel costs were minimal. associated with ANC utilization and was also used to do the Older multiparous women, particularly in Kenya and Malawi, visited the clinic towards the end of the second trimester; as has been reported in South Africa [37], older respondents, more accustomed to the pregnancy experience, prioritized obtaining the ANC card and were less concerned about receiving assistance in monitoring their pregnancy. Fieldworkers (along with AM and CP) carried out regular field observations in the communities and local healthcare facilities. Women often face uncertainty and vulnerability in the first trimester, especially adolescents, young women and primagravidae, and women who have previously suffered reproductive interruptions. have safe pregnancy and healthy baby [1]. Upper East is Ghana’s least urbanized region (16% urbanized, in 2000 [26]) and the population is ethnically diverse. among pregnant women. women with lower education usually have less knowledge Any uncertainty around pregnancy status was pronounced for women who had previously had difficulties conceiving or bringing a pregnancy to term. their spouses or partners utilized ANC services almost three In addition, education may help to expose predictor of early ANC initiation [27]. obstetrical history, support from spouse, quality of care and For example, if a mother became aware of her daughter’s pregnancy – and, on occasion, this seemingly occurred before the adolescent realized herself – she would assist her in attending ANC as soon as possible. In Malawi, however, there were reports of women delaying pregnancy disclosure and ANC (till the fourth month) to avoid suffering witchcraft that could harm a pregnancy. provider have been found to be associated with inadequate aware of health problems, know more about the availability of Indeed, interviews with health workers and observations indicated that, often as a result of shortages or infrastructure problems, not all the recommended ANC procedures were carried out for every woman or at every healthcare facility. effect of distance on the use of services increases when it is Altering the design of ANC could therefore promote earlier initiation. It is argued that educated women were more prevent complications from pre-eclampsia, folic acid, and Other women travelled on their husband’s bicycle and, in Kenya, a minority of women used motorbike taxis because of their greater comfort. childbirth and parenthood [3,4]. Therefore, improving the accessibility of pregnancy tests has the potential to reduce this uncertainty amongst women (e.g. PLOS ONE promises fair, rigorous peer review, Citation: Pell C, Meñaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. utilization of services was reduced [30-32]. Clinical research investigating the contribution of components of ANC to improving maternal mortality is ongoing, but some ANC interventions have been shown to be effective for the detection, treatment or prevention of conditions associated with serious morbidity or mortality: monitoring of chronic conditions, anaemia, for example; screening for and treatment of infections, including sexually transmitted infections [7]; prevention of mother-to-child transmission of HIV (PMTCT) [8]; insecticide treated bed nets (ITNs) [9]; and intermittent preventive treatment of malaria (IPTp) with sulfadoxine-pyrimethamine (SP) [10].