Why do rural women in the most remote and poorest areas of Zambia predominantly attend only one antenatal care visit with a skilled provider? A qualitative inquiry

Background: While focused antenatal care (ANC) has served as an entry point in the continuum of care for both mothers and children, fewer than a third of pregnant women in the most remote and poorest communities of Zambia achieve the four ANC visits recommended by the World Health Organization. Current evidence suggests that attending ANC provided by a skilled healthcare worker at least once is common and associated with skilled birth attendance. The aim of this study was to explain why one ANC visit with a skilled provider seemed more common than four ANC visits among women in the remote and poorest districts of Zambia. Methods: A qualitative case study design was conducted in 2012 among 84 participants in the selected remote and poorest districts of Zambia. Focus group discussions were conducted with mothers and community health volunteers, while key informant interviews were conducted with healthcare providers. Thematic analysis was conducted. Results: Most women delayed starting antenatal care visits due to uncertainties about the timing for initiation of ANC and due to waiting for confirmation of the pregnancy by an elderly woman. Attendance of ANC once with a skilled provider was due to the need to assess their health status and that of their baby. In some facilities, attendance of ANC at least once was enforced by financial charges imposed on women for late ANC initiation, and/or incentives provided by nongovernmental organisations. Unavailability of services at health posts closest to these remote communities led to failure to return for subsequent ANC visits. Women's livelihoods such as nomadic lifestyles made it harder for them to initiate and make additional ANC visits. Conclusion: The popularity of ANC attendance once by a skilled provider among the remote and poorest women of Zambia was explained through perceived unavoidable social and economic barriers to care, and the punitive and incentive procedures implemented by health services. Maximising comprehensive care by skilled healthcare workers in the one visit a woman makes at the health facility, may lead to optimal utilisation of quality focused ANC. Enhancing community-based interventions may increase the potential to reach the vulnerable populations.