Brighton and Sussex Medical School, UK
Dr Laing is an epidemiologist, trained at the London School of Hygiene and Tropical Medicine in London. For many years she worked in non-communicable diseases, cardiovascular disease, diabetes and cancer. For the past ten years, in addition to teaching at the Medical School, she has been volunteering in an Antenatal Clinic in the Gambia and during that time has been running the first cohort study of birth outcomes in the Gambia.
At the outset of this century the World Health Organisation recommended that the first visit to the antenatal clinic should be during the first trimester, women should attend at least 4 times and delivery accompanied by a trained birth attendant. Attendance in the first trimester enables both the early detection and treatment of existing complications and also offers opportunities to prevent complications. Between 2012 and 2016 we conducted a cohort study of 1611 consecutive pregnant women attending the antenatal clinic at a health centre in the Gambia. Overall 384 (23.9%) women attended during the first trimester. Of the 1366 women who were followed to the end of the pregnancy 468 (41.6%) had at least 4 antenatal visits. The women almost all planned an attended birth. Overall only 212 women (15.8%) complied with all 3 WHO recommendations. To examine factors associated with compliance we conducted a quantitative and a qualitative study. Following multivariate analysis women aged 30 or more, and women whose partner had tertiary education were most likely to attend in the first trimester. Married women and women with educated partners were most likely to attend at least 4 times. The qualitative study consisted of in-depth interviews with 25 women, 13 health care workers and 9 male partners. Three areas were identified: intentional concealment of early pregnancy was common inititally to avoid adverse social consequences or for fear that malign interventions would cause a miscarriage. In the absence of symptoms many women considered it unnecessary to attend the antenatal clinic until well into the second trimester. Practical barriers included conflicting domestic demands and the attitudes of some health care workers. Barriers to antenatal care are many and these will vary considerably from health centre to health centre. Prior to outreach programmes local issues should be considered.