Soc. Sci. Med. Vol. 40, No. 7, pp.

1003-1012, 1995
Copyright 1995 ElsevierScience Ltd
Pergamon 0277-9536(94)00175-8 Printed in Great Britain. All rights reserved
0277-9536/95 $9.50+ 0.00

RESEARCH NOTE

UNDER-USERS OF ANTENATAL CARE: A COMPARISON

OF NON-ATTENDERS A N D LATE ATTENDERS FOR
ANTENATAL CARE, WITH EARLY ATTENDERS
AFFETTE McCAw-BINNS ~, JANET LA GRENADE2 and DEANNA ASHLEY3
~Tropical Metabolism Research Unit, University of the West Indies, Mona, Kingston 7, Jamaica
2Department of Social and Preventive Medicine, University of the West Indies, Mona, Kingston 7, Jamaica
and 3Ministry of Health, 10 Caledonia Avenue, Kingston 5, Jamaica

Al~tract--Demographic, behavioural, environmental, economic and obstetric history data from the
Jamaican Perinatat Morbidity and Mortality Survey were examined to identify characteristics of women
who do not attend for antenatal care, or present late instead of early for care, using multiple logistic
regression.Non-attenders were more likely to be teenagers, unmarried, in unions of very short duration,
smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often
had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They
were often drawn from deprived environments (lack of sanitation, water supplies).Late attenders shared
features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed
and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had
previously uneventful pregnancies, including this one. Early attenders had little in common with
non-attenders or late attenders. They were older, many had a secondary or tertiary education, were married
and were generally middle class women. The group however included high risk multigravidae who had
previous pregnancy complications or bad outcomes.Programmes aimed at reaching non-attenders must
focus on the wider social and economic needs of these women and must give them a sense of their own power
to etfect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with
the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental
way as this is often a high risk pregnancy. More fundamental changes require improved educational and
employment opportunities for women as the best consumer is an educated consumer.

Key words--antenatal care, late attendance, non-attendance, user characteristics, Jamaica

INTRODUCTION MATERIALS AND METHODS

A confidential enquiry into all maternal deaths in
Jamaica (1981-83) [1] found that among the avoidable
factors, the most important was non-use of and
deficiencies in antenatal care. Then the maternal
mortality rate was 108 per 100,000 live births.
Five years later (1986-87) there was no decrease in the
death rate (ll5/100,000). When socio-economic
factors were examined it was found that lesser
educated women, those with fewer household
amenities (no running water or flush toilets), and
women dependent on agricultural workers were at
increased risk of maternal death [2]. Late attendance
for antenatal care has been associated with higher
incidence of maternal morbidity at delivery and higher
perinatal mortality and morbidity from complications
such as syphilis [3].
As access to and use of antenatal care have
socio-economic dimensions as well as personal
characteristics, a variety of social and biological
characteristics of Jamaican women who did not attend
for antenatal care or who attended late (third trimester)
instead of early (first trimester) are examined with an
aim toward influencing health education and policy.
The Jamaican Perinatal Morbidity and Mortality
Survey [4] was undertaken between September 1986
and August 1987 to identify factors predictive of
perinatal morbidity and mortality with the aim of
reducing these poor outcomes through a risk approach
to maternal and child health care. In the first two
months a cohort of 10,500 women who delivered
anywhere in Jamaica, regardless of outcome of
pregnancy, was identified and interviewed. The cohort
represented 94% of all live births occurring on the
island in that two month period [3]. In addition, a
morbidity study included all women whose newborn
babies were admitted to special care nurseries in the
first 28 days of life over 6 months ( n = 1850), and a
mortality study included all women who experienced
a perinatal death (stillbirth or neonatal death) over the
one year period (n = 2150).
Mothers were interviewed at delivery by midwives.
They collected information on social, economic,
demographic, environmental and obstetric history as
well as health service utilization. This paper examines
the socio-environmental and obstetric history factors
for women included in the cohort study, the

ss~ 4o,,7-J 1003

1004 AvF~T~ McCAw-BINNS et al.

relationship of these factors to the decision to attend
for antenatal care and when in pregnancy the first visit
Occurs.
Multiple logistic regression was used to determine
the independent associations between each set of
variables (demographic, behavioural, environmental,
economic, obstetric history) and non-attendance and
time of first visit. All variables were not modelled
together as the model would be too unwieldy.
Non-attenders arc compared with the rest of the study
population who attended for care. Late attenders (first
visit in the third trimester) are compared with those
who made their first visit in the first or second trimester
while early attenders (first visit in the first trimester) are
compared with those who made their first visit in the
second or third trimester. Odds ratios are presented
with their 95% confidence intervals. Variable
sub-groups marked with 'R' represent the reference
group. Variables whose adjusted P value fell between
5 and 10% are not discussed although presented in the
tables. An Appendix lists all variables examined and
definitions of terms used.
FINDINGS
The perinatal mortality rate was 38.0 per 1000
deliveries. Of the 10,382 women with data on antenatal
care utilization, 4% (n=414) had not attended for
antenatal care. Of the 9968 attending, data on
trimester of first visit were available on 9849. Of these,
10% (1012) delayed the first visit until the last trimester
while 29% (2812) presented for care in the first
trimester. The majority, 61% (6025) made their first
visit in the second trimester.

Table 1. Demographic predictors o f non-attendance, late and early attendance for antenatal care
Demographic variables Non-attendance Late attendance Early attendance
OR (95% C/) OR (95% CO OR (95% C/)
Maternal age * ** ** ** *

12-19 yr 1.7 (1.2-2.2) 1.5 (1.2-1.8) 0.5 (0.4-0.6)

20-29 yr 1.0R 1.OR 1.OR
30-39 yr 0.6 (0.4-0.9) 1.0 (0.7-1.2) 1.4 (1.2-1.6)
40 or more yr 0.4 (0. l-1.0) 1.3 (0.8-2.2) 0.9 (0.6-1.5)
Maternal education * * * **

Primary or less 1.OR 1.0R l .OR

Junior secondary 0.7 (0.5-0.9) 0.9 (0.8-1.1) 1.1 (0.9-1.3)
Secondary 0.9 (0.7-1.2) 1.3 (1.0-1.5) 1.5 (1.4-1.7)
Tertiary 0.7 (0.3-1.6) 1.1 (0.7-1.6) 3.3 (2.6-4.1)
Union status *** *** ***
Married 1.OR 1.OR 1.OR
C o m m o n law 2.3 (1.4--3.9) 2.4 (1.8-3.2) 0.5 (0.4-0.5)
Separated 3.2 (1.6-6.4) 2.1 (1.4-3.3) 0.5 (0.4-0.7)
Visiting 3.8 (2.2-6.5) 2.7 (2.0-3.7) 0.4 (0.3-0.5)
Years in union *** - ***

Under 1 yr 3.1 (1.6-6.2) 0.8 (0.5-1.4)

1-4 yr 1.OR 1.OR
5--9 yr 0.6 (0.5-0.8) 1.3 (1.2-1.5)
10-14 yr 0.7 (0.4-1.2) 1.6 (1.3-2.0)
15 or more yr 0.9 (0.5-1.8) 1.5 (1.0-2.1)
Children alive *** *** ***
0 1.0R 1.0R 1.0R
1-4 4.8 (3.4-6.7) 1,3 (1.0-1.7) 0,5 (0.4-0.7)
5-9 5.5 (3.5--8.7) 1.9 (1.3-2.6) 0.4 (0.3-0.6)
10 or more 12.4 (7.2-21.2) 2.1 (1.4-3,3) 0.4 (0.2-0.6)
Children f o r current
sexual partner -- ** ***
0 1.OR 1.0R
1-4 1.4 (1.1-1.7) 0.6 (0.5-0.7)
5-9 1.5 (l.0-2.1) 0.5 (0.3-0.6)
10 or more 2.0 0.3-3.3) 0.4 (0.3-0.6)
Adults in the household * -- --

1 1.6 (1.1-2.2)
2-4 1.OR
5 or more 0.8 (0.5-1.1)
Total household size -- -- ***
1-4 1 .O R

5-8 0.8 (0.7-0.9)

9-12 0.7 (0.6-0.9)
13 or more 0.7 (0.5-0.9)
Previous pregnancies -- -- *

0 I .OR
1-2 1.4 (1.1-1.9)
3-4 1.6 (I.1-2.3)
5 or more 1.5 (0.9-2.4)
* P < 0 . 0 5 . ** P < 0 . 0 1 . *** P < 0 . 0 0 1 .
 Research Note 1005

Table 2. Behaviourai predictors of non-attendance, late and early attendance for antenatal care
Behavioural variables Non-attendance Late attendance Early attendance
OR ( 9 5 0 C/) OR (95% C/) OR (95% C/)
Emotional
Pregnancy planned *** *** ***
Yes 1.OR 1.0 R 1.0R
No 2.8 (1.6-4.7) 2.2 (I.7-3.1) 0.5 (0.44).6)
Indifferent 1.0 (0.4-2.8) 1.8 (1.1-2.9) 1.0 (0.8-1.3)
Knew date of last
menstrual period * **
With certainty 1.0R 1 .OR
Uncertain 1.4 (1.1-1.9) 0.8 (0.7-0.9)
No period before pregnancy 2.4 (1.3-4.8) 0.8 (0.5-1.2)
Date not known 3.0 (2.1-4.3) 0.8 (0.641.9)
Friends~relatives not
supportive during preg. *** m
2.0 (1.4-2.9)
Felt sad during pregnancy
0.8 (0.7~).9)
Social
Age of first pregnancy
11-14 2.7 (1.2-6.2) 2.2 (1.3-3.6) 0.4 (0.34).5)
15-19 2.5 (1.2-5.3) 2.1 (1.4-3.3) 0.4 (0.3-0.5)
20-24 2.1 (0.9--4.6) 1.7 (1.1-2.7) 0.6 (0.5~.8)
25 or older 1 .OR 1.0 R 1.0R
Age initiated sexual activity
11-14 1 .OR
15-19 1.2 (1.6-1.4)
20-24 1.7 (1.3-2.1)
25 or older 2.2 (1.4-3.6)
Biological
Used over the counter drugs
1.4 (1.6-2.0) 0.6 (0.4-0.7) 1.6 (1.4-1.9)
Smoked tobacco
2.5 (1.8--3.4)
Consumed alcohol
0.7 (0.54).9) 1.1 (1.6-1.3)
Used contraceptives
1.4 (1.2-1.5)
Used home remedies +
0.9 (0.8-1.0)
+ 0.05< P < 0 . 1 0 . * P < 0 . 0 5 . ** P < 0 . 0 1 . *** P<0.001.

Demographicfactors behaviour in complex ways. Women with one or more

Table 1 shows the significant demographic
predictors of antenatal care attendance. Compared
to women in their twenties, teenagers were most
likely to not attend or attend late and were
unlikely to present early. Women in their thirties
were unlikely to not attend and frequently presented
early.
Women with a secondary or tertiary education were
more likely to attend early for care.
Married women were good attenders. Odds of
non-attendance doubled for women in common-law
unions and more than trebled for other union types
(separated, O R = 3.2; visiting, O R = 3.8). Unmarried
women were twice as likely to attend late (common-
law, OR = 2.4; separated, OR = 2.1; visiting, OR = 2.7)
and unlikely to present early.
Women in unions of under one year were 3 times
more likely to not attend than the 1-4 year reference
group. Unions of 5 or more years were associated with
early attendance.
Family size and composition influence maternal
living children had odds of non-attendance ranging
from 4.8-12.4; with late presentation for care the norm
( O R = 1.3-2. l) and early attendance unlikely.
Women without children for the current partner
(regardless of number of previous children) attended
early while those with children were more apt to attend
late, indicating that a baby for a new partner was
highly valued.
Women in lone adult households were at risk of
non-attendance. On the contrary, women from small
households (four or less total occupants) had the
highest early attendance rate with odds of early
attendance falling with increasing number of
occupants.
Number of previous pregnancies influenced early
attendance only. Compared with primigravidae,
gravida 1-2 ( O R = 1.4) and gravida 3-4 ( O R = 1.6)
women were more likely to attend early. After
accounting for number of children alive this variable
may be selecting those women with previous fetal loss
who were motivated by their bad experiences to attend
early.
 1006 A r r E ' r ~ M c C ^ w - B i r c N s et al.

Table 3. Environmental predictors of non-attendance, late and cafly attendance for antenatal care
Environmental variables Non-attendance Late attendance Early attendance
OR (95% C/) OR (95% C/) OR (95% C/)
*** ***
Place o f delivery ***
Pubfic hospital I .OR 1 .O R 1 .OR
Home/other 3.4 (2.6--4.3) 1,3 (1.0-1,5) 0.8 (0,7-0.9)
Primary care centre 0.2 (0. !-0.6) 1.6 (1.2-2.2) 0.5 (0.4-0.6)
Private hospital NA 0.2 (0.1-0.4) 6.3 (5.0-8.0)
Level o f secondary care
semices in parish o f residence *
Obstetric specialists 1.0R 1 .OR
Midwives only 0.7 (0.5-0.9) 0.6 (0.5-0.8)
+
Region o f residence ***
South east 1.7 (1.2-2.5) 1.5 (1.2-1,8) 1.0 o.9-1.1)
North east 1.4 (0.9--2. !) 0.8 (0.6-1,1) 0.9 (0.8-1.1)
West 1.OR 1 .O K 1 .OR
South 0.9 (0.6-1.3) 0.8 (0.6-1,1) 0.9 (i.o-1.3)
Type of community *
Remote rural area 1.0R
Rural town or village 0.8 (0.6-1.2)
Urban area 1.2 (0.8--1.6)
*** ***
Sanitary facilities +
Water closet 1.0R 1.0 R 1 .OR
Pit latrine 1.0 (0.8-1.3) 0.7 (0.6-0.9) 0.6 (0.54).7)
None 2.2 (1.1--4.2) 1.3 (0.7-2.4) 0.4 (0.3--0.7)
* +
Water supply *
Piped onto premises 1.0R l .OR l .OR
Catchment tank 0.8 (0.5-1.1) 1.4 (l.l-l.7) 1.0 (0.9-1.2)
Public standpipe 1.2 (0.8-1.6 1.3 (1.0-1.7) 0.9 (0.8-1.0)
Rivers, wells etc 1.5 (1.0-2.2 1.2 (0.9-1.7) 0.8 (0.7-1.0)
Home ownership ***
Family owned 1.OR
Rented 1.3 (1.0-1.6
Other 2.2 (1.5-3.2)
+ 0.05< P <0.10. * P<0.05. ** P<0.01. *** P<0.001. NA, not applicable.

Key

Obstetric specialists available

Midwife deliveries (supervised by general surgeon)

WEST ~ Falmouth NORTH EAST

Luce.t- Ha.over ,S,,ames / II

iTM / ' - - - - " ' ' ~ x I_, II ! a \ Prt Maria
7 . . . . . ~. , rrelawny II I =~
/---" Westmoreland -\ ~ - " II .... ~ ....
~ u a a~.mary _AnnottoBay

SOUTH SOUTH EAST

Fig. 1. M a p o f J a m a i c a s h o w i n g r e g i o n a l a n d p a r i s h b o u n d a r i e s a n d l o c a t i o n a n d type o f h o s p i t a l s
 Research Note 1007

Table 4. Economicpredictorsof non-attendance,late and early attendance for antenatal care

Economic variables Non-attendance Late attendance Early attendance
OR (95% C.I.) OR (95% C/) OR (95% C/)
Weekly food expenditure *** *** ***
Highest quartile 1.OK 1.0R 1.0R
Third quartile 1.9 (1.3-2.9) 1.4 (i,1-1.8) 0.7 (0.6-0.8)
Second quartile 2.0 (1.3-3.1) 1.5 (!.2-1.9) 0.6 (0.5~.7)
Lowest quartile 3.1 (2.1-4.7) 1.7 (1.3-2.2) 0.5 (0.4-0.6)
Occupation o f the M W E *** * ***
Higher order profession 1.OR 1.0P- 1,0a
Middle order profession 2.2 (1.4-3.5) 1.3 (I.0-1.6) 0.7 (0.6-0.8)
Lower order profession 2.3 (1.4-3.6) 1.0 (0.8-1.3) 0.7 (0.6-0.8)
M a t e r n a l occupation -- ** ***
Higher order profession 1.0~ 1.0R
Middle order profession 1.8 (1.3-2.5) 0.5 (0.4-0.5)
Lower order profession 1.3 (0.9-1.9) 0.4 (0.3-0.5)
Housewife 1.5 (1.1-2.0) 0.3 (0.2-0.4)
Unemployed 1.6 ( 1. 1-2.2) 0.3 (0.3-0.4)
Identity o f the M W E ***
Partner 1.0R
Parent 0.7 (0.6-0.8)
Relative 0.9 (0.7-1.1)
Non-relative 0.7 (0.4-1.2)
Mother herself 0.8 (0.7-1.0)
*P <0.05. ** P<0.01. *** P<0.001. MWE, major wage earner.

Behavioural factors sexually active at 14 years or younger, those who

became active later in life were increasingly more likely
Behavioural variables were classified into three
to attend early the older they were when this activity
groups: emotional, describing the clients attitude
first began.
toward pregnancy and reproduction; social factors,
Biological variables. Use of over the counter
describing the clients reproductive behaviour; and
drugs was associated with an increased risk of
biological, those actions which could conceivably
non-attendance. Unexpectedly, it was also associated
influence pregnancy outcome. These are presented in
with an increased likelihood of early attendance;
Table 2.
implying that maybe non-attenders were success-
Emotional factors. The most significant emotional fully managing their problems at home with these
variable was that measuring desirability of the
drugs while early attenders were not. Late
pregnancy. Women who were not trying to get
attenders were unlikely users of these products,
pregnant when they conceived were more likely to not
suggesting that the pregnancy may have been problem
attend (OR = 2.8) or attend late (OR = 2.2) and did not
free.
present early. A third group who were indifferent to the
Smokers were at high risk of non-attendance, while
pregnancy were only at risk of late attendance
alcohol users were a low risk group for non-attend-
(OR = 1.8).
ance. Previous contraceptive users attended early.
Compared to women who knew the date of their last
menstrual period (LMP) with certainty, those who
were uncertain of or totally ignorant of their LMP Environmental factors
were unlikely to attend or do so early.
Among environmental variables shown in Table 3,
Women who felt friends and relatives had not been
place of delivery featured in all outcomes. Compared
supportive during pregnancy were twice as likely to
with public hospital users, home delivery was
not attend. Those who said they felt sad during
more common among non-attenders (OR=3.4)
pregnancy were less likely to attend early.
and late attenders ( O R = 1.3) and unlikely among
Social factors. The older one was when one first
early attenders (OR=0.8). Women using primary
became pregnant the better one's attendance,
care centres* while likely to attend antenatal
regardless of current age. Compared to those who first
clinics, often did so late instead of early. All
became pregnant at 25 years of age or older, women
women delivering in private hospitals had ante-
whose first pregnancy occurred at a younger age were
natal care. They were 6 times more likely to attend
twice as likely to not attend or attend late and were
early.
unlikely to present early.
Women who lived in parishes with only midwife
Age of first sexual experience was significant for
hospital delivery services were less likely to not attend
early attendance. Compared with women who became
or attend late compared with women living in parishes
where obstetric specialists were available at the local
*Government operated birthing centres (rural maternity hospital.
centres and community hospitals) which are operated by Women who lived in the south east region (includes
midwives only, the former without medical supervision. the urbanized parishes of Kingston/St. Andrew and St.
1008 AFFETTEMcCAw-B1NNSet al.

Catherine) were at risk of both not attending for care Economic factors
( O R = 1.7) and attending late ( O R = 1.5). compared
Table 4 shows that the most important economic
with women living in the western end o f the island. See
variable was weekly food expenditure. W o m e n in the
Fig. 1.
three lowest expenditure quartiles were more likely to
Variables describing the quality of the home
not attend or did so late and were less apt to present
environment have been used as socio-economic
in the first trimester.
indicators however they are included here among
Occupation of the major wage earner was the other
the environmental variables. They were particularly
important measure. Compared with women supported
predictive of non-attendance. W o m e n with no
by persons in the highest professional group, women
sanitary facilities ( O R = 2.2), who got water
supported by persons in middle and lower order jobs
from traditional sources such as rivers or
were twice as likely to not attend and less likely to
streams (OR--1.5), who lived in rented accommo-
present early. Only those supported by persons in the
dation ( O R - - 1 . 3 ) or under other tenure such as
middle group however were at risk of late attendance.
leasehold or squatting ( O R = 2 . 2 ) were at high risk
The mother's occupation and her relationship to the
of not seeking care. W o m e n with no sanitary
major wage earner also influenced time of attendance.
conveniences were also unlikely to present early
W o m e n employed in higher order professions
(OR=0.4).
attended early while women dependent on their
W o m e n with access to pit latrines, while unlikely to
parents did not. Housewives, the unemployed and
attend late were not attending early, indicating a
women in middle order jobs were often late attenders.
preference for second trimester attendance. W o m e n
relying on private catchment tanks ( O R = 1.4) or
Obstetric history
public standpipes ( O R = 1.3) for water were more
often late attenders compared to those who had piped Table 5 shows that the most important obstetric
water. history variables were the inter-pregnancy interval

Table 5. Obstetric history predictors of non-attendance, late and early attendance for antenatal care
Obstetric experience Non-attendance Late attendance Early attendance
OR (95% C/) OR (95% C/) OR (95% C/)
Interpregnancy interval ***
< 1 yr 3.1 (1.6-6.2) 1.2 (0.6-2.2) 0.5 (0.3-0.9)
1-2 yr 2.2 (1.7-2.8) 1.3 (1.1-1.6) 0.6 (0.54).7)
2 or more yr 1.0a 1.0 x 1.0 s

Outcome of last pregnancy **

Full term livebirth 1.0R
Preterm livebirth 0.8 (0.3-1.8) 1.5 (0.9-2.2)
Stillbirth 0.5 (0.2-1.7) 1.1 (0.7-1.9)
Miscarriage 0.1 (0.01-0.6) 3.3 (2.6-4.3)
Termination 0.2 (0.01-1.6) 1.7 (0.8-3.3)
Prior miscarriage *
0.5 (0.3-0.9) 0.5 (0.3-0.6)
Prior termination
3.0 (1.7-5.1)
+
Prior stillbirth
0.7 (0.4-1.1)
Prior early neonatal death
1.5 (1.0-2.1)
Prior death > 7 days of age
1.6 (1.1-2.4)

*** ***
Previous pregnancies
1-2 1.0 t 1.0 x
3-4 1.3 (1.0-1.6) 0.9 (0.7-1.0)
5 or more 1.9 (1.5-2.4) 0.7 (0.64).8)
Prior caesarean section
1.8 (1.1-2.9)
Prior forceps defivery
2.3 (1.2-4.5)
** ***
Prior other complications
0.5 (0.3--0.8) 1.7 (1.3-2.3)
+
Prior pre-eclampsia
0.7 (0.4-1.1)
+
Prior puerperal depression
1.7 (0.9-3.0)
+ 0.05 < P< 0.10. *P< 0.05. **P<O.OI. ***P< 0.001.
 Research Note
(IPI) and outcome of the last pregnancy. Women
who became pregnant within two years of their
last birth were less likely to attend or show up
early. The risk of non-attendance increased from
2.2 to 3.1 for the shorter interval. Only an IPI of 1-2
years however was a significant predictor of late
attendance.
While multigravidae would eventually attend for
care, chances of late attendance increased and early
attendance declined as the number of previous
pregnancies increased.
A bad obstetric history provided the greatest
motivation for antenatal care attendance, the
most significant being miscarriage. Any history
of miscarriage reduced the odds of non-attendance
(OR=0.5), particularly if this pregnancy occurred
immediately before the study infant (OR=0.1),
which had an added independent effect. These
women were also unlikely to attend late.
Women with previous elective abortions (OR = 3.0),
early neonatal deaths ( O R = 1.5), forceps deliveries
(OR=2.3) or some other unspecified pregnancy
complication ( O R = 1.7) were highly motivated to
attend early. At variance with the bad outcome
hypothesis were women experiencing deaths
among infants over 7 days of age. They were 60%
more likely to not attend for care.
One difficult variable to explain was the association
of a previous Caesarean delivery with late attendance
(OR = 1.8).
DISCUSSION
The perinatal mortality rate of 38 per 1000 is higher
than we would like it to be. This is above the rate of
29.0/1000 reported more than a decade earlier for
Cuba in 197315] although similar to the rate of
34.5/1000 for 1984-5 for Curacao[6], two other
Caribbean islands.
The non-attendance rate of 4% while relatively
low, is high compared to industrialized countries.
In three European countries and the United States [7]
non-attendance rates ranged between 0.2% for France
and 1.0% for the United States. Attendance after the
first trimester was also much lower, being 4% for
France, 8% for Denmark, 13% for Belgium and 21%
for the United States compared with 70% for Jamaica.
The third trimester attendance rate of 10% is however
similar to that found for the Phillipines (11.7%) in
1984 [8].
There is significant room for improving total
attendance and encouraging earlier first visits.
Early initiation of antenatal care allows for base-
line determination of parameters such as weight,
haemoglobin and blood pressure before the physio-
logic adjustments to pregnancy take place as
well as early detection of pregnancy-related risk
factors, infections and complications, allowing for
rapid and adequate treatment and timely referral [9].
1009
The non-attender
Non-attenders were often teenagers, in unstable
unions and from depressed environs. Some were single
parents. The pregnancy was often unplanned, some
soon after the last delivery. They included smokers and
women who felt that friends and relatives had been
unsupportive during pregnancy. Multigravidae in-
cluded women who had children who died after 7 days
of age. Many were post neonatal deaths; deaths
usually associated with poor weaning practices and an
unhealthy environment.
These variables are suggestive of women with very
low autonomy, for whom the pregnancy represents
one more event that is 'happening' to them. Their
perception that friends and relatives have not been
supportive is not analysed by whether this perception
of supportiveness is financial or emotional. It is
probably a composite measure and may well have been
read by clients as financially supportive, when one
considers where they fell in Maslow's hierarchy of
needs [10].
This lack of control of their lives is consistent with
findings by McKinlay and M c K i n l a y [ l l ] who
described underutitizers of antenatal care as appearing
to sustain a crisis existence. Melkinow [12] et al. found
that women who had little or no prenatal care were
more likely to be multiparous, single, less educated,
reported significant tobacco and drug use and lived in
depressed communities.
Although the behavioural factors are separated for
classification purposes, there is an interplay of
variables, especially when one considers the import-
ance of the socio-economic indicators and the
inter-relationship between socio-economic status and
autonomy.
That teenagers, women not wanting to get pregnant,
women who felt friends or relatives were not
supportive and those in unions of very short duration
were among those most likely to not attend may
indicate self-delusion or denial of the pregnancy.
Media and community education programmes need to
be geared to reaching these persons early in pregnancy
as they may be in need of psychological support.
The common association between non-attendance
and poor maternal and perinatal outcome may more
often reflect the economic circumstance of these
mothers than simply failure to seek care. This is
supported by the observation by Bruce and
Winikoff [13] that when one corrects for socio-econ-
omic status, a large portion of the differentials in infant
and maternal mortality experienced by mothers of
different ages and parities is erased. Most risk
instruments . . . are thus, in effect, socio-economic
identifiers.
It should however be noted that the non-attenders
included an excess of women who delivered before 37
weeks (preterm) (29.3% of non-attenders compared to
14.8% of early attenders) and may indicate that some
of these women had their babies before they got
1010 AFFETTEMcCAw-B~IqS et al.
around to seeking care. This in part explains the higher
prevalence of hom e birth in this group as delivery may
have been precipitous. At best however, they would
have been included among the late attenders with
whom they shared some common features. This higher
prevalence of preterm delivery also explains a large
portion of the excess mortality among non-attenders
and is the reason why differences in pregnancy
outcome among the three groups are not presented.
Jelley and Madeley [14] point out that women of
lower socio-economic status spend proportionately
more time procuring the necessities for survival (food,
water, fuel, etc.) to maintain their subsistence level.
Use of antenatal services is likely to be low to the extent
that it reduces the time available to carry out these
basic tasks and thus threatens the family's day to day
survival.
Behavioural expression and socio-economic cir-
cumstances become inter-twined--the non-attender
being someone in depressed economic circumstances
who seems overwhelmed by both and perhaps lacks
the personality attributes to overcome them.
Thus, for women existing in an environment of
multiple deprivations, attendance for antenatal care
may not receive the priority attention it deserves unless
this attendance meets basic survival as well as health
care needs. To reach these clients effectively may
require a marriage of social welfare and health care
programmes which are valued by the recepients.
Conceptually, in Jamaica, the Food Stamp Pro-
gramme* could be such a programme. Pregnant and
lactating women enrol at government health centres.
If eligible, they are issued monthly vouchers to
purchase basic food items. At present however the
economic and social costs of attendance may far
outweigh the benefits received.
The late attender
Late attenders shared features common to non-at-
tenders; being often teenagers, unmarried and
multiparous. Many however were self employed
women or women supported by men in similar
occupations (often higglers or market vendors). While
time away from their stalls meant loss of income for
the women, the fact that partners in these occupations
was also significant suggests that the social group saw
little value in early attendance. They did however
appreciate the need to make arrangements for their
confinement at some point in the pregnancy.
Late attenders did not fit the depressed profile of the
non-attender and may represent multigravidae who
have had previously uneventful pregnancies and for
*Government programme aimed at reaching 12% of the
population (n = 300,000) including 25 % of pregnant and
lactating women. Other target groups are children < 5 yr
old, the elderly and households below the poverty line.
After referral by health workers and a home visit by a
social worker, women may receive up to Ja$150
(U.S.$4.50)/month. The national minimum wage is
Ja$500/week.
whom this pregnancy has been basically problem free.
Similar findings have been reported by Thomas[15]
et al. in the United Kingdom. This group generally
appeared to display high levels of autonomy which
often includes non-conformist behaviour unless the
individual is satisfied that the recommended health
seeking behaviour is personally applicable to them.
This is supported by the findings of Sargent and
Rawlins[16] who, in a study limited to users of the
Victoria Jubilee Hospital, a tertiary hospital in
Kingston, found that women did not see pregnancy as
a pathological condition. They made only one or a few
visits and only attended regularly if they were ill.
The history of Caesarean delivery may be an
indication however that habitual late attenders have
undiagnosed complications which require interven-
tions such as emergency Caesarean delivery.
With 52% of primigravidae under 20 years of age,
we must examine the attitude of school officials and
health workers to pregnancy in this population to
ensure that this high risk group receives adequate
antenatal care in a sympathetic or at least tolerant
setting. Reducing the incidence of early teenage
pregnancy (16 years and under) must also be
addressed. These data also show that there is early
initiation of sexual activity (20% sexually active by 15
years, 91% by 20 years) and low contraceptive
prevalence among primigravidae (29% ever use).
The fact that housewives and highly parous women
were late attenders is probably another indication that
pregnancy is viewed as a natural process which they
have been through before and see no need to come to
clinic. They are aware of the routine and may not wish
to sit through the prenatal lectures which are part of
the routine visit. Some health centres have attempted
to address this problem by holding separate clinics for
primigravidae, multigravidae and high risk women.
The attitudes of staff toward older women and women
who choose to 'have out their lot' also needs to be
examined as often midwives take a condescending
approach to the provision of care to these women.
The early attender
Early attenders had little in common with
non-attenders or late attenders. They were older,
better educated, often in stable, established relation-
ships. Many could afford private care. They had used
contraceptives, some had employed abortions in the
event of an unplanned pregnancy and desired this
pregnancy. These findings are again consistent with
McKinlay and McKinlay who described utilizers of
antenatal care as appearing to have control over their
lives and who live in situations conducive to planning
their future.
The early attendance of women with a prior elective
abortion may indicate that women who act early to
terminate an unplanned pregnancy will also act
decisively and responsibly once the pregnancy is
desired.
 Research Note
Early attendance may be a risk marker in the
developing world, given the higher prevalence of
women with bad obstetric histories (miscarriage, early
neonatal death, forceps delivery, unspecified compli-
cations) among early attenders. Sargent and Rawlins
also found that the most significant variable associated
with use of antenatal care was poor health during
pregnancy. One therefore must adjust for differences
in maternal risk when looking at the influence on
perinatal outcome of when women present for care.
SUMMARY
U n d e r users of antenatal care tended to be women
who were socially at risk and who could benefit from
interventions early in pregnancy such as dietary
supplementation. As medical and socio-economic risk
factors are correlated, reducing maternal and perinatal
deaths requires a broad based approach which aims to
improve social and environmental risk factors while
increasing access to and improving the quality of
medical care.
Long term improvements in health behaviour may
require fundamental changes in education and
employment opportunities for women as the best
attenders were the more socio-economically advan-
taged women. Better educated clients will be more
responsible users of the available service. Their
demand for better care will assist the drive for quality
improvement.
The interpretations of these findings need to be
viewed with caution and suggest the need for further
research to clarify the interplay of social, economic
and behavioural factors and health service utilization.
It will also be worthwhile to follow these children over
time to look at whether these social, environmental
and emotional factors present at birth influence later
childhood development.
Acknowledgements--Funding to support data collection was
generously provided by the International Development
Research Centre of Canada. Analysis of the data was
supported by the Science and Technology Programme of the
European Economic Community (Contract No. TS2-00410-
UK) and undertaken at the Institute of Child Health,
University of Bristol.We are grateful to our Jamaican
mothers and their babies without whose cooperation this
study would not have been a reality, as well as the team of
midwife interviewers, study coordinators, and other health
workers who gave of their time and effort.
REFERENCES
1. Walker G. J. A., Ashley D. E. C., McCaw A. M., Bernard
G. W. Maternal mortality in Jamaica. Lancet I (8479),
486, 1986.
2. Golding J., Ashley D., McCaw-Binns A., Keeling J. W.
and Shenton T. Maternal mortality in Jamaica:
socioeconomic factors. Acta Obstet. Gynecol. Scand. 68,
581, 1989.
3. McCaw-Binns A. Does antenatal care make difference?
An examination of antenatal care in Jamaica and its
relationship to pregnancy outcome, p. 160. PhD thesis,
University of Bristol, 1993.
1011
4. Ashley D. McCaw-Binns A. and Foster-Williams K. The
perinatal morbidity and mortality survey of Jamaica.
Pediatr. Perinat. Epid. 2, 138, 1988.
5. Golding J. and Butler N. R. Studies of perinatal
mortality: contrasts and contradictions. In A WHO
Report on Social and Biological Effects on Perinatal
Mortality, Vol. III (Edited by Golding J.), pp. 10-15.
University of Bristol Printing Unit, Bristol, 1990.
6. Wildschut H. I. J., Tutein Nolthenius-Puylaert M. C.,
Viedijk V. et al. Fetal and neonatal mortality, a matter
of care: report of a survey in Curacao, Netherlands
Antilles. Br. Med. J. 295, 894, 1987.
7. Buekens P., Kotelchuck M., Blondel B., Kristensen F. B.,
Chen J. and Masuy-Stroobant G. A comparison of
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J. Public Hlth 83, 31, 1993.
8. Wong E. L., Popkin B. M., Guilkey D. K. and Akin J.
S. Accessibility, quality of care and prenatal care use in
the Phillipines. Soc. Sci. Med. 24, 927, 1987.
9. Moore M. Behavioral Determinants of Maternal Health
Care Choices in Developing Countries: Working Paper 2.
Report prepared for the Agency for International
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Arlington, Virginia, 1990.
10. Maslow A. J. Towarda Psychology of Being, 2nd edn. D.
Van Nostrand, Princeton, 1968.
I1. McKinlay J. B. and McKinlay S. M. Some social
characteristics of lower working class utilizers and
under-utilizers of maternity care services. J. Hlth Sot'.
Behav. 13, 369, 1972.
12. Melkinow J., Alemagno S., Rottman C. and Zyzanski S.
Characteristics of inner-city women giving birth with
little or no prenatal care: a case-control study. J. Faro.
Pract. 32, 283, 1991.
13. Bruce J. and Winikoff B. Findings from the Seminar on
Reassessment of the Concept of Reproductive Risk in
Maternity Care and Family Planning Services. Robert H.
Ebert Program on Critical Issues in Reproductive Health
and Population, The Population Council, 1990, U.S.A.
14. Jelley D. and Madeley R. J. Antenatal care in Maputo,
Mozambique. J. Epid. Commun. Hlth. 37, 111, 1983.
15. Thomas P., Golding J. and Peters T. Delayed antenatal
care: does it effect pregnancy outcome? Soc. Sci. Med. 32,
715, 1991.
16. Sargent C. and Rawlins J. Factors influencing prenatal
care among low-income Jamaican women. Human Org.
50, 179, 1991.
APPENDIX
Complete list o f variables considered
Demographic variables
Maternal age, education, union status, union duration,
household size, household composition (adults, children
< 10, children 10-18), number of living children, number of
children for current sexual partner.
Behavioural factors
Grouped into three categories: social, describing sexual
history; biological, actions which can influence health; and
emotional, factors which describe attitudes toward preg-
nancy and reproduction.
Social variables
Age sexual activity initiated, age of first pregnancy,
number of previous sexual partners.
Biological factors
Use of tobacco, cannabis, alcohol, contraceptives, aspirin,
over the counter drugs, home remedies (traditional herbal
preparations).
Emotional factors
Whether pregnancy was planned; whether mother felt sad
1012 AFFETTEMcCAw-BINNS et al.
during pregnancy; whether mother felt that friends or
relatives were supportive during pregnancy.
Environmental variables
Region of residence, type of hospital facilities in the parish
of residence, place of delivery, housing tenure, source of
water supply, sanitary facilities.
Economic variables
Maternal occupation, occupation of the major wage earner
(MWE), mother's relationship to MWE, weekly food
expenditure (adjusted for household size; regional and
urban/rural differences in expenditure).
Obstetric history factors
Outcome of pregnancy before study infant, interpregnancy
interval, previous multiple pregnancies, miscarriages,
terminations, stillbirths, early neonatal deaths, deaths in
children > 7 days old. Previous Caesarean section, forceps
delivery, pre-eclampsia, eclampsia, antepartum or postpar-
tum haemorrhage, syphilis, puerperal depression and a
catchall variable 'other pregnancy complications not listed
above'.
Definitions
Multigravidae:
Women who have had pregnancies before the study baby.
Primigravidae:
Women for whom the study baby was the first pregnancy.
Multiparous:
Women who have had one or more previous deliveries.
Gravidity vs parity:
Gravidity counts number of pregnancies regardless of
outcome while parity refers only to those pregnancies which
have continued to fetal viability (usually 24-28+ weeks
gestation).
Early neonatal death:
Death of a liveborn baby within the first 7 days of life.
Perinatul death:
Fetal deaths (stillbirths) after 28 weeks of pregnancy and
newborn deaths up to 7 days of age (early neonatal death).
Stillbirth:
Death of the fetus prior to delivery or expulsion from the
womb.
Miscarriage:
Spontaneous fetal loss prior to viability (<24 weeks
gestation).
Trimester:
Pregnancy duration divided into three periods of 14 weeks
duration; first (weeks 0-14), second (weeks 15-28) and third
trimester (weeks 29-42)
Interpregnancy interval:
Period between last delivery and subsequent conception.
Average weekly food expenditure:
Amount spent weekly on food averaged over number of
persons in the household and adjusted to reflect regional and
urban/rural differences in expenditure, divided into four
expenditure quartiles.
Major wage earner:
Person contributing the largest portion of income to
support the household.
Occupation:
Coded into 25 groups and condensed into 3 categories;
higher order (professionals, managers, skilled non-manual),
middle order (semi-skilled non-manual, skilled manual),
lower order (semi-skilled manual, unskilled manual).
Union status:
Relationship between the mother and the father of her
child [coded as married, common-law (co-habiting but not
married), visiting (partner lives elsewhere but visits the
mother) and separated (other/no relationship)].