Demand-Side Causes and Covariates of Late Antenatal Care Access in Cape Town, South Africa

  • Anja SmithEmail author
  • Ronelle Burger
  • Vivian Black


Objectives The objective of this study was to investigate the causes and covariates of late antenatal care access in South Africa. Methods A cross-sectional study was conducted, interviewing 221 women at four public-sector labour wards in Cape Town, South Africa in 2014. A definition of late attendance as attending ≥ 5 months was used. Data were analysed using univariate, bivariate and multivariate methods. Results Of the women who attended antenatal care at a public-sector clinic (n = 213, 96.4%), more than half (51.2%) attended ≥ 3 months and < 5 months, and a quarter (26.3%) attended ≥ 5 months. For those attending ≥ 5 months, 51.8% cited late recognition of pregnancy as the major reason for delayed attendance. Supply-side barriers were not identified as large contributing factors to delayed attendance. Late antenatal care access was predominantly associated with demand-side factors. Women who accessed antenatal care ≥ 5 months were more likely to be in the poorest 40% of the wealth-index distribution (p = 0.034) and to not have completed high school (p = 0.006). They were also more likely to report alcohol consumption during pregnancy (p = 0.020) and be multiparous (p = 0.035). Having completed high school was protective of late antenatal care access in stepwise logistic regression analysis (OR 0.403, CI 0.210–0.773, p < 0.01). For women who attended ≥ 3 months, late access was associated with unwanted pregnancy (p = 0.030). Conclusions for Practice Improved access to pregnancy tests could assist in earlier pregnancy identification. Interventions to increase awareness of the importance of early antenatal care attendance among vulnerable women may help.


Antenatal care HIV Unintended pregnancy Health seeking 



We would like to acknowledge the fieldwork team who helped with the data collection—Didi Gobile, Lucy Luphondo, Nomfuzeka Sikota, Christine Abrahams, Mpumi Ketelo and Marché-Lerice Potgieter. We also thank the women who were willing to share their experiences on accessing ANC care. The contribution of Ijeoma Solarin in developing the survey instrument used in an earlier study (Solarin and Black 2013) and replicated in this study is acknowledged. We thank the Western Cape Provincial Department of Health for permission to conduct the study in the government MOUs and district hospitals. AS thanks the National Research Foundation (NRF) for funding for her PhD and post-doctoral fellowship.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. Abrahams, N., Jewkes, R., & Mvo, Z. (2001). Health care-seeking practices of pregnant women and the role of the midwife in Cape Town, South Africa. Journal of Midwifery and Women’s Health, 46(4), 240–247.CrossRefGoogle Scholar
  2. Booysen, F., Van der Berg, S., Burger, R., Von Maltitz, M., Rand, Du, G (2008). Using an asset index to assess trends in poverty in seven sub-Saharan African countries. World Development, 36(6), 1113–1130.CrossRefGoogle Scholar
  3. Conway, K. S., & Deb, P. (2005). Is prenatal care ineffective? Or, is the ‘devil’ in the distribution. Journal of Health Economics, 24(3), 489–513.CrossRefGoogle Scholar
  4. Conway, K. S., & Kutinova, A. (2006). Maternal health: Does prenatal care make a difference? Health Economics, 15(5), 461–488.CrossRefGoogle Scholar
  5. Day, C., & Gray, A. (2016). Health and related indicators. In A. Padarath, J. King, E. L. Mackie, J. Casciola, (Eds.), South African Health Review 2016 (pp. 243–348). Durban: Health Systems Trust. Retrieved March 20, 2017, from
  6. Downe, S., Finlayson, K., Walsh, D., & Lavender, T. (2009). ‘Weighing up and balancing out’: A meta-synthesis of barriers to antenatal care for marginalised women in high-income countries. British Journal of Obstetrics and Gynaecology, 116, 518–529.CrossRefGoogle Scholar
  7. Finlayson, K., & Downe, S. (2013). Why do women not use ANC services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Medicine, 10(1), E1001373.CrossRefGoogle Scholar
  8. Gissler, M., & Hemminki, E. (1994). Amount of ANC care and infant outcome. European Journal of Obstetrics, Gynaecology and Reproductive Biology, 56(1), 9–14.CrossRefGoogle Scholar
  9. Haddad, D. A. N., Makin, J. D., Pattinson, R. C., & Forsyth, B. W. (2016). Barriers to early prenatal care in South Africa. International Journal of Gynaecology and Obstetrics, 132, 64–67.CrossRefGoogle Scholar
  10. Haddrill, R., Jones, G. L., Mitchell, C. A., & Anumba, D. O. C. (2014). Understanding delayed access to antenatal care: A qualitative study. BMC Pregnancy and Childbirth, 14, 207.CrossRefGoogle Scholar
  11. Hoffman, R. M., Black, V., Technau, K., Van der Merwe, K. J., Currier, J., Coovadia, A., et al. (2010). Effects of highly active antiretroviral therapy duration and regimen on risk for mother-to-child transmission of HIV in Johannesburg, South Africa. Journal of AIDS, 54, 35–41.PubMedGoogle Scholar
  12. Jeffery, B. S., Tsuari, M., Pistorius, L. R., Makin, J., & Pattinson, R. C. (2000). The impact of a pregnancy confirmation clinic on the commencement of antenatal care. South African Medical Journal, 90(2), 153–156.PubMedGoogle Scholar
  13. Kost, K., Landry, D. J., & Darroch, J. E. (1998). Predicting maternal behaviours during pregnancy. Does intention status matter? Family Planning Perspectives, 30(2), 79–88.CrossRefGoogle Scholar
  14. MacPhail, C., Pettifor, A. E., Pascoe, S., & Rees, H. V. (2007). Contraception use and pregnancy among 15–24 year old South African women: A nationally representative cross-sectional survey. BMC Medicine, 5, 31.CrossRefGoogle Scholar
  15. Massyn, N., Peer, N., Padarath, A., Barron, P., & Day, C. (2015). District Health Barometer 2014/2015. Durban: Health Systems Trust. Retrieved March 20, 2017, from
  16. Moodley, J. (Ed.), (2014). Saving Mothers 2011–2013: Sixth report on confidential enquiries into maternal deaths in South Africa, Short report. Pretoria: Department of Health. Retrieved March 20, 2017, from
  17. Morroni, C., & Moodley, J. (2006). The role of urine pregnancy testing in facilitating access to antenatal care and abortion services in South Africa: A cross-sectional study. BMC Pregnancy and Childbirth, 6, 26.CrossRefGoogle Scholar
  18. Myer, L., Zullier, R., Bekker, L. G., & Abrahms, E. (2012). Systemic delays in the initiation of antiretroviral therapy during pregnancy do not improve outcomes of HIV-positive mothers: A cohort study. BMC Pregnancy and Childbirth, 12, 94–94.CrossRefGoogle Scholar
  19. National Department of Health. (2014). National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults. Pretoria: National Department of Health. Retrieved March 20, 2017, from
  20. National Department of Health. (2015). The 2013 National Antenatal Sentinel HIV Prevalence Survey in South Africa. Pretoria: National Department of Health. Retrieved March 20, 2017, from
  21. Ngomane, S., & Mulaudzi, F. M. (2012). Indigenous beliefs and practices that influence the delayed attendance of antenatal clinics by women in the Bohlabelo district in Limpopo, South Africa. Midwifery, 28(1), 30–38.CrossRefGoogle Scholar
  22. Pattinson, R. (Ed.), (2012). Saving Mothers 2008–2010: Fifth report on the confidential enquiries into maternal deaths in South Africa. Pretoria: Department of Health. Retrieved March 20, 2017, from
  23. Schnippel, K., Mongwenyana, C., Long, L. C., & Larson, B. A. (2015). Delays, interruptions, and losses from prevention of mother-to-child transmission of HIV services during antenatal care in Johannesburg, South Africa: A cohort analysis. BMC Infectious Disease, 15, 46.CrossRefGoogle Scholar
  24. Schwartz, S. R., Rees, H., Mehta, S., Venter, W. D. F., Tah, T. E., & Black, V. (2012). High incidence of unplanned pregnancy after antiretroviral therapy initiation: Findings from a prospective cohort study in South Africa. PLoS ONE, 7(4), e36039.CrossRefGoogle Scholar
  25. Solarin, I., & Black, V. (2013). “They told me to come back”: Women’s antenatal care booking experience in inner-city Johannesburg. Maternal and Child Health Journal, 17(2), 359–367.CrossRefGoogle Scholar
  26. Wabiri, N., Chersich, M., Khangelani, Z., Blaauw, D., Goudge, J., & Dwane, N. (2013). Equity in maternal health in South Africa: Analysis of health services access and health status in a National Household Survey. PLoS ONE, 8(9), E73864.CrossRefGoogle Scholar
  27. Western Cape Government: Health. (2015a). Annual performance plan 2015/2016. 2015; Cape Town: Western Cape Health Department. Retrieved March 20, 2017, from
  28. Western Cape Government: Health. (2015b). Antenatal (pre-birth) health services. Cape Town: Western Cape Government: Health. Retrieved March 20, 2017, from
  29. World Health Organization. (2015). World Health Statistics. Geneva: World Health Organization. Retrieved March 20, 2017, from

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Research on Socio-Economic Policy (ReSEP), Department of EconomicsStellenbosch UniversityStellenboschSouth Africa
  2. 2.Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
  3. 3.Wits Reproductive Health and HIV InstituteUniversity of WitwatersrandJohannesburgSouth Africa

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