Early enrolment for antenatal care (ANC) is an important strategy in attaining Sustainable Development Goal 3.1 of reducing maternal mortality rates to < 70 per 100 000 livebirths by 2030.^1,2 Sub-Saharan Africa (SSA) has the highest estimated maternal mortality ratio in the world, 542 reported deaths per 100 000 live births in 2017.^3,4 Preventable causes of maternal mortality in SSA such as anaemia, infections and hypertensive disorders can be identified and treated in the early antenatal period, thereby improving maternal and foetal outcomes.⁵ The World Health Organization (WHO) recommends that the first ANC visit take place within the first trimester (gestational age [GA] of < 12 weeks) with an additional seven visits.⁶ Antenatal care when provided in the first trimester, or no later than 16 weeks of pregnancy, enables timely intervention for pregnancy-related complications and can potentially prevent maternal and perinatal deaths from avoidable causes.^7,8,9

Despite the evidence on the benefits of early initiation of ANC, the uptake of early ANC in SSA remains poor.¹⁰ A recent systematic review reported that the proportion of pregnant women in SSA who initiated ANC early (less than 12 weeks of gestation) ranged from 14.5% in Mozambique to 47.3% in Cameroon to 68.6% in Liberia, with an overall rate of 38.0% (95% CI: 37.8–38.2).^11,12 Women with secondary or higher education, higher income households, close proximity to health facilities and exposure to media were more likely to initiate ANC early.¹¹ Past obstetric history is also a strong predictor of early initiation of ANC as women with previous abortions, caesarean sections and pregnancy-related complications are more likely to present early.¹³ Late presentation for ANC was more likely with women in rural areas and those who had unplanned pregnancies.^11,14

Apart from social and obstetric factors, the perceptions of women regarding ANC is an important determinant of the timing of ANC.⁵ Most women consider pregnancy as a normal part of life and not a health issue. There are also misconceptions about early ANC as many pregnant women perceive that early ANC visits are only for those with severe symptoms, such as vomiting, backache and headache and those with HIV.¹³ Previous positive pregnancy outcomes also undermine the value of early ANC in health facilities.⁵ Many pregnant women are often reportedly reluctant to start ANC because of long waiting times at clinics, overcrowded conditions and negative experiences of healthcare providers.^5,15

South Africa, a middle-income country in SSA, implemented the WHO ANC recommendations through the Basic Antenatal Care (BANC) policy in 2017 with results similar to other SSA countries.¹⁶ Despite the availability of free ANC, only 69.6% of pregnant women enroled within the first 20 weeks of gestation, ranging from 64.7% in KwaZulu-Natal to 86.1% in the Northern Cape.¹⁷ Recommendations from the recent Saving Mothers report to prevent maternal deaths included early identification of pre-existing medical conditions and hypertensive disorders in pregnancy.¹⁸ When BANC was implemented early, there was a significant improvement in the detection and management of hypertensive disorders in pregnancy.¹⁶ However, an audit of ANC records in KwaZulu-Natal identified several gaps in the implementation of BANC on the first ANC visit.¹⁹ This study evaluates the prevalence of late booking for ANC and audits the adherence to screening guidelines among pregnant women on their first visit at a primary health facility in KwaZulu-Natal, South Africa.

The services provided at the study facility to pregnant women on the first antenatal visit met expected standards. Almost all women were screened and managed for treatable conditions such as anaemia, HIV and syphilis on their first visit. However, in the majority of women, these conditions were detected after their first trimesters. Only 18% of pregnant women started ANC in the first trimester (12 weeks of gestation) and 20% booked within 20 weeks of gestation. The prevalence of late booking in this study was much higher than that reported in other studies in South Africa and SSA.²¹ No association could be found between the timing of booking and the age, marital status, education, employment status or parity. This differs from other studies where higher levels of education, partner support, office employment and null parity were all found associated with early booking.¹¹ One possible factor for late enrolment for ANC could be the rural residence of women who used ANC services. Studies in SSA report that women in rural locations were more likely to book late.¹⁴ Also, socio-cultural practices such as the use of traditional health practitioners and traditional medicines may delay attendance at antenatal clinics by pregnant women.²²

The GA of pregnant women when initiating ANC was estimated using the SFH or the last normal menstrual period. At the time of the study, there were no ultrasound services at primary care clinics. Hence, women could only access an ultrasound in the private sector or at regional hospitals. The WHO recommends that all pregnant women have one antenatal ultrasound before 24 weeks of pregnancy.²³ Early ultrasound provides accurate GA and important information about pregnancy that could encourage women to access ANC services earlier. However, in resource-constrained settings in SSA, there is a scarcity of trained ultrasound technicians and limited ultrasound services. Several studies have investigated how training of primary care providers in point-of-care ultrasound (POCUS) influences the quality and uptake of ANC services.²⁴ In Uganda, facilities that offered routine antenatal ultrasound services reported a 32% increase in the first ANC attendance compared to other facilities.²⁵ One solution in resource-limited settings may be task shifting. Training of doctors, nurses and midwives in POCUS is effective.^26,27

Late presentation for ANC posed another challenge in the study population where the prevalence of HIV was (40.8%). Fortunately, screening and treatment at the antenatal clinic were successful in meeting the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of ensuring that more than 95% of ANC attendees knew their HIV status and more than 95% of ANC attendees diagnosed with HIV received ART.²⁸ However, this study did not examine the viral load of pregnant women on their first visits. Other possible factors for late ANC presentation such as partner support, perceptions of clinic services and health provider behaviour were not evaluated in the current study. Late presentation for ANC was highlighted in the Saving Mothers report as a modifiable risk factor for adverse perinatal and maternal outcomes. This study did not report on the outcome of the pregnancies of the participants. However, there is a need for greater community awareness of the benefits of early initiation of ANC services.

The standard of ANC services at midwife-run unit met national standards. However, low uptake of early ANC services is of concern, especially in high HIV-prevalence settings. Increased community awareness and training of primary health care providers in POCUS may improve early uptake of ANC services.