Perceived knowledge of ANC and its importance.

All participants were aware of the importance of ANC, but the perceived level of importance varied. Women recognised that it was a “human being inside” (P11) them and care was necessary to “prevent any dangers” (P13). Some participants had limited knowledge of why ANC was important: “I don’t know what would happen to the baby if I didn’t come to the appointments” (P6) Some referred only to basic functions of appointments, such as monitoring the growth of the baby and the “day the baby is due” (P7), rather than the identification of complications. In contrast, others had a better understanding and were able to provide examples of what may happen if they did not attend appointments: “for example abortion, prematurity” (P3).

The majority of primiparous women identified that it was especially important for them to gain knowledge from ANC: “because I am a mother for the first time I didn’t have enough knowledge, or no knowledge” of pregnancy (P12). Another said that, because she was “very young and the baby was [her] first” (P8), she knew it was more important to engage in ANC. One woman explained that she only understood the need to attend through information provided “at the beginning I didn’t think that it was so important, but when I had the antenatal classes the obstetricians said that it’s very important to have the appointments” (P19). Multiparous women did not think that ANC was any less important than primiparous women. All participants, regardless of parity, expressed a desire to gain knowledge, and wanted to receive “more appointments to have more knowledge of the care of the baby” (P5). Few women acknowledged that the ANC was for both themselves and the baby, referring only to the health of the baby: “If I didn’t have these appointments the baby could have illnesses” (P3).

Appointments and information received.

Satisfaction with appointments:

Several women explained that they “would have liked to receive more appointments” (P5). Participants usually received one appointment per month, followed by weekly appointments after eight months’ gestation. Based on this schedule, most women would only have been able to attend more if they had presented earlier or had not experienced barriers, such as employment. One participant, although wanting more appointments, “agreed with the number of appointments” (P12) received, acknowledging that you may only receive limited appointments through the clinics. Another participant “only wanted to receive good care” (P3), giving greater importance to the quality of the care and information received during appointments, rather than quantity.

Amount of information received:

The women wanted to “have more knowledge” to allow for “thorough care of the baby” (P7). Most interviewees reported receiving “a lot of information”, but there were still things that they thought important to know. For example, “the sex of the baby” (P2), “more knowledge about the development of the baby” (P9) and “to teach me how to give birth, how to look after myself…what is good and bad for the pregnancy” (P15). Some also wanted to have “more scans” (P17). In antenatal classes, women learnt “how to care for the pregnancy” (P19). Without this, one woman “didn’t know how to have the baby” (P16). Others believed it to be the best aspect of their care and “started to want to have the baby” (P20).

Women reported a lack of consistency in the provision of information. During the antenatal period, some participants reported they “sometimes felt that [they] didn’t receive enough information” (P17), especially if seen by impatient HCPs who “just wanted to see [them] quickly without answering any questions [they] asked” (P19). Some believed that the “nurses…didn’t want to give enough information” (P6). One participant reflected that “I didn’t know why [they] didn’t give me enough information. I don’t know if I had to ask for the information” (P15). Similarly, there appeared to be a perceived lack of consistency between pregnancies: “The information for each baby was different” (P10). The same participant reflected “that each woman receives different information according to their ideas and beliefs” (P10). An HCP might have provided different information to women of different cultural backgrounds attending appointments at the same healthcare facility. In contrast however, some participants felt that overall “the staff who worked here, they gave me enough information, they explained things very well” (P16).

Interaction with HCPs.

Rapport and the patient-practitioner relationship:

Throughout interviews, women appeared to make no distinction between the words obstetrician, doctor and nurse. This might have been a lack of awareness of the differing roles of professionals within the team, simply viewing all members of staff as caregivers.

All women reported receiving appointments from obstetricians throughout their ANC. Of the women interviewed, the majority received their ANC in local primary healthcare facilities through their SIS. These women were “attended by several obstetricians” (P17) throughout their appointments, resulting in a lack of continuity in their care. The remainder of participants received care from only one HCP, attending a different healthcare facility such as a private hospital funded via other social security schemes. They commented on the quality of care experienced in these facilities: “the person who cared for me was very patient and had a great responsibility” (P16). Women reported hurried appointments with obstetricians who “just wanted to see [them] very quickly” (P19). One participant recalled unpleasant experiences when “doctors are sometimes not kind, they’re a little…rough” (P5). It was reported that “it was good to feel that the obstetricians were interested in the care of the baby” (P14). One participant reflected that poor experiences of care were as a result of the patients themselves and not the staff: “Some people say they aren’t attended with patience here. I think that these people are also not patient people…sometimes they have a bad attitude towards the staff who work here” (P17).

Effects of HCP Gender:

Most of the participants commented that they would “feel strange and uncomfortable” (P20) if they were seen by a male HCP, regardless of whether they had experienced this. One woman justified this, saying “I didn’t like it when the male obstetricians touched my stomach, or when they had to look at my parts” (P15). Another “received bad appointments from the male nurses” and believed “the man…wasn’t patient” (P2). Many participants expressed the preference for a female HCP: “I wanted to receive the appointments from a female” (P2). This view was not universal however; with some reporting that they “felt good about care from males and females” (P13).

Perceived barriers, motivators and enablers to accessing ANC.

Barriers to accessing care:

The majority of participants could identify no direct barriers to accessing care. However, this might be a reflection of the women recruited, since in this study all had attended ANC. Of those able to provide reasons for non-attendance, the main barrier was employment: “Sometimes I had to ask for a permit from the principal of the school [where I worked] to come here for my appointment…sometimes he didn’t want to give me a permit” (P12). As previously reported, other women did not have as many appointments as they would have liked because of their work: “I had to work and didn’t have time to come here for my appointments” (P14). One working woman attended a hospital where this was not a barrier, since she was able to have her appointments in the evenings (P5). However, the majority of women who worked reported difficulty in arranging appointments at convenient times. A few women referred to the weather as a factor preventing attendance, since downpours and flooding are common in Iquitos: “sometimes when it rained a lot I couldn’t go to my appointments” (P7).

Most women reported long waiting times at the healthcare centres, which might have acted as an unconscious barrier to accessing care: “I had to wait two hours or more” (P14). Despite care being free, and intended cover of transport costs by the SIS [9], lack of money was still a barrier for some women: “Sometimes I didn’t have enough money to pay for the transport to get to my appointments” (P7). Furthermore, some participants felt that having to book their own appointments was awkward and they saw this as a high level of responsibility, which may have acted as a barrier: “I have a responsibility to book an appointment again” (P5).

Motivators to accessing care:

All of the women interviewed expressed a motivation to attend appointments: “I never missed any appointments. I believe that the appointments in my pregnancy are very important” (P20). They reflected that “a woman who doesn’t visit the doctor or nurse, they don’t know how their baby is growing” (P7). One participant explained that “I didn’t want to lose my baby by my own responsibility” (P16). Another interviewee initially had no motivation to attend, but at her antenatal classes “the obstetricians said that it’s very important to have the appointments and come here for care” (P19).

Enablers to accessing care:

There were a number of enablers for the women accessing care. Most women had a SIS [9], meaning “there weren’t any costs” (P3) when attending appointments. Some women voluntarily paid for further ultrasounds at separate clinics. One participant “had some problems with [her] SIS” (P2), so was unable to access ANC until eight months’ gestation: “they told me that my SIS was not from here and that I had to make a change in order to be served”. (P2)

The women reported the ease of getting to, and booking, appointments. Most of the healthcare facilities care for “people who live close” (P11) and “it’s very easy to get an appointment” (P13). The day when the women were required to next attend the clinic was written on their patient-held antenatal card at the end of their consultation: “the nurse has to give me an exact date to return again” (P6). Occasionally appointments were booked by the obstetrician, but usually the patient called on the given day, or day before, to arrange the appointment.

Expectations and preferences for labour and delivery.

Preference of location:

The majority of participants recognised that giving birth in designated healthcare facilities carried fewer risks than homebirths and acknowledged the need for skilled professionals: “having babies at home is prone to complications and is dangerous” (P2) and “they don’t have enough knowledge at homes compared to the nurses and doctors” (P18).

A couple of women preferred home births: “For me it’s better to have babies at home because I can be with my family…the family give me good care” (P6), whereas in facilities any relatives have to wait outside the delivery room. One woman had previously given birth at home with the assistance of her neighbour (P2). Another believed that “it’s the same to have the baby at home as it is in the hospital. The one difference, after giving birth to the babies the nurses clean your parts” (P13). In one instance the main barrier to giving birth at home was the family’s concern for safety: “my mum didn’t want this baby born at home because she was afraid for me” (P2). One woman recognised the limitations of deliveries in health centres and that, for this reason, many women were referred to hospitals for caesareans: “I couldn’t have the baby here because the staff who work here don’t attend to women who are going to have babies by caesarean. They don’t have enough instruments” (P4).

Some women expressed a preference to giving birth in hospitals over healthcare centres following past negative experiences: “I didn’t want to have more babies there, because I felt that I wasn’t cared for very well because the obstetricians weren’t good and patient with me …I decided to have the next baby at the hospital. There I felt happier to be cared for” (P18).

Expectations of labour and delivery:

The majority of women expected a natural birth, without complications: “I expected to have the baby without problems” (P15), “I wanted to have it naturally without caesarean” (P19). They believed that “to have babies by caesarean is complicated” (P7). Women thought they had “learnt how to give birth to the baby” (P20) and “knew all the changes [they were] going to feel” (P16) during labour.

Women’s expectations of the pain they might experience varied, with multiparous women referring to the pain experienced previously during labour. Of the primiparous women, some believed that they “wouldn’t feel a lot of pain” (P4), while another woman commented that “many people that I met would tell me all the time that I would feel a lot of pain, and that I would need to tolerate it” (P17). Some participants expressed a desire to use pain relief, as they believed it would be effective. The remaining women preferred to “have babies with all the pain that you get” (P13), believing that “nothing would relieve their pain” (P13).

Actual experiences of labour and delivery.

Ease of accessing care:

All women interviewed gave birth in either Iquitos Hospital or the healthcare centre. This centre did not have the capacity to conduct caesarean sections. Women made their own way to the healthcare centre upon going into labour, where 24-hour care was available. Since the women were local to the centre, this care was easy to access: “when I felt the pain I came here immediately to receive the necessary care…I came here by motorbike” (P6). However, initially some were turned away and told to return later: “I was already in pain, I felt symptoms. They made me go back to my house” (P15). Any women attending the centre for a delivery, who were assessed as needing an emergency caesarean section, were transferred by provided transport to the local hospital: “I had to have a caesarean at Iquitos Hospital and I was transported there” (P17). Caesarean sections were planned in only a few of the women, where expected complications of labour had already been elicited and surgical delivery had been deemed to be the safest option. These women made their own way to their local hospital.

In one instance, a woman “wasn’t seen quickly” so her mother decided that she “had to have the baby at Iquitos hospital because there they see you more quickly” (P19). Some women experienced difficulties when their babies required further attention, providing a barrier to access to care in this period: “I stayed at iquitos hospital for one week, but the baby stayed there for two weeks…I didn’t have enough money to keep coming back home and going to the hospital” (P17).

Perceptions of labour and delivery:

The majority of women reflected that their experience of labour was not as expected: “when the doctor told me that I was going to be operated [caesarean section] on, I felt afraid because I thought that something could happen to the baby” (P9). As a result, it appeared that the women were left feeling dissatisfied with their IPC. There was one participant who reported being unaffected by her unexpected method of delivery: “I thought that it was great…because it was a new experience to have a baby by caesarean” (P7). Another woman retrospectively agreed, after having to be transferred to Iquitos Hospital for an unplanned caesarean section: “births are better…at the hospital because I think the staff have enough instruments to help them”. (P9)

A lot of the women reported that they were unhappy with the care received. They reported that they lacked attention and the nurses were “so rude with the patients” (P6), especially prior to birth: “My waters broke and I lost blood…but the obstetricians didn’t pay attention to me” (P15). One participant reflected that, while struggling following birth, “all the nurses were very impatient with me and just told me to breastfeed the baby, nothing else” (P11). Another woman however, reported that it was different after she had given birth compared to during her delivery: “I felt I got more attention from the nurses…asking if I felt good and didn’t have any problems” (P14). In healthcare centres specifically, some women felt that they should have been being attended to, but “the obstetrician was seeing other females” (P3). Women “had to wait a long time to be attended” (P4) and one woman initially attended a healthcare centre for delivery but was taken to hospital by her mother as she “wasn’t seen quickly” (P19). One woman reflected that “the care would be better if staff who worked here…would attend people not just when it is so important and an emergency.” (P14) Those attended at the hospitals reported being cared for by multiple staff during their labour, sometimes up to “ten people” (P1), whereas those delivering at healthcare centres frequently reported the presence of only two or three members of staff.

Comfort during labour and delivery:

Most women reported the area in which they gave birth was clean. However, this was not universal. One woman explained that “it was dirty” and in “the bed where [she] lay, [she] felt something bite” (P6). Another explained that she perceived that her “cut was infected because [she] had a bad caesarean” where “the doctors used dirty instruments” (P8). Only one woman reported the use of pain relief when giving birth naturally at a healthcare centre (P3). Another woman “was afraid to ask for pain relief, because the nurses sometimes don’t have patience” (P6). Many women reported feeling “very afraid” (P1) and “anxious” (P2) during the birth, “in case there was something wrong with the baby”. In contrast, some commented that they “felt relaxed” (P2) and “very excited” (P5). Most women, regardless of their thoughts and feelings at the time, “just wanted to have the baby here” (P2).

Effects of HCP Gender:

Largely, women seemed more content receiving care from males during IPC than ANC: “I didn’t feel afraid [of being attended to by males] because I just wanted to have the baby” (P5). One participant was still not happy to be attended to by a male but due to the unpredictable nature of delivery this was unavoidable: “I didn’t feel good, I felt I wasn’t comfortable receiving care from the man…I couldn’t do anything because I was going to have a baby” (P10).