A qualitative study exploring barriers to adequate uptake of antenatal care in pre-conflict Syria: Implications for post conflict interventions addressing the demand-side barriers

Abstract Background Until the onset of the conflict in 2011, Syria has made noticeable progress in reducing maternal mortality and morbidity. Despite the improvement in antenatal care (ANC) coverage and patterns of use, analyses of national surveys demonstrated wide regional variations in uptake, timing and number of visits even after controlling for women’s socio-demographic characteristics. The main aim of this study is to highlight the barriers to women’s adequate uptake of ANC that existed in Syria pre-conflict, comparing two governorates: Latakia, where uptake of antenatal care was high and Aleppo, where uptake of ANC was low. Methods This qualitative study carried out 30 in-depth interviews with (18–45 year old) pregnant women from Aleppo and Latakia and conducted 15 participant observation sessions in different types of health facilities that provide ANC. Participants were purposively recruited from randomly selected rural and urban, public and private health facilities, and independent midwives’ clinics, with onward sampling of women who did not attend ANC. Transcripts and fieldnotes were analyzed using the framework approach. Results Inadequate uptake of ANC in Aleppo included not attending ANC, discontinuing care or seeking care with unqualified providers. Three themes emerged that explained the disparities in uptake of ANC in Aleppo compared to Latakia: women’s assessment of their own health status in pregnancy, women’s evaluation of the risks of seeking ANC, and women’s appraisal of the value of different types of service providers. These evaluations were connected with the availability, accessibility (geographical and financial) and acceptability of ANC services however women’s views were shaped by the knowledge and prevailing opinions in their families and community. Conclusions Findings are utilized to discuss low-cost interventions addressing the disparities in uptake of ANC. Interventions should be aimed at increasing vulnerable women’s capacity and capabilities to make informed decisions. Women’s groups that foster education and empowerment and which have been effective in other low resource settings are worth exploring in Syria. Increased use of mobile phones and social media platforms that were not present pre-conflict, suggests mobile health technologies (mHealth) may present efficient platforms to deliver these interventions.