Interpretation
All predictors were significantly associated with late antenatal care initiation which confirms inequalities shown in previous studies.9-13 Also in line with other studies, the results from our hypothetical intervention suggest that the inequality in antenatal care initiation could be reduced if the pregnancy would be timely recognized.18, 19 The majority (>80%) of our participants recognized the pregnancy within 6 weeks. To detect a pregnancy, most people use home tests.37 Home pregnancy tests are easily available in drug stores, pharmacies, grocery stores and online retailers. Still, ensuring timely recognition may be challenging due to several reasons. Firstly, some people may experience an access barrier to home pregnancy tests, potentially due to costs to purchase them, or being able to get to the store.37 Secondly, even though most manufacturers claim that home pregnancy tests are 99% reliable, in practice this is lower due to user errors, or testing too early.38 Thirdly, recognizing a pregnancy requires knowledge of the reproductive system, which may be more limited in women with lower socioeconomic position.39-41 Finally, some people may feel ambivalent about a potential pregnancy, and wait with testing because they fear the result or want time to think about what to do if pregnant.37 In a recent pilot study, people with increased risk of delayed pregnancy recognition (i.e., young people, people with irregular menses, and those who have recently had a second trimester induced abortion) were provided free home pregnancy tests. The results of this study suggested that self-testing was feasible and acceptable and many participants described to continue to test after the study.43 Another study showed that young age, being single, unintended pregnancy, lower education and lower income were associated with a later pregnancy recognition.42Together, these and our results suggest that providing information and free home pregnancy tests to a specific group of people with an increased risk of delayed pregnancy recognition, may help to reduce inequalities in the timing of antenatal care initiation.
The results of our study showed that early pregnancy recognition could partly reduce inequalities in antenatal care initiation, suggesting that other mechanisms may also occur. Based on analyses in the same dataset as the current study, Choté et al. (2011) focused on ethnic inequalities in early antenatal care initiation and reported that mothers with migration background were relatively more likely to be less educated, less likely to be employed, and relatively more likely to be multiparous. All of these factors were also predictors for a later antenatal care initiation as identified in our study. Additional adjustment for enabling factors (educational level and employment), predisposing factors (age, parity, relationship status, pregnancy intention), and behavioral factors (intake folic acid, maternal smoking, alcohol use) showed a reduction in the ethnic inequalities in antenatal care initiation.23 Together with our findings, this suggests that antenatal care initiation is affected by a complex interplay of many different factors in which causal factors are hard to distinguish from correlational factors when using regular regression methods. Other explanations underlying inequalities mostly come from qualitative studies. The results of these studies suggested that some pregnant women postponed their first appointment because they felt healthy, had other responsibilities or did not feel it was urgent.19, 44 This is in line with research from non-Western countries showing that some people do not perceive a pregnancy as a health condition.45 In addition, some pregnant women wanted to avoid antenatal care, because they were afraid of judgement or stigma. This occurred notably for young people and for those with ambivalent feelings toward the pregnancy,19two predictors that were also identified in our study. Finally, having difficulties with navigating antenatal healthcare, in particular when encountering a language barrier, may also lead to delayed access. This hypothesis is supported by our finding that those with reduced Dutch language skills entered antenatal care 1.3 weeks later than those with sufficient Dutch language skills.44