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