Beyond Attendance: Drivers of Delayed and Discontinued Antenatal Care in Karisimbi Health Zone, Eastern DRC; a Triangulated Qualitative Study
Abstract:
In unstable urban environments such as Karisimbi in the eastern of the Democratic Republic of Congo (DRC), timely access and completion of antenatal care (ANC) remains challenging. To explore how women, community leaders, and health providers in Karisimbi Health Zone understand the delayed and incomplete ANC use. We conducted a triangulated qualitative study. 64 participants were purposively enrolled: 51 women delivered in the previous 12 months, 7 healthcare providers, 5 religious leaders, and 1 community leader. Data was collected through focal group discussion and in-depth interviews in Swahili and French depending on the preference of the participants. Data was recording, transcribed, translated in English and imported in Nvivo15 for thematic framework analysis and triangulation. Six themes were identified: ANC as a valued but not always urgent service, cumulative cost of seeking care, livelihood and waiting time, social judgment, service experience, and household and community support. Delayed and incomplete ANC use was shaped by interacting with financial, social, and health-system constraints, including care-related costs and income loss; low perceived need without symptoms; fear of social judgment, provider reception, and trust; and limited household or community support. Improving uptake requires integrated action on affordability, quality of care, trust, and community support.References:
[1]. Tunçalp Ö, Pena-Rosas JP, Lawrie T,
Bucagu M, Oladapo O, Portela A, et al. WHO recommendations on antenatal care for a positive
pregnancy experience—going beyond survival. BJOG. 2017;124(6):860-2. https://doi.org/10.1111/1471-0528.14599
[2]. World Health Organization. WHO
recommendations on antenatal care for a positive pregnancy experience. Geneva:
World Health Organization; 2016. Available from: https://iris.who.int/handle/10665/250796
[3]. Abdiwali SA, Adesina OA, Fekadu GA,
Geta TG. Barriers and
facilitators to antenatal care services utilisation in Somaliland: a
qualitative study. BMJ Open. 2024;14(11):e085073. https://doi.org/10.1136/bmjopen-2024-085073
[4]. Gage A, Conrad M, Knight M,
Banke-Thomas A, Bintz C, Bienhoff K, et al. Measuring antenatal care timing and
content across 131 low-income and middle-income countries, 1995-2023: a
systematic analysis of trends. Lancet Glob Health. 2026;14(5):e702-13. https://doi.org/10.1016/S2214-109X(26)00010-0
[5]. World Health Organization. Trends in
maternal mortality 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank
Group and UNDESA/Population Division. Geneva: World Health Organization; 2025.
Available from: https://www.who.int/publications/i/item/9789240108462
[6]. Howell EA, Brown H, Brumley J,
Bryant AS, Caughey AB, Cornell AM, et al. Reduction of peripartum racial and
ethnic disparities: a conceptual framework and maternal safety consensus
bundle. J Midwifery Womens Health. 2018;63(3):366-76. https://doi.org/10.1111/jmwh.12756
[7]. Montalmant KE, Ettinger AK. The
racial disparities in maternal mortality and impact of structural racism and
implicit racial bias on pregnant Black women: a review of the literature. J
Racial Ethn Health Disparities. 2024;11(6):3658-77. https://doi.org/10.1007/s40615-023-01816-x
[8]. Okonji OC, Nzoputam CI,
Ekholuenetale M, Okonji EF, Wegbom AI, Edet CK. Differentials in maternal
mortality pattern in Sub-Saharan Africa countries: evidence from demographic
and health survey data. Women. 2023;3(1):175-88. https://doi.org/10.3390/women3010014
[9]. Tran P, Jreij B, Sistani F, Shaya
FT. Disparities in maternal mortality. J Clin Transl Sci. 2023;7(1):e192. https://doi.org/10.1017/cts.2023.520
[10]. Lee H, Park SJ, Ndombi GO, Nam EW.
Community-based maternal and child health project on 4+ antenatal care in the
Democratic Republic of Congo: a difference-in-differences analysis. Reprod
Health. 2019;16:157. https://doi.org/10.1186/s12978-019-0819-1
[11]. Ameyaw EK, Baatiema L, Naawa A,
Odame F, Koramah D, Arthur-Holmes F, et al. Quality of antenatal care in 13
Sub-Saharan African countries in the SDG era: evidence from demographic and
health surveys. BMC Pregnancy Childbirth. 2024;24:303. https://doi.org/10.1186/s12884-024-06459-2
[12]. Habte A, Hailegebreal S, Simegn AE.
Predictors of maternal health services uptake in West African region: a
multilevel multinomial regression analysis of demographic health survey
reports. Reprod Health. 2024;21(1):45. https://doi.org/10.1186/s12978-024-01782-5
[13]. Aboagye RG, Osborne A, Anyasodor AE,
Yikindi SV, Adnani QES, Ahinkorah BO. Utilisation of eight or more antenatal
care visits and its associated socio-economic-related inequalities in
Sub-Saharan Africa: a decomposition analysis. PLoS One. 2025;20(3):e0312412. https://doi.org/10.1371/journal.pone.0312412
[14]. United Nations Office for the
Coordination of Humanitarian Affairs. Democratic Republic of the Congo. 2026.
Available from: https://www.unocha.org/democratic-republic-congo
[15]. Levesque JF, Harris MF, Russell G.
Patient-centred access to health care: conceptualising access at the interface
of health systems and populations. Int J Equity Health. 2013;12:18. https://doi.org/10.1186/1475-9276-12-18
[16]. Andersen RM. Revisiting the
behavioral model and access to medical care: does it matter? J Health Soc
Behav. 1995;36(1):1-10.
[17]. Lattof SR, Tunçalp Ö, Moran AC, Bucagu
M, Chou D, Diaz T, et al. Developing measures for WHO recommendations on antenatal care for a
positive pregnancy experience: a conceptual framework and scoping review. BMJ
Open. 2019;9(4):e024130. https://doi.org/10.1136/bmjopen-2018-024130
[18]. Noble H, Heale R. Triangulation in
research, with examples. Evid Based Nurs. 2019;22(3):67-8. https://doi.org/10.1136/ebnurs-2019-103145
[19]. Munyabarenzi GN, Masemo ZB.
Entreprendre à Goma: analyse des dynamiques entrepreneuriales et des écarts
sectoriels entre ambitions et contraintes. Ann Univ Goma. 2025;15(2). Available from: https://pugoma.com/index.php/UNIGOM/article/view/534
[20]. International Committee of the Red
Cross. DRC: Health-care system on verge of collapse. 2025. Available from: https://www.icrc.org/en/news-release/drc-health-care-system-verge-collapse-north-south-kivu
[21]. Alem AZ, Yeshaw Y, Liyew AM, Tesema
GA, Alamneh TS, Worku MG, et al. Timely initiation of antenatal care and its
associated factors among pregnant women in Sub-Saharan Africa: a multicountry
analysis of demographic and health surveys. PLoS One. 2022;17(1):e0262411. https://doi.org/10.1371/journal.pone.0262411
[22]. Okedo-Alex IN, Akamike IC,
Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in
Sub-Saharan Africa: a systematic review. 2019. https://doi.org/10.1136/bmjopen-2019-031890
[23]. Suandi D, Williams P, Bhattacharya
S. Does involving male partners in antenatal care improve healthcare
utilisation? Systematic review and meta-analysis of the published literature
from low- and middle-income countries. Int Health. 2020;12(5):484-98. https://doi.org/10.1093/inthealth/ihz073
[24]. Nkrumah DO, Ebenezer B, Baah A. Too
young to be seen? Disparities in antenatal care use between teen and adult
mothers in Nigeria. J Public Health Epidemiol. 2025;17(4):130-9. https://doi.org/10.5897/JPHE2025.1544
[25]. Ndatinya GI, Ikuzwe RS, Nkurunziza
EC, Taremwa FB, Keza LU, Ishimwe P, et al. Exploring the lived experiences of
adolescent mothers and the factors affecting their access to antenatal care
services in Rwanda. 2025. https://doi.org/10.21203/rs.3.rs-6276235/v1
[26]. Roed MB, Engebretsen IMS, Mangeni R,
Namata I. Women's experiences of maternal and newborn health care services and
support systems in Buikwe District, Uganda: a qualitative study. PLoS One.
2021;16(12):e0261414. https://doi.org/10.1371/journal.pone.0261414
[27]. Jayakody C, Malalgoda C, Amaratunga D,
Haigh R, Liyanage C, Witt E, et al. Approaches to strengthen the social cohesion between
displaced and host communities. Sustainability. 2022;14(6):3413. https://doi.org/10.3390/su14063413
[28]. Lucas B. Impacts of internally displaced populations on their host communities. Brighton: Institute of Development Studies; 2024. https://doi.org/10.19088/K4DD.2024.028
