Ngxongo Thembelihle Sylvia Patience*, Sibiya Maureen Nokuthula and Gwele Nomthandazo Sylvia
Durban University of Technology Department of Nursing, Educational Qualifications D: Nursing, General Nurse and midwife, South Africa
Received date: 10/11/2016; Accepted date: 16/12/2016; Published date: 23/12/2016
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Purpose: The purpose of the study was to describe the experiences and views of the pregnant women regarding the antenatal care services received in the Primary Health Care clinics that were implementing the Basic Antenatal Care (BANC) approach. The BANC approach is listed as one of the priority interventions for reducing maternal and child mortality in South Africa and is used in the public health institutions to provide health care services to the pregnant women. Methods: A descriptive qualitative design was used to conduct the study in the 12 primary health care clinics that were providing antenatal care services and implementing the BANC approach in eThekwini district, KwaZulu-Natal The study took place seven years following the introduction of the BANC approach. Data were collected using semistructured interviews conducted with 54 pregnant women from October 2014 to March 2015. Data were analysed using Tesch’s method of data analysis. Findings: Although some participants highlighted how the BANC approach had brought about improvement in the quality of care, other participants were concerned regarding the waiting times, the intervals between antenatal care visits, integration of antenatal care with other primary health care services, limited space at the clinics and attitudes and performance of clinic staff. Conclusion: In the current study, the participants shared their experiences and views regarding the antenatal care services that were provided using the BANC approach. Most of the situations that the participants had encountered and their views regarding Antenatal care services highlighted specific areas of the BANC approach that needed attention. Guided by this, the researchers were able to provide the recommendations from the study that would assist to improve implementation of the BANC approach. These included special emphasis on compliance to service delivery guidelines and protocols by antenatal health care providers, availability of the clinic staff members who had been trained and oriented towards the implementation of the BANC approach, integration of services and reviewing human and material resources for adequacy when new programs are introduced.
Antenatal care, Approach, Basic antenatal care, Implementation, Pregnancy, Perceptions, Primary health care.
The focused antenatal care (FANC) approach is a goal-oriented antenatal care (ANC) approach that was recommended by researchers during 2001 and adopted by the World Health Organisation (WHO) in 2002 following realisation that traditional ANC programmes that were meant for developed countries, were poorly implemented and largely ineffective when used in developing countries . Subsequently, the FANC approach was adopted by South Africa to replace the traditional ANC approach that was previously used in the country following the realisation by the National Department of Health (NDoH) that the traditional ANC approach was not working well for South Africa. South Africa modified the FANC approach to suit the South African circumstances and referred to it as the Basic Antenatal Care (BANC) approach [2,3].
In 2007 the National Department of health gave instructions that all health care institution that were providing antenatal care services were to implement the BANC approach by 2008 . Therefore, the study took place seven years following the introduction of the BANC approach. According to Ngxongo and Sibiya, (69% n=27) of the 57 PHC clinics in eThekwini District were implementing the BANC approach during 2011 . The outline of the BANC approach as presented in the Principles of Good Care and Guidelines depicts several variations between the BANC and the traditional ANC approach . These include: the timing of the first and follow up visits, the total number of visits, the interval between visits, and the structure of visits. The traditional approach does not provide for the use of checklist, whereas the BANC approach strongly recommends the use of the two checklists . The differences in these two approaches are presented in Table 1.
|ELEMENT||Traditional approach recommended by SANC||BANC approach|
|First visit||First trimester||Before 20 weeks|
|Follow up||Monthly till 28 week 2 weekly till 38 week Weekly till delivery||20 weeks 26 weeks 32 weeks 38 weeks|
|Interval between follow up visits||Depends upon period of gestation||6 weeks|
|Structure of visits||Routine||Goal oriented|
|Clinic checklist||Not used||Two checklists first/follow up|
|Last Visit at PHC level||40 weeks refer at 41||38 weeks refer at 40|
|Routine Tests||RPR, Hb and RH||RPR, Hb, RH, HIV|
|Routine preventative therapy||Iron Tetanus toxoid||Iron Tetanus toxoid and calcium|
|Total visits||12 or more||4-5|
Table 1: Comparison between BANC and traditional approaches to ANC.
It is reported that more than 90% of women in South Africa have access to ANC services and that 83.5% of the women who died during pregnancy or childbirth during the 2008-2010 triennium attended ANC [2,6]. The question is “Why do women continue to die despite ANC attendance if ANC is the key to the reduction of maternal deaths? Can these deaths be attributed to poor quality ANC services or is ANC not the key as advocated by most authors?” The purpose of the study was to explore and describe the experiences and views of the pregnant women regarding the ANC services received from the PHC clinics that were implementing the BANC approach. Gaining the perspective of the pregnant women who are the consumers of the ANC service, assisted the researchers to identify the areas of the BANC approach that could be used to strengthen the implementation of this approach and to establish a client focussed approach to service delivery.
Describe ANC as an umbrella term that is used to describe health care and procedures that are carried out to and for the pregnant women . It is the health care that is rendered to the pregnant women throughout pregnancy until the child’s birth and is aimed at detecting already existing problems and/or problems that can develop during pregnancy affecting the pregnant woman and/or her unborn child . According to Snyman the quality of health care that a pregnant woman receives during ANC has an impact on the health of the woman and on the outcome of pregnancy . Oakland attests that, quality is meeting the customer’s requirements and that it is often used to signify excellence of a product or service .
If acceptance is one of the three sensitising concepts that influence implementation then the pregnant women’s experiences and perceptions of the ANC services could have an influence on the success of the ANC programme . Kruger and Steenkamp support this as they state that perception of a customer is one of the measures for quality . Furthermore, the views of Iyaniwura and Yussuf that understanding the preferences of people and the various factors that influence their preferences, could help to implement strategies that would improve the utilisation of skilled obstetric services and thereby reduce unnecessary loss of lives . The researchers could not find any studies done in South Africa on the views of women regarding ANC and therefore were unable to establish what is already known in the country about the subject. This is supported by Gregory et al.  who wrote that, ANC user’s perceptions of quality are not known in African communities. However, several studies done in other African Countries such as Cameroon, Ghana, Nigeria and others highlight that the user’s perception of quality of ANC services crucially impacts continuity of use of these services and hence pregnancy outcome [14,15]. Furthermore, Gregory et al.  argue that although using patient views to evaluate health care has been criticized for that the views of pregnant women concerning their care is generally positive simple because they tend to be uncritical of healthcare, accepting whatever care they receive as appropriate, the patient views provide an insight to the care provided and the system as a whole especially because the quality of care provided is one of the contributory factors to the women’s choice of health centre. On the other hand, Emelumadu et al. , state that women utilising maternal health care services are increasingly becoming aware and desirous of the need to improve quality of the services provided to them. The NDoH  identified BANC as an ideal approach to ensure that quality and effective ANC is provided. Snyman  agrees that the implementation of BANC is a positive measure to improve the quality of ANC in PHC clinics and that effective and quality ANC could assist South Africa to address the problem of constantly increasing maternal and perinatal mortalities.
A descriptive qualitative research design was used to conduct the study. The choice of using a qualitative design was influenced by the ability of this research design to provide descriptions of how people experience a given research issue and to provide information about the ‘human’ side of an issue . A descriptive design was chosen to aid in providing an in-depth description of participants’ experiences in a narrative type .
The study was conducted in the eThekwini district, one of the eleven districts of the KZN province in South Africa. Twelve PHC clinics that were providing the ANC services and were implementing the BANC approach were purposively selected. The participants were systematically selected by including every fifth pregnant woman who was attending for ANC services in the sampled PHC clinics from October 2013 till March 2014. All women who were approached voluntarily agreed to take part in the study. The women with high risk factors and/or conditions requiring urgent referral to hospitals were excluded to avoid delays in their referral.
Individual semi-structured interviews that were guided by an interview guide were conducted by the principal researcher in either English or IsiZulu depending on the choice of the participants (Appendices 1 and 2). The interview guide consisted of two sections. Section A was used to identify the participants and to gather two distinguishing characteristics regarding the participants; whether they had been pregnant before and whether they attended ANC during their previous pregnancies. Section B was an interview guide with one grand tour and several guided tour questions. Question six and seven applied only to the participants who had been pregnant before and had attended ANC during their previous pregnancies.
The principle of data saturation which was monitored per PHC clinic was used to determine the number of interviews that were conducted in each PHC clinic. The researcher remained in one PHC clinic; conducted and analysed all interviews until data saturation was reached and confirmed before moving to the next PHC clinic. Data saturation in one PHC was reached after an average of three interviews were conducted. One to two more interviews were conducted to confirm data saturation in each PHC clinic. A total of 54 interviews were conducted for the whole study.
Data analysis was performed simultaneously with data collection in order to detect data saturation. Data were organised and stored using the ATLAS TI program and analysed using Tesch’s open coding approach . The ATLAS TI program allowed the researcher to capture, organise and store data into categories and sub-categories, themes and sub-themes and to assign codes. This arrangement of data facilitated understanding, interpretation and creation of the meaning of the qualitative data. Each day after conducting the interviews, the researcher picked up and listened to one interview at a time from the audiotapes again and again and also read and re-read the corresponding field notes to get a sense of the whole data. Some ideas were jotted down as they emerged. The transcribed data was read and re-read until the researcher fully understood the meaning of the data. The transcribed data were sorted out and coded in order to allow for organising it into themes and sub-themes. Important quotations from the participants’ responses were identified and in vivo coding was used in order to present the true experiences by the interviewees.
Ethical principles included getting ethical approval from the university’s Institutional Research Ethics Committee (REC 27/13) and getting permission to conduct the study from the provincial and district offices of the KZN Department of Health and the eThekwini municipality. The researcher ensured that the three ethical principles, on which the standards of ethical conduct in research are based, (beneficence, respect for human dignity and justice) as described by Polit and Beck were adhered to. Procedural and interpretive rigour was ensured through precise documentation of all steps and processes taken to conduct the study and how the decisions were reached till the establishment of an audit trail . The researcher used a voice recorder to ensure that data were accurately recorded and representative of the data as a whole. In an attempt to ensure confirmability, the researcher ensured honest reflectivity, remained neutral and did not allow her personal feelings to crowd her responsibilities as a researcher.
Characteristics of the Participants
The study did not consider participant’s demographic information such as age, parity, employment status, etc. However, two characteristics of the participants were deemed important for the study. These were whether the woman had been pregnant before and whether she had attended antenatal care. It was expected that the participants who had been pregnant before and had attended ANC would have noticed the change from the traditional ANC to the BANC approach which would confirm the implementation of the BANC approach and give their views/opinion about the changes if they had observed any. The study findings on these two characteristics were quantified in order to give meaning to the study. There were (56%, n=30) participants who had been pregnant before out of the 54 participants who were interviewed. All of them (100%, n=30) had attended ANC during their previous pregnancies. A total of (67%, n=20) participants had noticed some changes in the way ANC services were provided compared to the previous and (70%, n=14) of these were happy about the changes. Table 2 present the breakdown of this information (Table 2).
|Total interviewed||Pregnant before||Attended ANC||Aware of change||Happy about change|
|54 (100%)||30 (56%)||30 (100%)||20 (67%)||14 (70%)|
Table 2: Characteristics of the study participants.
Themes and Sub-Themes
A total of six themes and several sub-themes emerged. These are presented in Table 3. The majority of the themes were presented by the participants as the situations that they had personally experienced but also presented by other participants as their views/perceptions about ANC services even though they had not personally experienced the situations. The women’s view regarding almost all the themes were similar in most clinics except the comments about the structure and organisation of clinics and attitude and performance of nurses which were each mentioned in two of the twelve PHC clinics included in the study (Table 3).
|1. Change from the traditional ANC to BANC approach||1.1 Awareness of the change 1.2 Opinion about the change|
|2. Availability of and access to ANC services||2.1 Antenatal care services not provided daily 2.2 Clinics not accepting all pregnant women who present for ANC 2.3 First visit ANC not provided on the first day the woman presents at the clinic or on the first day pregnancy is diagnosed 2.4 Combining the first and repeat visit ANC clients on the same day 2.5 Antenatal care not provided according to specification in the maternity case record|
|3. Clinic organization and management||3.1 Structure and organisation of the clinic 3.2 Supply of medication 3.3 Combining ANC clients with other clients|
|4. Involvement of the pregnant women||4.1 Involvement in own care 4.2 Scheduling of follow-up visits 4.3 Developing pregnancy management plans|
|5. Communication||5.1 Quality of communication 5.2 Accuracy and consistency of information|
|6. Satisfaction of the pregnant women with the ANC Services||6.1 Attitude of nurses 6.2 Performance of the nurses 6.3 Waiting time at the clinic 6.4 Time spent with the midwife|
Table 3: Themes and sub-themes that emerged from the study.
Theme 1: Change from the traditional to basic antenatal care approach
Sub-theme 1.1: Awareness of the change:
Some of the study participants were aware of the change while others were not. This was evident in the following excerpts. “...Nothing much has changed. Spacing of clinic visits is still the same. It is four weeks apart at the beginning and closer towards the end” (Participant 5 from MS1). In contrary to this other participant stated: “...When I attended for my two elder babies we were not compelled to do HIV testing but during this pregnancy it was compulsory to do an HIV test. This is very helpful because they also have treatment for you in case you test positive so that you stay healthy and do not infect the baby” (Participant 5 from PW2).
Sub-theme 1.2: Opinion about the change
Theme 2: Availability of and access to antenatal care services
The participants differed in their opinion regarding the change with some being happy and others not happy about the change. This was evident in the following statements: “...We now spend a long time at the clinic they do so many things unlike before but I am happy because it is for the good of my baby,” (Participant 5 from PN1). “...I feel the current approach is much better. We get more information and I feel the baby will be more protected” (Participant 2 from PW2). Another participant stated: “…I feel the dates are spaced too far apart…In the past we used to attend more frequent especially when you get closer to delivery. I have noticed with this pregnancy that I have been attending the same way from the time I started the clinic I am scarred it is not safe for the baby” (Participant 5 from PW2).
Sub theme 2.1: Antenatal care services not provided daily
The participants stated that ANC services were not provided every day. “...I know if you come on any other day other than your scheduled clinic day you are not accepted. They will not help you unless you come on a Tuesday which is the day for the pregnant women (Participant 2 from PS2).
Sub theme 2.2: Clinics not accepting all pregnant women who present for antenatal care
It was evident from the statement made by the participants that not all the clients who presented at the PHC clinics for ANC were accepted. “...When I came for the first time I did not get any help. I was told by the reception staff that the clinic was full; I should come back another day...” (Participant 1 from MN2).
Sub theme 2.3: First visit antenatal care not provided on the first day the woman presents at the clinic or on the first day pregnancy is diagnosed
The participants commented that the first visit consultation was not conducted on the first day the women presents at the clinic or on the first day pregnancy is diagnosed but they were made to come back another day. Some participants indicated that they did not return to the clinics as advised. “...I came, I was one month pregnant and I was sick. They told me it was too early I must come back later in pregnancy. I decided to stay at home and only came back to the clinic when I was six months pregnant…” (Participant 2 from MS1).
Sub theme 2.4: Combining the first and repeat visit ANC clients on the same day
It appeared that different practices regarding scheduling of clinic days for first and repeat visits existed in the PHC clinics. In some PHC clinics the participants highlighted that the clinics had set days for the first and different ones for the repeat visit ANC clients. Clients who were not aware of this information came on wrong days and were not accepted. “…I came on Thursday and was sent back home without being attended to and told Thursday was the day for the first visits only that caused me a lot of inconvenience because I had taken a day off from work because we are told health services should be available everyday” (Participant 1 from MN2). In other PHC clinics the participants mentioned that the clinic days for the first and repeat ANC visits were the same. Some of the clients were not in favour of this practice of servicing the first and repeat visit ANC clients on the same day. “... Mixing of new and old clients is a problem. It takes the whole day being in the clinic.” (Participant 1 from PN2).
Sub theme 2.5: Antenatal care not provided according to specification in the maternity case record
Some of the participants verbalised their concerns that the nurses were not carrying out some of the procedures and test that according to the maternity case record they were supposed to done and they were not given an explanation about why these were not done. “…I am worried that some of the things that are indicated on the card were not done for me and nobody told me why. Even when I asked, for example they only gave me injection on the shoulder once yet other women had the same injection three times.” (Participant 2 from PW1). I was hoping they will do a pap smear for me as we are always advised over the radio to have it done…also it is written in our card that it should be done; mine has not been done. They just tell you long stories that you fail to understand if you enquire why” (Participant 5 from SW1).
Theme 3: Clinic organization and management
The participants had varying experiences linked to how the clinics were organised and managed. These were in relation to:
Sub-theme 3.1: Structure and organisation of the clinic
The participants commented that because they were mixed with other clients there was not enough space at the PHC clinics to accommodate all of them. “...This clinic is too small has limited rooms, no privacy, consultation is done in the same room as observations. Also there are not enough chairs for us to sit” (Participant 4 from PS1). “…Last time I was made to spend the whole day at the clinic because I missed my turn. I did not hear when my name was called because we were sitting outside; there was no place to sit inside the clinic. I was made to join the end of the queue. The waiting area is too small and is usually very full (Participant 4 from MW1).
Sub-theme 3.2: Supply of medication
The participants commented about dispensing of medications about which they were concerned that they were not issued with sufficient supplies. “...They make six-week interval for clinic visits but do not give enough medication to last you for that long and if you come back before your next appointment date they do not agree to attend to you so most of the time you have no treatment…I feel it is not safe” (Participant 4 from PS1).
Sub-theme 3. 3: Combining ANC clients with other clients
The participants commented that being mixed with sick clients led to long waiting times at the clinic. “...There is long delay and long queues. They make us to wait with sick patients…We are made to stand for long hours in a queue yet we are pregnant. It takes hours before you can see the sister” (Participant 4 from MN2).
Theme 4: Involvement of the pregnant women
Sub-theme 4.1: Involvement in own care
Some participants stated they were involved and others verbalised that they were not involved. “...We cannot expect to be here every day. We are taught how to take care of ourselves so we need to learn and follow the orders” (Participant 5 from PW1). In contrary other client stated “...I am not involved but I am satisfied with not being involved because the nurses know what is best for me” (Participant 3 from PN2).
Sub theme 4.2: Scheduling of Follow-up visits
Some participants indicated that the follow-up visits were scheduled based on their convenience while others stated that this was not happening. “…I requested to come back on Thursdays because that is the day when I am off at work they agreed” (Participant 3 from MW1). “...sometimes the date that they give me is not convenient for me but I can’t tell them because they will be angry with me. So I try to do as they please they give me the date that suit them and I am forced to abide” (Participant 3 from MN1).
Sub theme 4.3: Drawing of plans of management
It was stated by the majority of the participants that the plans for pregnancy management were mostly not compiled in consultation with the pregnant women. However different women had differing views regarding this. Some stated: ‘…I am not involved but I am not worried because I know the sisters know what is best for me and my child” (Participant 5 from MN1). Others complained: “...I listen to them and follow what they ask me to do. But they do not get me involved and I feel it is not fair because I am an adult and have my rights and choices not fair to be always instructed” (Participant 5 from PW1).
Theme 5: Communication
Sub theme 5.1: Quality of communication
Some of the participants were satisfied with the communication stating it was good. Other participants verbalised that they had not been given complete information about the ANC service and other relevant issues regarding their care. “…I know the clinic is open all the time even on Sunday but I am not sure whether they attend to pregnant women on Sundays or not; no one tells you these things you just learn them along the way” (Participant 3 from PW1). In contrary other participants stated: “...The sisters explain what they are doing; they are very approachable and good” (Participant 4 from MN2).
Sub theme 5.2: Accuracy and consistency of information
The participants were also concerned about the inconsistency of information that they were given at the PHC clinics. Their concerns were verbalised in the following statement: “...In the classes you are told one thing but they end up doing something different. For an example they will say if you come to the clinic early you will be able to go home early, yet when you are early they make you to wait whist they are doing other things. This makes planning very difficult; I am working and I do not know whether to take a half or full day leave for coming to the clinic. It is so frustrating” (Participant 3 from PN1).
Theme 6: Satisfaction of the pregnant women with the antenatal care services
Sub-theme 6.1: Attitude of nurses
Several participants verbalised their concerns regarding the attitude of the nurses. An example is one participant who stated: “...When you come with a problem they call you to where they are sitting as a group and they ridicule you; scold you in front of others and sometimes they will first just sit and look at you as if you are stupid” (Participant 3 from PW2). However, other participants appraise the nurses: “...Most people usually say nurses are rude as a result I was scared to come to the clinic. They have been very patient with me and they tried to understand my situation even though I was late” (Participant 3 from MWI).
Sub-theme 6.2: Performance of the nurses
While other participants praised the nurses for doing a good job, other participants were not satisfied with the way some of the nurses attended to them. These differing opinions were noted in the following statements: “...Very good care; the sisters are amazing very patient even when they are checking the baby‘s heart they take their time.” (Participant 3 from PS1). “…There are so many nurses here but most of the time only one sees to us and you do not see what the others are doing you see them having private conversations and the next thing they tell us they are going for a break.” (Participant 4 from MW1).
Sub-theme 6.3: Waiting time at the clinic
The participants commented about long waiting times in the PHC clinics that were implementing the BANC approach. The concerns about the waiting times were expressed as follows: “…We were here from 07h00 till 16h00 they do everything well but they are too slow with this new approach one patient seat with a sister for almost the whole hour. (Participant 3 from MN1).
Sub-theme 6.4: Time spent with the midwife’
The participants also verbalised their concern about the amount of time that they spent with the midwife at the clinic and how soon they were able to see the midwives stating that much time was spent with other categories of clinic staff members. One of the participant stated: “...Also there is a long delay before you see the sister most of the time is spent with the other staff and too little time with the sister” (Participant 3 from PN2).
Several participants were unaware of the change from the old traditional ANC to the new BANC approach. The two possible reasons for the clients to be unaware of the changes in the system include that either they are unaware of the change because the PHC clinics did not implement the changes or that the clients might have overlooked the changes suggested . Previous research findings indicate that not all PHC clinics had successfully implemented the BANC approach and that a number of PHC clinics who had initially attempted implementation failed to sustain and reverted to the traditional ANC approach due to the challenges regarding the implementation of the BANC approach . The current study did nor explore why the participants were not aware of the change.
The participants commented that the ANC services were not available every day of the week in the PHC clinics. The South African National Department of Health recommends that an attempt should be made to ensure that healthcare services are available every hour and day of the week . The working hours should also be convenient for pregnant women because inconvenient operating time is one of the barriers to accessing services [22,23].
It was evident from the comments by the participants that a number of PHC clinics were not providing ANC services everyday when the clinic was open. Instead, a specific day was set aside for ANC services. The provision of ANC service as a vertical program interferes with availability and accessibility of services to the community every day of the week and prevents access to health services to every client that visits the clinic .
Some participants reported that they were not accepted at the clinic because they were either first or repeat visits and had come on the wrong day. Sending these clients home without attending to them created missed opportunities because some of them did not return to the clinic on the day that they were advised to come back. Missed opportunities have been identified as one of the contributory causes to maternal deaths [6,24,25]. The practice of not accepting all clients that presents at the clinic could potentially increase the number of clients who never initiate ANC, booked late and/or attend ANC clinics poorly all of which have been identified as contributing to maternal and perinatal deaths or untoward pregnancy outcomes . The participants commented about inadequate supplies of medication. Inadequate supplies of medicines defeat the purpose of ANC part of which is to provide excellent opportunities to reach pregnant women with prophylactic medications, vaccinations, diagnosis and treatment of infectious diseases .
The participants were concerned that there was not enough space in the clinics to accommodate all the clients. South Africa, in its strategies towards ensuring good quality care for patients, include that the waiting areas for the patients should be convenient and provide adequate shelter and seating for patients . It is true that with the increased number of services there is an obvious increase in the number of clients. Thus, the need that reconstruction of clinic spaces be considered at the inception of the new model to ensure individualised consultations, privacy and confidentiality, and to permit care providers to see each client in a defined location at each visit .
In the current study there were several concerns about the waiting times which, according to the interviewed participants, were too long. Sokhela attest to that the waiting time at clinics might influence the clients’ level of satisfaction with healthcare services because the shorter the time that the clients wait at the PHC clinic, the more satisfied they are with the services received . Very long waiting times at facilities sometimes result in patients being turned away as staff might not always cope with the large numbers that turn up each day . The waiting times should be monitored and anticipated waiting times should be communicated to the clients so that they become aware of this and are able to plan for the wait . In the current study the participants indicated that although they understood that the long waiting times were sometimes beyond the control of the clinics’ staff members, they would prefer being informed about the expected waiting times. Long waiting times can be a cause of clients’ missing appointments in future .
According to the participants, provision of the first ANC consultation on the day pregnancy was confirmed or the first time the woman attended the clinic did not happen most of the time. Not providing the first ANC consultation on the day when the pregnancy is confirmed or at the very first clinic attendance, creates missed opportunities and could also be a cause for late ANC booking by some women. The recommendations by most authors is for the first visit consultation to happen as soon as the pregnancy is confirmed ideally before the end of the first trimester [6,31,32].
While several participants verbalised their satisfaction with the ANC services, it could be concluded from the comments from other participant that they were not satisfied with some aspects of the ANC services. Client satisfaction is considered as one of the desired outcomes of healthcare and it is directly related with the utilisation of healthcare services .
The comments by the participants regarding the performance of the clinic staff and their satisfaction with the ANC services was that some activities were not done as expected or as stipulated in the maternity case record. According to Gross et al. , inadequate and inappropriate care leads to a lack of confidence in the system and low utilisation of these services. These authors advise that national guidelines should serve as a “gold standard” to assess healthcare workers’ observed performance during patient consultations.
The participants commented about communication between them and the clinics’ staff members which according to most participants was poor. According to Oakland  excellent communication between customers and suppliers is the key to total quality performance. ANC visits in many Sub Saharan African countries provide opportunities to reach pregnant women with messages and interventions . Individual interactions between the pregnant women and the health care providers are an essential component of ANC visits because the provider and the woman should talk about important issues affecting the woman’s health, her pregnancy and the plans for childbirth and the newborn period . The role played by maternal education in influencing the utilisation of ANC content is articulated by Bbaale who states that, education and counselling as well as individual counselling programme calls for a fundamental change in the attitudes, the skills and qualities required from ANC personnel .
The participants reported that the follow-up appointments were not scheduled based on their’ convenience, they were not involved in their own care and the plans of pregnancy management were not drawn up in consultation with them. This was identified as one aspect of positive culture that needed to be strengthened in the PHC clinics. Anderson et al  state that cultural issues relating to language and staff insensitivity are important factors that could deter some women from accessing ANC early and regularly.
Participation is enhanced when information is shared with the stakeholders, their views are listened to and they are involved in processes of development planning and decision-making  and this contributes to their capacity-building and, ultimately, empowers them to initiate, manage and control their own self-development.
The following recommendations were made: All health care workers involved in the implementation of the BANC approach should comply with relevant policies, service delivery guidelines and protocols to ensure safe and standardized practice. Planning for health care services should include strategies to facilitate accessibility and availability of ANC services every day of the week at every health facility where women present for both first and repeat ANC visits. Human and material resources should be reviewed for adequacy when new programs are introduced. A broader study involving nurses from the clinics and pregnant women from PHC clinics that adhered to the old traditional approach to ANC should be conducted in order to gain a broader perspective of how the BANC approach is being implemented.
Data collection did not include gathering information from the clinics’ staff members who were involved in the implementation of the BANC approach and pregnant women from ANC clinics that adhered to the old traditional approach. These sources of information could have enriched the study’s findings.
While several participants perceived the ANC that was provided in the PHC clinics that were implementing the BANC approach to be good and appropriate, other participants raised several concerns about this service. Some of the pregnant women were not even aware that there has been any change from the traditional to the BANC approach. These and several other factors identified from how the pregnant women perceived the BANC approach are included in the BANC principles of good care and guidelines as the processes that should be adhered to when providing the ANC services in the PHC clinics.
The authors wish to acknowledge Durban University of Technology as the academic institution that provided ethical clearance for the study to be conducted, eThekwini Municipality and the KZN Provincial and eThekwini District Departments of Health for granting the permission for the study to be conducted in eThekwini PHC clinics.
Santrust, Nrf and Fundisa.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.