'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries

In high-resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated. To identify the factors affecting access to antenatal care for marginalised pregnant women living in developed countries. We included qualitative studies from developed countries published in English language journals (1980-2007). Qualitative studies exploring the views of marginalised women living in developed countries who either failed to attend for any antenatal care or did so late or irregularly. Eight studies fulfilled the selection criteria and were synthesised in accord with the techniques derived from meta-ethnography. Initial access is influenced by late pregnancy recognition and subsequent denial or acceptance. Continuing access appears to depend on a strategy of weighing up and balancing out of the perceived gains and losses. Personal resources in terms of time, money and social support are considered alongside service provision issues including the perceived quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect. A nonthreatening, nonjudgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake.