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Table 2 Contextual factors limiting ANC engagement for FSW in Port Elizabeth, South Africa

From: Antenatal care presentation and engagement in the context of sex work: exploring barriers to care for sex worker mothers in South Africa

Theme

Description of theme

Illustrative quotes

Fear

Many participants described fear as a barrier to ANC engagement. FSW reported fear of testing, fear of obtaining or disclosing test results, fear of needles, fear of stigma, and fear of nurse response which limited ANC engagement. Many women sought ANC services once and for a single purpose: to access a clinic card out of fear of not being seen or experiencing maltreatment during labor.

“P: I have a friend that is almost 9 months pregnant but doesn’t want to go to the clinic, she knows that she is positive but doesn’t want to go for the safety of the child, now she has things oozing out of her ears, rash breaking out, and her stomach changes oddly.

I: What is her reason for not wanting to go to the clinic?

P: I think it’s because she knows that she is positive and she doesn’t want us to know that she is positive but the people [man] she was sleeping with have passed on.” (Postpartum FSW, 2 children)

“P: They [ANC nurses] will attend to you, but they will punish you a bit [if you don’t have your clinic card], they will not attend to you immediately, they’ll ask you why you didn’t attend the clinic especially because when you are pregnant and HIV positive, you must go to the clinic in good time as to protect the baby … but you must at least have a clinic card, they don’t talk nor attend you when you don’t have a clinic card.” (Postpartum FSW, 2 children)

“P: They were going to ask why do I practice sex work while I am pregnant; I went there once, I didn’t go again, I just wanted the clinic card.

I: Do you get it when you go for ANC?

P: Yes, and if you do not have it then the ambulance will not take you.” (Postpartum FSW, 3 children)

Lack of familial or partner support

Some participants expressed experiencing a lack of support or fearing a lack of support from their family or partner due to pregnancy. This experience or feared experience delayed some FSW to seek care late into their pregnancies.

“I: What is the reason [you’ve never been to the hospital or the clinic]?

P: I just don’t feel like it because I’ve never been alone, all my pregnancies, the baby’s father was always with me. Now I must do everything alone, nah I don’t feel like it.” (Pregnant FSW, 3 children & 1 expecting)

“I: At what point in your pregnancy maybe how many weeks when you first went for ANC?

P: 7 months [laughs]

I: 7 months?!

P: They didn’t know because I was big so they no one knows if I’m pregnant just even now, no one knows; so they found out when I was 7 months and I was too scared to tell them at the time so they forced me to go to the clinic …

… I: How many times have you attended ANC?

P: It was 3 times then I went into labor [laughs]” (Pregnant FSW, 1 child & 1 expecting)

“P: I don’t want to lie, I changed my mind at the [clinic] door and I left …

I: … Let’s talk about your first visit, why did you turn around and leave?

P: I was scared.

I: What were you scared of?

P: What was ringing in my head was where [do] I even begin telling my father about this.” (Postpartum FSW, 1 child)

Alcohol use

Some participants expressed using alcohol during their pregnancy. Participants either directly or indirectly linked their limited ANC engagement or late ANC presentation to their alcohol use.

“I’m lazy to walk to ANC … When am I going to go get drunk if I’m going to be walking there?” (Postpartum FSW, 3 children)

“I drank a lot at that time, and when I was drunk I would pass out, so maybe I fell on my tummy [and caused a miscarriage], I don’t know; because I wasn’t stressed or anything.” (Pregnant FSW, expecting 1)

“I: What did they [ANC] say when you told them that you drink and you smoke?

P: They told me I should stop for the time being, and so I agreed while I was in front of them but I would buy alcohol on the weekends. I also continued smoking [cigarettes], and you need the courage to practice sex work, you can’t do that when you’re sober.” (Postpartum FSW, 1 child)

Substance Use

Many participants expressed using drugs during their pregnancy for assorted reasons including coping with previous traumatic experiences. Drugs varied from marijuana to heroine, Mandrax, ‘rock’, and ‘tick’ (crystal meth). Participants either directly or indirectly linked their limited ANC engagement or late ANC presentation to their drug use.

“I planned the whole thing to give birth [alone]. My water was breaking for about a week; the whole week my water was breaking. It was actually the first time in my life that my water broke by itself ever since I got the babies. So I didn’t have any pains, no labor pains I wasn’t even in pain. It’s the first time in my life that I didn’t have any pains. When a woman is pregnant and she gave birth she is supposed to have pains but I didn’t even have pains. I just pushed her out 2 times...The baby already came out, I held myself and the 9 months when I wasn’t bleeding like that sack of blood I coughed because it was nearly out already. So I just coughed to just bring it out. And I didn’t know there was still something [a second fetus] stuck inside me …

… When they [ANC staff] see me with drugs they take it but I did do it when they couldn’t see me but not a lot of times.” (Postpartum FSW, 7 children)

Perceptions of ANC

A few participants expressed perceptions that 4 or 5 months was the ideal/correct time to seek ANC. Certain months into pregnancy were seen as too early to seek ANC. Previous pregnancies and previous engagement in ANC limited or delayed current or subsequent pregnancy ANC care seeking.

“I: How far along [into] your pregnancy were you when you found out that you were pregnant?

P: 2 months with the 1st one.

I: And this one?

P: A month and a half.

I: So why did you wait so long to attend antenatal care?

P: I don’t know; I didn’t want to go at that time

I: Why not?

P: It’s just one of those feelings; I just felt I should go at 4 months.”

(Postpartum FSW, 2 children)

“You know when you’re not pregnant for the first time, you already know everything and then someone says what are you rushing for going to the clinic it’s still early to go and you would be waiting, so I figured let me go there … I was close to my due date.” (Postpartum FSW, 1 child)

Discontent with previous healthcare-related experience

Some participants expressed discontent with previous healthcare-related experiences; some reported this discontent limited their engagement in ANC services.

FSW described challenges of waiting in queues and maltreatment by providers as barriers to engagement. Maltreatment by providers as a result of sex work-related stigma was rarely described by participants. Women felt providers typically treated them the same as other women as FSW did not disclose their profession to ANC providers.

“I: When did you go for your first ANC?

P: At 6 months

I: Why did you start that late?

P: I was afraid to go there as I was insulted and hurt when I went there because of the comments that they make, she asked me how many children have I had, I told her the truth, so I told her this is my third child and she passed on a comment that you are so young to be on your third child. And even when she shouted at me, she did that in front of people and didn’t even close the door …

I: How many times did you go for ANC?

P: Once.

I: Why?

P: I just wanted to have the clinic card because I knew I was going to be insulted every time I go there.”

(Postpartum FSW, 3 children)

“P: Yes, they [ANC] explained everything, and they told me to come back after a certain time, but I didn’t.

I: Why?

P: I just didn’t want to go; going to the clinic is annoying.

I: What annoys you there?

P: They repeat the same thing over and over again.” (Postpartum FSW, 2 children)

Resources

Although resources were not a prominent driver limiting ANC engagement and we did not reach data saturation, it was expressed as a concern.

“P: I haven’t been to any … I went to the doctor last Friday but I haven’t been to the clinic because it’s far from me I hate walking, so it’s there in Provincial I can’t go there, they said I must come at 6 o’clock

I: In the morning?

P: Look at this, 6 o’clock and then walk all the way there, I don’t have fare money, I told myself I’m gonna go there or go to a doctor when I have money.” (Pregnant FSW, 1 child & 1 expecting)