Trustworthiness.

The researchers followed the trustworthiness principles of credibility, confirmability, dependability, and transferability to ensure the validity and rigor of the present investigation [18]. Only participants who met the research inclusion requirements were selected to be in the study to maintain credibility. Member checking was achieved through calling some participants to verify findings their feedback was incorporated into the final analysis to strengthen the trustworthiness of the results. Consistency was achieved between the two investigators, who analysed the data independently by cross-checking codes and themes during the process. A third member of the research team assisted in resolving discrepancies to reach a consensus, further supporting the inter-related reliability. Reflexivity was used throughout the process, beginning with the research team’s expertise and experiences in midwifery and nursing. To increase credibility and integrity, the research team had regular discussions and iterative reflections to verify that interpretations remained grounded in the data.

Stigma dynamics.

Pregnant women reported that stigma is one of the barriers to attending ANC visits. This stigma is associated with an unplanned or unwanted pregnancy or early weaning of the young infant from breastfeeding due to a short interval between births.

The stigma attached to unintended pregnancies. Adolescent girls and women with unintended pregnancies are often stigmatized in society, causing delays or preventing the attendance of ANC. In this study, the participants faced shame and feared being laughed at while attending ANC visits. Some participants reported a delay in ANC visits due to the shame and embarrassment of others seeing them during pregnancy.

For example, one participant reported what happened to a colleague: “By attending ANC, everyone will know that she is pregnant, and she will be ashamed. An unmarried young girl will give birth at her family’s house and then fear being stigmatized and dismissed by the family”. (HC2-P4) In a similar context, another participant explained that adolescents first hide pregnancies from their parents and other family members to avoid stigma in their families. “... you hide the pregnancy from your parents… and then they will know…at about the time of delivery”. (HC3-P7)

Stigma attached to multiparity and early weaning. Many women who had previously given birth faced barriers to accessing ANC; they may attend only one time and then give birth. Women who gave birth when their youngest child was still an infant were among those who avoided ANC for fear of stigma and humiliation from within the community due to a very short interval between pregnancies and early weaning. Furthermore, women having many births may become depressed, and this condition may lead them to be late or not attend ANC, and then there is the added stress of where she gives birth. For example, a participant mentioned:

“My neighbour became pregnant when her youngest child was only nine months old. She delayed her first antenatal care visit to hide her pregnancy and ultimately gave birth during her second visit, fearing that people would judge her for getting pregnant again so soon”.(HC2- P6) Another participant recalled that women from large families might avoid attending antenatal care services to escape negative comments and judgment from members of their community. For example, one said, “This pregnant woman is often giving birth as if she has a funded project!” (HC1-P1)

Women who weaned their children early [before two years] hide their pregnancies to avoid negative comments from colleagues. In this context, a participant stated: “When people see that you got pregnant while you have a very young child, they start talking about your ability to care for all of these children”.(HC2- P6)

Socio-economic and cultural beliefs.

Some participants reported that delaying ANC attendance was caused by socio-economic and cultural beliefs that place women at the center of domestic chores, cultural misbeliefs, intergenerational behaviours, and social context.

Gender roles. Participants described that Rwandan women are the heart of the family. They must juggle multiple responsibilities that could hinder their individual ability to attend an ANC visit. In addition to the domestic chores, many women have to dig daily for food on the farm to support the family. They fetch water for drinking and washing, raise goats, and feed cattle, among their many activities. Not only they are the homemakers and raising and educating children, but women may also have an outside job, such as a farmer. For various reasons, it can be difficult for those with many children or women who work away from home to attend the ANC. For instance, one participant noted:

“When you have school children, you are in charge of their books, clothes, and all other necessities for them to pursue their studies. Therefore, sometimes women miss out on reaching the health center or nearest hospital for an ANC visit”. (HC4-P3)

Many rural residents lack the adequate time and energy to think about their unborn babies and decide not to travel to health facilities due to their multiple responsibilities and the overwhelming number of activities.

“Men treat women as if they are not human beings. They use us for heavy work, exhaustive work. However, when you are pregnant, you can say that you are tired and have no energy. However, after delivery, they do not care about you again”. (HC2- P1)

Economic situation: A woman’s ability to initiate ANC was highly dependent on community-based health insurance (CBHI), which covers the cost of pregnancy care. If women do not have CBHI, they often delay ANC until the third trimester or fail to attend due to financial constraints. One participant noted, “... she comes late due to the struggle to find money to pay for health insurance”.(HC4-P2) Another participant recalled, “In my community… there was a woman in the lowest economic level… she has eight children and finds it … very hard to afford CBHI”.(HC2- P6) Women had financial problems that hindered ANC attendance, not only CBHI payments but also the money to buy an ANC card that is needed to write information, including the next appointment, as the following participant reported: “I had a challenge of making my ANC appointment due to lack of money to buy an ANC card. I waited for it”.(HC1- P6)

Cultural misbelief: Some women do not attend ANC on time or at all due to cultural misbeliefs, traditions, or ignorance. Some participants recounted how others hid their pregnancies to protect themselves from being targeted by witchcraft, which was a significant barrier to attending in the first trimester. Some mentioned the presence of harmful beliefs and superstitions in their community, including fears that such practices could hinder the growth of the fetus or cause complications during labor and delivery. “Women then perceive a need to be careful so that no one knows that they opt for antenatal care”.(HC2- P4) Similarly, another participant added,

“I wanted to come early but thought I might meet someone I know. We don’t want people from our village to see us coming to ANC early in pregnancy, as they can harm our pregnancy… and this is why we are late… we are hiding from those people”. (HC4-P4).

Some women were noted to follow some ancient practices to overcome these misconceptions, which delay their ANC attendance until after the first trimester or go to a traditional healer for informal support. For example, a participant said: “... I know some women who meet liars advocating for traditional healers and their medicine. They go there instead of the health centers where they would get the correct information, assessments, and treatment”.(HC4-P3).

Influence of intergenerational behaviours. Some compare this generation to their mothers who delivered at home; if there was no problem with the pregnancy, they could wait until the baby was at term. One participant recalled: “My mother-in-law told me she came [to the health center] at eight months and no one blamed her. Therefore, there was no reason to rush my husband, and that the husband [her son] will arrange an antenatal visit when he has time “.(HC3-P7). Similarly, another participant confirmed this: “… A husband might say, ‘There is still time; don’t rush me. In the past, pregnant women gave birth at home without attending antenatal care at health facilities, and they still had healthy children. (HC3- P5) Women who attended early ANC were perceived in the community to need more visits due to pregnancy complications.

Social context. Given the social nature of pregnancy, women like to look smart for their ANC visits and may wait until their husbands have bought them new clothes. A participant explained: “A woman may feel like she has nothing to wear, which would make her ask: ‘How am I going to an ANC visit while other mothers have new clothes?’ Sometimes she stays at home”. (HC1 P3)

In addition, some participants reported having difficulty attending the initial visit with their husbands. The women explained that sometimes it is challenging when their husbands work far away and only return home on weekends. If the husband is absent, the wife has to go to the local leader to request permission to attend ANC without him. Consequently, some women may delay attending, or others may prefer traditional healers. One participant reported,

“If you cannot get to the health center with your husband for the right information, assessment, and the appropriate treatment…, you may meet a pregnant woman talking about a traditional healer who helped her,and you may opt to go to there instead….”.(HC4-P3)

Lack of partner support.

Participants reported that ANC visits were delayed due to a lack of support from their partners due to family conflict, domestic violence, conflicting priorities, and fear of HIV testing. Some women prefer to be alone without communicating with others, depending on their situation.

Family conflicts. Women reported that misunderstandings and conflicts with their husbands can delay ANC visits. If the couple has conflict, women may hide their pregnancy from their husband and, therefore, would not be accompanied to their first ANC visit. They may also hide any evidence of attending care. A participant mentioned, “These women... may hide the ANC card that they received at the health facility or even hide their pregnancy from their husbands”.(HC2- P2)

Sometimes, these conflicts lead to domestic violence, which results in delays or avoidance of ANC. Some participants were afraid of their husband’s reactions to an unwanted pregnancy, particularly those on a family planning method to prevent pregnancy. They explained that they were unsure how they got pregnant while using a contraceptive method, although they may not have used it properly, such as missing an oral contraceptive one day.

Furthermore, a husband may ask his wife, where did that pregnancy come from? when the husband had previously sent his wife to the family planning clinic. If the method fails, the husband may become angry at his wife and state, I am not the father of this baby. The wife may then decide not to attend ANC and instead deliver at home. In some extreme cases, the husband may accuse the wife of adultery, and the pregnant woman will decide not to attend ANC services. One participant asked, “How can I seek ANC when my husband denies the pregnancy? Who will be the father of the child on the birth registration? I may decide not to attend the health center”(HC1 P3).

Partners’ competing priorities. Participants reported that some partners may not prioritize ANC and avoid responsibilities for the family expenses. The partner might be the only one with an income and may buy personal items instead of paying for his wife’s ANC expenses. For example, “A wife may talk about going for an ANC visit, and the husband says, ‘he doesn’t have the money and what he has is reserved for beer’”. It is difficult for some women to raise a family and pay ANC-related costs such as the CBHI, transportation, and admission fees. Consequently, they prioritize their children’s needs over their own. One participant described the following situation:

“You suspect that your colleague is seven to eight months pregnant. When you ask why she came late to the ANC... she replies, ‘I am jobless. I don’t have CBHI, even for my other children. How can I use all that money for an unborn child while his siblings are hungry?’”. (HC2- P5)

Fear of HIV testing among partners. A husband often refused to accompany his wife to the initial ANC visit as they feared the HIV test and a positive result. “They told us to bring our husbands on the first visit because some women test positive for HIV/AIDS. When he is not there, there is a conflict. Some husbands refused to come, asking, ‘How can I handle my wife if I test positive?’”.(HC1-P1)

Challenges to and at the healthcare setting.

Participants reported several challenges to attending and adhering to the ANC appointment setting, including the long distance to the facility, scattered health services at the site, long wait times, and negative attitudes and actions of healthcare providers.

Distance to the health facility: Many women reported that living far away and lacking access to transportation, such as a motorcycle or bicycle, deterred women from attending ANC visits. Some women arrived late and tired after traveling long distances on foot and climbing mountains to reach the health facility. Knowing that they had to do the same journey home after a day at the health facility made matters worse. This exhausting situation led many women to attend ANC only once during their pregnancy. For example, a participant noted, “... if I were pregnant and lived far away in a small village near the river (lake), plus the weakness of carrying this pregnancy… I would not be able to attend all ANC visits”.(HC2-P4) In this similar context, another participant confirmed this by saying: “There is an issue of long trips and bad roads that make it not easy to even use motorcycles for transport”.(HC4-P2).

Scattered services at the health center. Pregnant women reported frustration in accessing the services they needed at the facility, such as the laboratory, restrooms, and other essential services. Feeling weak and hungry while trying to locate the various buildings made this even more challenging. For example, one participant recounted, “Let me tell you another challenge that delays people in the health center... the long walk to the bathrooms”.(HC2-P2). In a similar vein, another participant added:

“When a woman is pregnant, she may not have anything to eat, and she may be weak. They make you go to various services in different buildings until you become exhausted and frustrated. Additionally, there are no toilets nearby”.(HC1-P3)

The attitudes and actions of healthcare providers. The attendance of pregnant women at ANC visits was negatively affected by nurses’ and midwives’ attitudes and actions. Participants criticized some of the HCP’s behaviours, such as shouting, scolding, pettiness, and talking to them as if they were children. For instance, one participant explained what happened to her colleague:

“The husband had not shown up, and so the nurse did not communicate with the pregnant woman; she told her nothing. The woman said, ‘Please forgive me and provide antenatal care to me’. Instead, the nurse chased her away. The pregnant women left dissatisfied and discouraged [without receiving ANC]. The pregnant woman replied, ‘If I am back after my pregnancy has grown, you will shout at me that I am late’”. (HC1-P3)

In some cases, the long waiting time in health centres can be attributed to misconduct or disorganization by HCPs. Some HCPs were observed making lengthy phone calls during work hours, causing delays in care and likely discouraging pregnant women from returning for follow-up visits as the following woman recalled:

“Since these phones came out (smartphones), the person responsible for providing care may take calls and delay care for some hours… while we wait for her help. You feel embarrassed, but you must calm down and wait for her! That makes us not want to return”. (HC1-P4)

A woman sent home without HCP support may turn to traditional healers. Pregnant women can become discouraged when faced with disrespectful care and share that experience with others, as displayed in the following excerpt.

“The healthcare provider may talk badly to a pregnant woman by saying, ‘Come back tomorrow because you paid without asking me.’ The pregnant woman may never return and will tell her story to a friend… or her neighbour!”(HC3-P5)