Why do at-risk mothers fail to reach referral level? Barriers beyond distance and cost.

In southern Tanzania, few high-risk pregnancies are channeled through antenatal care to the referral level. We studied the influences that make pregnant women heed or reject referral advice. Semi-structured interviews with sixty mothers-to-be, twenty-six health workers and six key-informants to identify barriers to use of referral level were conducted. Expert-defined risk-status was found to have little influence on a woman's decision to seek hospital care. Besides well known geographical and financial barriers, we found that pregnant women have different perceptions and interpretations of danger signs. Furthermore, rural women avoid the hospital because they fear discrimination. We conclude that a more individualised antenatal consultation could be provided by taking into account women's perception of risk and their explanatory models. Hospital services should be reorganised to address rural women's feelings of fear and insecurity.