Background Antenatal care (ANC) is an opportunity to provide education, screening, ongoing assessment and preparation for delivery and motherhood. Socio-demographic factors such as education, ethnicity and low socio-economic status are associated with late initiation of ANC. In Ireland, all women are entitled to free maternity care. Using the Pregnancy Risk Assessment Monitoring System (PRAMS), a modified version of the CDC methodology, we examined the factors associated with late initiation of ANC in Ireland.

Methods An alternate sample of hospital discharge records was selected from approximately 2450 mother-infant pairs, discharged between May and August 2012, from a large urban, obstetric hospital in the South of Ireland (9000 live births per year). Mothers of stillbirths and neonatal deaths were excluded. Postpartum women were sent an invitation including option to opt out, followed by a modified PRAMS survey (3 mailings), a reminder letter and a telephone follow-up. The questionnaire covered socio-demographics, health behaviours and experiences before, during and after pregnancy. Multivariate logistic regression was used to examine the impact of predisposing, enabling and need factors on late initiation, which was defined as >12 weeks gestation at the time of the first booking appointment.

Results Of the 1184 women contacted, 718 participated (61% response rate). The average age was 33 years (SD=4.6). 82.3% were 3^rd level educated (n=587, 95% CI 80–85%) and 31% were pregnant for the first time (n=219, 95% CI 27–34%). 191 were late initiators of ANC (27.6%, 95% CI 24–31%). Women without private health insurance before pregnancy were twice as likely to be late initiators (OR=1.8, 95% CI 1.2–2.9, p < 0.05). Age, education, ethnicity, marital status, parity, BMI pre-pregnancy, folic acid pre-pregnancy and smoking were not significantly associated with the outcome. The effect persisted in subgroup analyses by parity. Among multiparous women (n = 419), late initiation was significantly more likely amongst women without private insurance (OR=1.9, 95% CI=1.1–3.3). The effect was similar although non-significant among primiparous women (n = 256) (OR=2.0, 95% CI=0.9–4.5). Women who did not have an adverse pregnancy outcome (miscarriage, stillborn, termination or neonatal death) in their last pregnancy were more likely to delay initiating ANC (OR=2.7, 95% CI=1.5–4.8) (p < 0.05).

Discussion Over 25% of women in this well-educated sample were characterised as late initiators of ANC. Private health insurance was associated with timely attendance. While all women are entitled to free maternity care in Ireland, private insurance is supplementary and offers more choice over providers and health care settings. Health insurance may be an indicator of preparedness for pregnancy in an Irish context.